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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

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3 Background: Measles ssRNA paramyxovirus Acute viral respiratory illness – 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

4 Complications of Measles 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

5 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

6 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

7 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 1 st birthday less effective – <1% of 2-dose recipients susceptible, if both doses given after 1 st birthday and at least 28 days apart 2-dose recommendation for all children with catch up of older children and college students in 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 study: measles antibodies in 95.9% of US population aged 6-49 years. Lowest in those born (92.4%)

8 Current Measles Vaccine Recommendations Children: 2 doses, first after 1 st birthday, second before Kindergarten – Dose 2 may be given as soon as 4 weeks later Adults, aged 19 up to those born before 1957: 1- 2 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…

9 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 measles- containing vaccine (MCV) – Special considerations for HCP born before 1957 Of the 911 US measles cases , 37 (4%) born before 1957 During an outbreak, age alone not good enough

10 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:

11 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

12 Measles: Tennessee April/May 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

13 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

14 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 ( ) 24/7 if measles is suspected after examination They can facilitate state testing of high probability patients

15 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

16 Contact Management Guidelines for public health outbreak response detailed in CDC’s online VPD Surveillance Manual, Chapter 7 (last updated 2013): – 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

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20 Key Data Elements for Suspected Patient

21 Key Data Elements for Contacts

22 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

23 Considerations for Today 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: CDC main measles page: Resources and handouts for HCP: TN Immunization Program at TDH: – Dr. Kelly Moore, Robb Garman (epidemiologist) – (24/7 TDH number)

24 Other Resources

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26 Ebola Update Marion Kainer MD MPH Tennessee Department of Health Sept 8, 2014

27 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

28 Epi-Curve, Ebola Virus Disease West Africa, 2014 (WHO)

29 Total Cases/Deaths as of Sept 5, 2014 Guinea, Liberia, Sierra Leone (WHO)

30 GUINEA SIERRA LEONE LIBERIA

31 Total Cases/Deaths as of Sept 5, 2014 Nigeria and Senegal (WHO)

32 Identification: Early recognition critical

33 TDH Resources for Ebola

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38 Please ensure all staff (including lab staff) know proper sequence to don and remove PPE

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40 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)

41 Interim CDC Laboratory Guidance If have suspect case, please contact TDH 24/7 – (615)

42 CDC Infection Control Recs Precautions: – Standard – Contact – Droplet Upon entry into patient’s room

43 Healthcare Personnel Protection All persons entering the room should wear at least: – 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

44 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)

45 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

46 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)

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51 Practice Run Through/Table-Top Exercises Measles Ebola MERS Co-V How many have done this? How many are planning to do this?


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