Ohio local health jurisdictions are continuing their tireless efforts to prevent and control the spread of measles. As of June 23, there have been 341 cases of measles reported in Ohio and we expect that number will continue to grow. The following guidance was developed by the Ohio Department of Health (ODH) in collaboration with the Centers for Disease Control and Prevention (CDC) to provide you with updated guidance regarding healthcare personnel vaccination, serologic testing of healthcare personnel, and hospital isolation.
Guidance for Measles Vaccination of Healthcare Personnel
To prevent disease and transmission in healthcare settings, healthcare institutions should ensure that all persons who work in healthcare facilities have presumptive evidence of immunity to measles. Healthcare personnel (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 healthcare 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 HCPs and patients.
Presumptive evidence of immunity to measles for persons who work in healthcare facilities includes written documentation of vaccination with 2 doses of live measles-containing or MMR vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957. Healthcare facilities should use secure, preferably computerized, systems to manage vaccination records for HCP so records can be retrieved easily.
Although birth before 1957 is considered acceptable evidence of measles immunity, healthcare facilities should consider vaccinating personnel born before 1957 who do not have laboratory evidence of measles immunity; laboratory confirmation of disease; or vaccination with 2 appropriately spaced doses of vaccine for measles. Vaccination recommendations during outbreaks differ from routine recommendations for this group.
During an outbreak of measles, healthcare facilities should recommend 2 doses of MMR vaccine at the appropriate interval for unvaccinated HCP regardless of birth year who lack laboratory evidence of measles immunity or laboratory confirmation of disease. With the current measles outbreak in Ohio, Ohio counties where confirmed cases of measles have occurred are considered part of the outbreak area and should follow this guidance. For a list of all affected counties, please visit http://www.odh.ohio.gov/features/odhfeatures/Measles%202014.aspx.
In addition, as many Ohio residents travel long distance for their hospital care, given the current measles outbreak, ODH strongly recommends that all hospitals in Ohio review their policies and consider recommending 2 doses of MMR vaccine for all unvaccinated HCP regardless of birth year who lack laboratory evidence of measles immunity or laboratory confirmation of disease.
Serologic Testing of Healthcare Personnel for Measles Immunity
Pre-vaccination antibody screening before measles vaccination for healthcare personnel who do not have adequate presumptive evidence of immunity is not necessary unless the medical facility considers it cost effective. For healthcare personnel who have 2 documented doses of measles-containing vaccine or other acceptable evidence of measles immunity, serologic testing for immunity is not recommended. If healthcare personnel who have 2 documented doses of measles-containing vaccine are tested serologically and have negative or equivocal titer results for measles, it is not recommended that they receive an additional dose of MMR vaccine. Such persons should be considered to have acceptable evidence of measles immunity; retesting is not necessary.
Hospital Isolation Guidance
Following airborne infection control precautions is important to control the spread of measles but might fail to prevent all nosocomial transmission, because transmission to other susceptible persons might occur before illness is recognized. Persons infected with measles are infectious 4 days before rash onset through 4 days after rash onset.
When a person who is suspected of having measles visits a healthcare facility, airborne infection control precautions should be followed stringently. The patient should be asked immediately to wear a medical mask and should be placed in an airborne-infection isolation room (i.e. a negative air-pressure room) as soon as possible. If an airborne-infection isolation room is not available, the patient should be placed in a private room with the door closed and be asked to wear a mask. If possible, only staff with presumptive evidence of immunity should enter the room of a person with suspect or confirmed measles. Because of the possibility, albeit low (~1%), of measles vaccine failure in HCP exposed to infected patients, all staff entering the room should use respiratory protection consistent with airborne infection-control precautions (i.e. use of an N95 respirator or a respirator with similar effectiveness in preventing airborne transmission), regardless of presumptive immunity status.
HCP in whom measles occurs should be excluded from work until ≥4 days following rash onset. Contacts with measles-compatible symptoms should be isolated, and appropriate infection-control measures (e.g. rapid vaccination of susceptible contacts) should be implemented to prevent further spread.
If measles exposures occur in a healthcare facility, all contacts should be evaluated immediately for presumptive evidence of measles immunity. HCP without evidence of immunity should be offered the first dose of MMR vaccine and excluded from work from day 5-21 following exposure. HCP without evidence of immunity who are not vaccinated after exposure should be removed from all patient contact and excluded from the facility from day 5 after their first exposure through day 21 after the last exposure, even if they have received postexposure intramuscular immune globulin. Those with documentation of 1 vaccine dose may remain at work and should receive the second dose.
Centers for Disease Control and Prevention (CDC). (2011, November 25). Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Reports (MMWR). Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm.
Centers for Disease Control and Prevention (CDC). (2013, June 14). Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (MMWR). Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm?s_cid=rr6204a1_w .