Until recent years the risk of being exposed to measles was not the first illnesses to come to mind when considering the risk of disease transmission from patients to healthcare workers. Even now there are reported outbreaks in many states of both measles and mumps. One can no longer be confident that during the delivery of healthcare they will not be exposed to one of these childhood illnesses even if your practice is not pediatrics or primary care.
The CDC defines healthcare workers as:
“all paid and unpaid persons working in health-care settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. HCP might include (but are not limited to) physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the health-care facility, and persons (e.g., clerical, dietary, housekeeping, laundry, security, maintenance, administrative, billing, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from HCP and patients.”
Measles is highly contagious. In fact, 90 to 99% of individuals who are not immune will become infected once exposed. Individuals are considered contagious from four days prior to outbreak of a rash to four days after the rash has appeared. The virus is spread by direct contact with infectious droplets or by airborne transmission. The measle virus can remain in the air for up to two hours after the patient has left the area.
Signs and symptoms of the illness appear anywhere from 10 to 14 days after exposure and include:
- Runny nose
- Sore throat
- Koplik’s spots which are tiny white spots with bluish white centers located inside the mouth on the inside of the cheeks
- Rash, beginning on the face and spreading, often described as large, flat blotches that overlap
Documented complications include pneumonia, bronchitis, ear infections and encephalitis. Children under age five, adults 20 years and older, pregnant women and those with a weakened immune system are at higher risk for more severe illness and complications.
A college student is home on spring break and comes to the practice because he is feeling like he has the “flu” or keeps that hygiene appointment because even though he doesn’t feel well, this is the only time he can get his teeth cleaned. It is later determined that he has the measles.
How do you handle this situation?
It is best for healthcare workers with proof of immunity to provide care to the suspect patient. Airborne precautions should be taken. Provide the patient with a mask and isolation in a negative air-flow room as soon as possible. Workers, even those considered immune, should wear appropriate respiratory protection (N-95 respirator mask or equivalent) to reduce exposure to the virus. The challenge is that most out-patient facilities do not have negative air-flow rooms on site, and they have not implemented a respiratory protection program. Each practice should perform a risk assessment to evaluate the potential exposure risks to workers and others in the practice. Then, based on the assessment, determine steps that need to be taken.
At a minimum a practice or facility should document the immune status of workers for many communicable diseases including measles, mumps and rubella.
Accepted evidence of immunity based on CDC and ACIP recommendations is outlined in Healthcare Personnel Vaccination Recommendations. They provide the following information:
- HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella.
- Individuals born before 1957 are generally considered immune to measles, mumps, and rubella. For these individuals, if there is not laboratory evidence of disease or immunity to measles then 2 doses of MMR vaccine should be considered.
Even though exposure to measles may be considered a low risk for your work environment, do not discount the possibility of a severe illness for those who are not immune and exposed. In some scenarios, a worker may be excluded from work from day 5 through day 21 after exposure which could have an impact on the ability to deliver patient care. If you don’t have a plan, now is the time to determine how to handle a potential exposure. Start the process of documenting workers immunity for the good of your practice and your patients.
For further reading:
Immunization of Health-Care Personnel – Recommendations of the Advisory Committee on Immunization Practices. November 25, 2011.
Ask the Experts – Measles, Mumps, Rubella – Immunization Action Coalition – EXCELLENT resource for questions and answers about the diseases and vaccination recommendations.