Measles (Rubeola) Outbreak 2019
Chances are good, most of you have, at minimum, seen headlines about outbreaks of chickenpox and measles. In recent years, these types of airborne illness have played a larger role in community acquired diseases throughout the United States. And the reality is, we all breathe.
According to Centers for Disease Control and Prevention (CDC) measles is an acute viral respiratory illness. It is characterized by what is referred to as a prodrome. Prodrome is the time following exposure to a disease that your body is infectious, often without classical outward signs of disease. Of interest the word prodrome is derived from the Greek word prodromos, meaning "running before". Measles prodrome usually consists of fever (as high as 105°F) and malaise. Measles prodromal stage also includes cough, coryza, and conjunctivitis, the three “C”s, and (Koplik spots). Thereafter the classic maculopapular rash presents itself. The rash usually appears about 14 days after a person is exposed. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash.
In 1978, Centers for Disease Control and Prevention (CDC) set a goal to eliminate measles from the United States by 1982. Although this goal was not met, widespread use of measles vaccine dramatically reduced disease rates. By 1981, the number of reported measles cases was 80% less compared with the previous year. In 1989, measles outbreaks among vaccinated school-aged children prompted the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) to recommend a second dose of MMR vaccine for all children. Following widespread implementation of this recommendation and improvements in first-dose MMR vaccine coverage, reported measles cases declined even more. Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the United States in 2000.
Since 2000, the United States has indeed experienced a number of outbreaks. It is important to note, measles is an airborne disease, lending itself to sudden widespread transmission of disease in any community. CDC states "measles is so contagious, that if one person has it, 90% of the people close to that person who are not immune will also become infected." Because measles is airborne, the challenge lies in persons who vector the disease to non-immune persons either through an increase in the number of travelers who get measles abroad and bring it into the U.S., and/or further spread of measles in U.S. communities with pockets of unvaccinated people.
From January 1 to 31, 2019, 79 individual cases of measles have been confirmed in 10 states. The states that have reported cases to CDC are California, Colorado, Connecticut, Georgia, Illinois, New Jersey, New York, Oregon, Texas, and Washington. For most of us, these states are simply a sneeze away.
VACCINATION OF HEALTHCARE WORKERS
CDC states, "healthcare workers (HCW's) are at risk for exposure to serious, and sometimes deadly, diseases. If you work directly with patients or handle material that could spread infection, you should get appropriate vaccines to reduce the chance that you will get or spread vaccine-preventable diseases. Protect yourself, your patients, and your family members. Make sure you are up-to-date with recommended vaccines." Healthcare workers are defined by CDC as "physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff."
Following, please find CDC recommendations for MMR vaccination
If you were born in 1957 or later and have not had the MMR vaccine, or if you don’t have an up-to-date blood test that shows you are immune to measles or mumps (i.e., no serologic evidence of immunity or prior vaccination), get 2 doses of MMR (1 dose now and the 2nd dose at least 28 days later)
If you were born in 1957 or later and have not had the MMR vaccine, or if you don’t have an up-to-date blood test that shows you are immune to rubella, only 1 dose of MMR is recommended. However, you may end up receiving 2 doses, because the rubella component is in the combination vaccine with measles and mumps.
Although birth before 1957 is considered acceptable evidence of measles, rubella, and mumps immunity, health-care facilities should consider vaccinating unvaccinated personnel born before 1957 who do not have laboratory evidence of measles, rubella, and mumps immunity; laboratory confirmation of disease; or vaccination with 2 appropriately spaced doses of MMR vaccine for measles and mumps and 1 dose of MMR vaccine for rubella. Vaccination recommendations during outbreaks differ from routine recommendations for this group
CDC SEROLOGIC TESTING RECOMMENDATIONS
Prevaccination antibody screening before measles, rubella, or mumps vaccination for health-care personnel who do not have adequate presumptive evidence of immunity is not necessary unless the medical facility considers it cost effective.
For health-care personnel who have 2 documented doses of measles- and mumps- containing vaccine and 1 documented dose of rubella-containing vaccine or other acceptable evidence of measles, rubella, and mumps immunity, serologic testing for immunity is not recommended.
If health-care personnel who have 2 documented doses of measles- or mumps- containing vaccine are tested serologically and have negative or equivocal titer results for measles or mumps, it is not recommended that they receive an additional dose of MMR vaccine. Such persons should be considered to have acceptable evidence of measles and mumps immunity; retesting is not necessary.
Similarly, if health-care personnel (except for women of childbearing age) who have one documented dose of rubella-containing vaccine are tested serologically and have negative or equivocal titer results for rubella, it is not recommended that they receive an additional dose of MMR vaccine. Such persons should be considered to have acceptable evidence of rubella immunity.
WOMEN OF CHILDBEARING AGE
All women of childbearing age (e.g., adolescent girls and premenopausal adult women), especially those who grew up outside the United States in areas where routine rubella vaccination might not occur, should be vaccinated with 1 dose of MMR vaccine or have other acceptable evidence of rubella immunity.
Nonpregnant women of childbearing age who do not have documentation of rubella vaccination, serologic evidence of rubella immunity, or laboratory confirmation of rubella disease should be vaccinated with MMR vaccine.
Birth before 1957 is not acceptable evidence of rubella immunity for women who could become pregnant.
Women known to be pregnant should not receive MMR vaccine. Upon completion or termination of their pregnancies, women who do not have evidence of rubella immunity should be vaccinated before discharge from the health-care facility.
Women should be counseled to avoid becoming pregnant for 28 days after administration of MMR vaccine.
Measles is a serious illness that can result in significant morbidity and mortality in adult patients. Because rubeola is an airborne disease, it is essential that all members of your team be immune to prevent additional prodromal spread of the disease among your team, your patients, and the community.