Rising Number of Measles Cases Creates Numerous Patient Safety Issues

Debbie Hill, MBA, RN, Senior Patient Safety Risk Manager

New cases of measles (rubeola) continue to make national headlines. In 2018 and into 2019, hundreds of cases were reported to the Centers for Disease Control and Prevention (CDC). Outbreaks occurred in many states, including Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas, and Washington.1

The largest outbreaks occurred in Rockland County, New York, and New York City. Most of these cases resulted from the exposure of unvaccinated individuals. In 2018, 82 individuals brought measles into the United States when traveling here from other countries—the greatest number of imported cases for any year since the disease was declared to have been eliminated from the United States, according to the CDC.1

As more measles cases are diagnosed in 2019, physicians should implement effective screening protocols, infection control techniques, and patient education to reduce liability risks and promote patient safety.

Measles outbreaks most often occur in the United States when an unvaccinated traveler gets the disease while traveling in other countries and then spreads it to individuals who have not been vaccinated.2 In addition, the anti-vaccine movement has contributed to the recent spread of measles by creating pockets of unvaccinated people. Washington State and Oregon allow parents to opt out of vaccinations for their children, resulting in “hot spots” within those states. Given the disease was essentially eliminated from the United States, some physicians may not be familiar with the clinical manifestation of the disease and may not consider measles as a potential diagnosis. Since initial presenting symptoms of measles are similar to those of upper respiratory infections, measles may be misdiagnosed before a patient presents with the familiar red rash.

Exposure to measles in a medical office or facility is a serious patient safety issue because of the potential for complications from the disease, including death. The disease is airborne and extremely contagious; 90 percent of unimmunized individuals who are exposed to the disease could be infected.3 An infected individual is considered contagious from four days before to four days after the rash appears. The rash usually appears 14 days after a person is exposed; however, the incubation period ranges from 7 to 21 days.4 To protect staff and patients, medical offices should establish screening protocols that limit exposure risk from infected individuals.

Unlike hospitals, most medical offices are not equipped with negative pressure isolation units that offer better protection from airborne diseases. Your practice, however, can reduce liability risks and promote patient safety by:

  • Developing screening protocol for patients calling in with symptoms of upper respiratory infections and measles. Staff should query the individual regarding exposure to known measles cases, travel abroad, and immunization status.
  • Documenting all discussions with patients and parents of minors regarding measles, including the risks and benefits of inoculation. When patients/parents decline measles immunization, consider using an informed refusal form. Patients who contract measles and claim that their physician never discussed inoculation represent a potentially significant liability.
  • Providing serologic testing for immunity, when necessary, and documenting all related discussions with patients who are unsure of their immunity status against measles.
  • Ensuring that immunization tracking is up to date and well documented in the medical record so that patients remain on schedule.
  • Complying with state laws for the provision of vaccines to healthcare workers. Ideally, healthcare workers should demonstrate evidence of immunity to work with patients who are suspected of having measles or patient populations, including infants, who are susceptible to measles themselves.
  • Advising those who may have come in contact with an infected individual to contact their physician immediately.
  • Ensuring that office staff members are trained to use personal protective equipment and proper isolation techniques when working with an infected individual.

Physicians who are not familiar with diagnosing measles should obtain additional training. It is essential to be knowledgeable about signs and symptoms, potential complications, diagnostic testing, and infection control recommendations from the CDC.

Follow these tips if you or your staff suspects a patient has measles symptoms:

  • Use standard and airborne precautions as appropriate and as outlined by the CDC.5 6
  • Follow the procedures for cleaning and disinfection of environmental surfaces as outlined by the CDC.7
  • Minimize the risk of exposure to others by admitting the patient through a separate entrance and isolating him or her in an exam room. If possible, schedule the patient at the end of the day. It is preferable that the exam room not be used until the following day since the virus can live on surfaces for up to two hours. Keep the exam room door closed.
  • Place a surgical mask on the patient and ensure that all office staff members wear protective equipment, including gloves, eye protection, masks, or an N-95 particulate respirator (properly fit-tested), if needed.
  • Obtain specimens for disease testing. Report suspected cases to the local health department.
  • Consider making post-exposure prophylaxis available to those who have been exposed. Post-exposure vaccination can be effective in preventing measles in some individuals. As an alternative, Immunoglobulin, if administered within six days, can offer some protection against measles or lessen the manifestation of the disease.
  • Contact your local health department for additional guidance.

References

  1. CDC: Measles Cases and Outbreaks. https://www.cdc.gov/measles/cases-outbreaks.html
  2. CDC: Frequently Asked Questions about Measles in the US. http://www.cdc.gov/measles/about/faqs.html
  3. CDC: Transmission of Measles. http://www.cdc.gov/measles/about/transmission.html 
  4. CDC: Immunology and Vaccine-Preventable Disease—Pink Book—Measles. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf
  5. CDC: Infection Control: Standard Precautions for all Patient Care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html
  6. CDC: Infection Control: Transmission-Based Precautions. https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html
  7. CDC: Infection Control: Guideline for Disinfection and Sterilization in Healthcare Facilities. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/cleaning.html

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

04/19

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