Transcript Preparing for Measles in the Healthcare Setting

A Guy with A Rash Walks into Your ED
-Preparing for Measles in the
Healthcare Setting
Marion A. Kainer, MD, MPH, FRACP, FSHEA
Director, Healthcare Associated Infections and
Antimicrobial Resistance Program
Tennessee Department of Health
September 11, 2014
Background: Measles
• ssRNA paramyxovirus
• Acute viral respiratory illness
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Malaise
Fever (as high as 105F)
3 C’s: cough, coryza (runny nose), conjunctivitis
Koplik spots (early sign, tiny red spots on oral
mucosa with bluish-white center)
– Maculopapular rash starts 3-7 days after
prodrome begins
• Head  Trunk  Extremities
• Immunocompromised patient may not have rash
– Rash appears ~14 days after exposure
(incubation period ranges from 7-21 days)
– Infectious ~4 days before through 4 days after
rash onset
Complications of
Measles
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Common: Otitis media, pneumonia, bronchitis, diarrhea
1 per 1,000 develop acute encephalitis
1-2 per 1,000 will die
Subacute sclerosing panencephalitis (SSPE): rare, fatal
degenerative CNS disease, develops 7-10 yrs after infection
• People at high risk for complications, if susceptible
– Infants and children aged <5 years
– Adults aged >20 years
– Pregnant women
– People with compromised immune systems, e.g., leukemia
and HIV
Measles Transmission
• 9 out of 10 exposed susceptible people will
become ill after close contact
• Transmitted by direct contact with infectious
droplets or by airborne spread when an
infected person breathes, coughs, or sneezes
• Virus can remain infectious on surfaces and
in the air for up to two hours after an
infected person leaves an area
Diagnostic Testing
• Acute Illness
– Serum for IgM+
• In susceptibles, IgM testing early may be negative,
retest at least 72h after rash onset
• In persons with past immunization, serologic results
tricky (IgG may rise quickly, IgM may not spike)
– rtPCR (throat or NP swab)
• Use plastic or metal swab, no wood, with Dacron tip, placed in
viral transport media
• State will facilitate or conduct rapid testing of high
probability suspects
– Testing at state lab requires approval of TDH medical epidemiologist
Measles Immunity Basics
• Almost all people born before 1957 had illness
• Effective, live vaccine introduced 1963
– ~5% of 1-dose live virus vaccine recipients are susceptible
– Doses given before 1st birthday less effective
– <1% of 2-dose recipients susceptible, if both doses given after 1st
birthday and at least 28 days apart
• 2-dose recommendation for all children with catch up of older
children and college students in 1989-90 after measles resurgence
– Persons born in 1960s through early 80s who never went to
college, military or healthcare work more likely to have 1 dose
– A 1999-2004 study: measles antibodies in 95.9% of US population
aged 6-49 years. Lowest in those born 1967-1976 (92.4%)
Current Measles Vaccine Recommendations
• Children: 2 doses, first after 1st birthday, second
before Kindergarten
– Dose 2 may be given as soon as 4 weeks later
• Adults, aged 19 up to those born before 1957: 12 doses documented in writing
– 2 doses for healthcare workers
– 2 doses for military, college
– 2 doses for international travel
• Adults in general born before 1957
– Presumed immune
– Healthcare personnel (HCP) are different…
Measles Immunity: Healthcare Personnel (HCP)
Recommendations of CDC
• HCP: Anyone who has any contact with patients in a
healthcare setting (anyone expected to be in any room
where patients would be present)
• Acceptable presumptive evidence of immunity for HCP:
– Documented lab confirmation of immunity or lab
confirmation of disease
– Documented 2 age-appropriate doses of measlescontaining vaccine (MCV)
– Special considerations for HCP born before 1957
• Of the 911 US measles cases 2001-11, 37 (4%) born
before 1957
• During an outbreak, age alone not good enough
Measles Immunity: Healthcare Personnel (HCP)
born before 1957
• CDC’s language on HCP born before 1957 in absence of outbreak:
– “For unvaccinated personnel born before 1957 who lack laboratory
evidence of measles immunity or laboratory confirmation of disease,
health-care facilities should consider vaccinating personnel with 2
doses of MMR vaccine at the appropriate interval.”
