1. Group Exercise Infection Control of Aerosol Transmissible Diseases

2. Scenario You are a health care worker in a busy family practice clinic. A mother calls for an same day appointment. Her 4 year old child developed a fever ~ 3 days ago and it’s getting worse. The receptionist has scheduled the appointment for 2 PM. 2 PM: The family walks into the waiting room. The receptionist is concerned about a contagious illness because the child has a rash. She asks you, the clinic charge nurse, to immediately evaluate the patient.

3. Question 1 Which aerosol transmissible diseases would you be concerned about? (fever/rash illness) airborne: measles, varicella (chickenpox) droplet: meningococcal disease, rubella (german measles) note: other infectious agents can cause fever/rash but are not on ATD list

4. Scenario (continued) The receptionist obtained this additional history: The family has just returned from a vacation to Europe. The child has had a fever, runny nose, cough, for 3 days. Initially the fever was 101ºF but has been increasing, and was 104ºF today. Her child developed a rash last night which is spreading.

5. CDC Photo / Barbara Rice You immediately recognize this as a possible case of _________

6. Question 2 What would you do? Hint:  source control and HCW protection At triage promptly screen & isolate patients with fever and rash Mask & isolate suspect cases (negative pressure – if not available, private room with door closed) HCW protection –Ensure HCW immunity. Only immune persons to enter room. –N95 respirator  Determine vaccination status; other risk factors? Check vaccine records. If not available, check immunization registry www.cair.org. Note- hx MMRx2 does not preclude measleswww.cair.org International travel to endemic area/ foreign visitors

7. Question 2b If the mother had given a history of fever, rash over the phone What policies/procedures should be in place to avoid potential exposures?  Phone call protocol for fever, rash, especially if concern re: varicella /measles- If notified in advance, schedule an appt late in the day, avoid others, separate entrance if possible. If ATD suspected, child to wear mask, consider evaluating patient in car/outside building  Office protocol for fever, rash Ensure source control  HCW protection Ensure respiratory protection program in place Vaccination policy

8. Scenario (continued) You review the chart for vaccination.  The parents have declined vaccination for their child in the past. Physician examines the patient. Makes diagnosis of probable measles.  writes orders to send child to the laboratory to have blood drawn for a serologic test for measles.

9. Question 3 a.What arrangements should be made for laboratory testing ? Avoid exposure to others. Discuss with local health dept for best strategies. Draw blood in office if possible. Some health depts can assist w specimen collection & testing. If necessary to send to a commercial lab, alert first. Arrange blood draw at end of day, mask patient, only those with measles immunity should see patient. Phlebotomist should wear N95 respirator. b.Should any one else should be notified ? c.Any special instructions/precautions as the family leaves?

10. Question 3 (continued) b.Should any one else should be notified ? Contacts should be notified Alert public health immediately; public health will coordinate follow up of contacts c.Any special instructions/precautions as the family leaves? Mask patient. Leave by separate entrance if possible, avoiding contact w/ others. Stay at home during infectious period unless medically necessary.

11. Question 4  What about the examination room after the patient leaves? Close door. Do not use any regular exam room for at least 2 hours after a suspect measles patient has left room. Decontaminate high-touch surfaces before next use.

12. Measles highly contagious, 90% attack rate Prodrome – fever, cough, coryza, conjunctivitis 2-4 days Rash – begins on face & head, spreads, lasts 5-7 d Infectious 4 days before to 4 days after rash onset Incubation period (exposure to first symptoms) 14 days (7-18 d) person to person, respiratory droplet and airborne transmission documented airborne up to 2 hrs after person with measles occupied the area in enclosed spaces) One in 1000 children with measles die Increasing cases in CA (international travel, vaccine refusal)

13. http://www.cdph.ca.gov/programs/immunize/Documents/IMM-908.pdf