– During an outbreak of measles: health-care facilities should
recommend 2 doses of MMR vaccine
– Exposed HCP who lack lab or MMR verification may be furloughed
days 5-21 post-exposure to a case in order to protect patients.
Immunization of Healthcare Personnel: Recommendations of the Advisory
Committee on Immunization Practices (ACIP) MMWR published Nov. 25, 2011:
http://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf
CDC does not Favor
Pre-vaccination Serologic Testing of HCP
• For those without documentation:
– Not recommended unless facility considers it cost
effective
– During an outbreak? Not recommended: need rapid
vaccination
• Those who have had 2 age-appropriate doses of
measles-containing vaccine (MCV)? No.
– If serology done and negative, additional MCV not
recommended (vaccine history supersedes titer result)
• National data on MMR coverage of HCP unavailable
Measles: Tennessee April/May 2014
• 1 adult traveler, rash onset 4/25 (infectious April 20-29).
Not infectious while traveling.
• Visited outpatient clinic 4/22, work 4/24, hospital ER 4/25
(isolated quickly, admitted 4/25-27). Public health
contacted as soon as measles suspected.
• Recovered
• 4 known secondary cases among contacts identified by
public health
– 1 outpatient healthcare worker, born before 1957
– 3 adult co-workers
• 2 with unknown history had MMR PEP, mild disease
• One refused PEP based on convincing “recollection” of 2 MMRs,
immunization records obtained later showed just one MMR
Secondary Cases: Potential Exposures
• Residents of West TN: exposures concentrated there
• One visited Hamilton County while infectious
• No additional healthcare facilities involved in
secondary cases
• No cases among their identified contacts
• Close surveillance 2 incubation periods after last
infectious day of last case…
• Given increase in US import-related cases, outbreaks
in Philippines and Vietnam, ongoing risk in most of
world, including Western Europe and the UK…
– A measles patient could walk in at any time
A Suspect Measles Case Walks into a
Clinic…
• Who do I suspect?
– Febrile, rash illness
– Prodromal symptoms and reports contact with someone with
febrile rash illness or recent international travel
– Do not leave in a waiting area
• Swift airborne isolation (in AIIR if possible)
– At least, place mask on patient (if tolerated), place in private
room with door closed, wearing mask
• Do not place in a positive pressure room
– Only staff with presumptive evidence of immunity should
contact patient (using airborne precautions)
– Call your local health department or TDH (615-741-7247) 24/7
if measles is suspected after examination
• They can facilitate state testing of high probability patients
Measles contact evaluation:
Act quickly, work with Public Health
• Identify patients, visitors, all workers who
were in room with patient (document names,
age, contact information at least)
– Includes everyone in waiting room with patient up
to 2 hours after patient left
– Evaluation for presumptive evidence of immunity
• For non-HCW, birth before 1957 is acceptable
• Documentation of 2 doses of MCV or disease/immunity
• Age appropriate immunization of small children
Contact Management
• Guidelines for public health outbreak response detailed in CDC’s online
VPD Surveillance Manual, Chapter 7 (last updated 2013):
– http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html
• Contacts without presumptive evidence of immunity should get MMR
within 72h of exposure to modify or prevent disease
• If contact is an admitted patient, quarantine until 21 days after exposure
and observe for signs/symptoms
• Those who cannot receive MMR should be offered IM immune globulin
within 6 days (0.25ml/kg standard for non-immunocompromised) and
observed for 28 days (incubation may be prolonged)
• MMR may be offered to anyone not fully immunized even if too late for
PEP to protect from future exposures
Key Data Elements for
Suspected Patient
Key Data Elements for
Contacts
Considerations for Today
• Review documentation of presumptive evidence
of immunity for all who work in facility
– For those whose only evidence is birth before 1957
• Consider 2 doses of MMR or a titer now
• If not now, know who they are in event of exposure
• In event of exposure, titer results useful as proof of
immunity only if drawn soon after an exposure
– Be prepared to furlough any exposed HCP lacking
evidence of immunity days 5-21 after exposure
(regardless of PEP)
• Including those with no evidence except age
Considerations for Today
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Review signs/symptoms, risk with ED staff
Review procedures for rapid isolation and evaluation
Ensure public health contact information readily available
Educate all HCP about value of MMR, address any without documented
presumptive evidence of immunity
Helpful references:
• Immunization of Healthcare Personnel: Recommendations of the Advisory
Committee on Immunization Practices (ACIP) MMWR published Nov. 25,
2011: http://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf
• CDC main measles page: http://www.cdc.gov/measles/
• Resources and handouts for HCP: http://www.immunize.org/hcw/
• TN Immunization Program at TDH:
– Dr. Kelly Moore, Robb Garman (epidemiologist)
– 615-741-7247 (24/7 TDH number)
Other Resources
http://health.state.tn.us
Ebola Update
Marion Kainer MD MPH
Tennessee Department of Health
Sept 8, 2014
Background: Ebola Outbreak
• Largest ever recorded
– 3,685 cases (as of Aug 31, 2014)
– 1,841 deaths
– First in West Africa: Guinea, Liberia, Sierra Leone, Nigeria
• Incubation period 2-21 days (peak 8-10 days)
• Highly virulent
– Case fatality up to 90%
– Spread through body fluids (including vomitus, diarrhea)
• Two infected US aid workers returned to Atlanta
– Now recovered and discharged
• One infected US aid worker returned to Nebraska on
9/5
Epi-Curve, Ebola Virus Disease
West Africa, 2014 (WHO)
http://www.who.int/csr/disease/ebola/5-september-2014-en.pdf
Total Cases/Deaths as of Sept 5, 2014
Guinea, Liberia, Sierra Leone (WHO)
http://www.who.int/csr/disease/ebola/5-september-2014-en.pdf
GUINEA
SIERRA LEONE
LIBERIA
http://www.who.int/csr/disease/ebola/5-september-2014-en.pdf
Total Cases/Deaths as of Sept 5, 2014
Nigeria and Senegal (WHO)
http://www.who.int/csr/disease/ebola/5-september-2014-en.pdf
Identification:
Early recognition critical
TDH Resources for Ebola
• http://health.state.tn.us/Ceds/ebola.htm
• Please ensure
all staff
(including lab
staff) know
proper
sequence to
don and
remove PPE
www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf
Ebola: High Risk Exposures
• Contact with a person with confirmed or
suspected of EVD (percutaneous or mucous
membrane exposure or direct contact with body
fluids)
• Laboratory processing of body fluids of
suspected or confirmed EVD cases without
appropriate PPE or standard biosafety
precautions
• Participation in funeral rites or other direct
exposure to human remains without proper PPE
(in geographic area where the outbreak is
occurring)
Interim CDC Laboratory Guidance
• If have suspect case, please contact TDH 24/7
– (615) 741-7247
CDC Infection Control Recs
• Precautions:
– Standard
– Contact
– Droplet
• Upon entry into patient’s room
Healthcare Personnel Protection
• All persons entering the room should wear at
least:
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Gloves
Gowns (fluid resistant or impermeable)
Eye protection (goggles or face shield)
Facemask
• Additional PPE may be required in certain
situations, including: double gloving, disposable
shoe covers and leg coverings
• Perform frequent hand hygiene before and after
all patient contact
Patient Placement and Care
• Patients should be placed in single patient room
with door closed (containing private bathroom)
• Maintain log of all persons entering room
• Dedicated medical equipment (prefer
disposable)
• All non-dedicated, non-disposable medical
equipment used for patient care should be
cleaned and disinfected (manufacturer instruct)
Patient Care Considerations
• Limit use of needles and other sharps as
much as possible
– Use extreme care, dispose in puncture proof
containers
• Limit phlebotomy, procedures and laboratory
testing to minimum necessary for essential
diagnostic evaluation and medical care
• Avoid aerosol generating procedures
– If perform– use AIIR, N-95 or above
Environmental Infection Control
• Diligent environmental cleaning and disinfection
(agent with activity against non-enveloped
viruses such as norovirus)
• Those performing environmental cleaning and
disinfection should wear recommended PPE
• Wear face protection (facemask and eye
protection) when perform tasks that can
generate splashes (e.g., liquid waste disposal)
• Disposal of textiles (e.g., bed-linen, privacy
curtain)
Practice Run Through/Table-Top Exercises
• Measles
• Ebola
• MERS Co-V
• How many have done this?
• How many are planning to do this?