Dr Tara Anderson ACIPC 24 th November 2015

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1 Dr Tara Anderson ACIPC 24 th November 2015

2 Measles Virus (MeV) Genus Morbillivirus Family Paramyxoviridae Spherical, enveloped, non-segmented, singlestranded, negative-sense RNA virus nm diameter Human reservoir

3 WHO announced Australia s elimination of measles on 20 March 2014 Australia remains at risk of limited transmission and small-moderate sized outbreaks due to imported cases

4 Classic Measles INCUBATION PERIOD Exposure to prodrome 7-18 days (average 10 days) PRODROME phase 1-7 days (av. 2-4 days) Fever then cough, rhinorrhoea and/or conjunctivitis KOPLIK spots EXANTHEM phase Rash (face/head > trunk /arms > legs) (usu. lasts 5-6 days) EXPOSURE -> RASH 7-21 days (average 14 days) INFECTIOUS PERIOD 24 hours prior to onset of prodromal symptoms until 4 days post-rash onset 5 days before until 4 days after rash onset

5 Highly contagious Exposed susceptible individuals have >90% probability of acquiring disease (i.e. secondary attack rate) Infectious period 5 days before to 4 days after rash onset MeV may be detected in clinical specimens routinely >7 days after rash onset, up to 3 months particularly in immunosuppressed patients Unclear whether the infectious period is prolonged however Routes of transmission Primarily from person to person via respiratory droplets Airborne transmission via aerosolised droplet nuclei, up to 2 hours after infectious person occupied area Contaminated environment

6 Droplets and Aerosols Droplets generated by talking, laughing, coughing and sneezing may lead to generation of infectious droplets and aerosols Droplet transmission via droplets Short range transmission, usually < 1 metre interaction of breathing zones Large droplet >60 µm, small droplet 60 µm and droplet nuclei <10 µm Droplet nucleus = airborne residue of infectious aerosol from which most of the liquid has evaporated Airborne transmission via infectious aerosols Long range transmission, usually > 1 metre primarily governed by air flows Aerosol = particle size to over 100 µm Movement determined by; Particle size Airflow patterns Temperature/humidity Moving bodies/equipment Door openings Open window Ventilation system

7 40 original studies (3/40 = measles outbreaks)

8 MeV in the Environment Short survival time (< 2hours) in the air or on objects/surfaces Viability dependant on environmental factors; Temperature, humidity/air flows, UV radiation Enveloped viruses are easily inactivated by routine surface cleaning and disinfection Appropriate PPE should be worn when cleaning room or area Limit aerosol generation whilst cleaning

9 First published report of the environmental burden of MeV during routine care of a patient hospitalised with measles Unvaccinated, immunocompetent, young female patient with measles (genotype D8) Exposure to known measles case Day 4 post exposure MMR vaccine Day 13 post exposure rash consistent with measles Day 18 post exposure (day 5 post rash onset) admitted to Wake Forest Baptist Medical Centre (885-bed tertiary care teaching hospital) with suspected pneumonia Single negative pressure isolation room 6 total air changes/hour at 20-40% relative humidity Contact and airborne precautions Daily cleaning of high-touch areas MeV testing days 1-4 (i.e. day 5-8 post rash onset) air samples (3 locations), environmental swabs (3 locations) and mid-section of P2 (N95) mask

10 Air sampling Positive samples from day 5 and 7 post rash onset Surface sampling Positive samples from all 4 study days; 5-8 post rash onset Head of the bed hand rail Middle of the food tray table Table approx. 3 m from foot of bed P2 (N95) sampling 4/134 samples positive; all of these were day 6 post rash onset (av. 333 MeV RNA copes/cm^2) Study supports MeV transmission via the following routes: Airborne Droplet Contact with surfaces Shedding patterns are likely to vary considerably between patients Testing of PCR-positive samples in cell cultures failed to detect viable MeV, making it impossible to assess the potential for infectivity

11 Healthcare facility exposure noted to be a risk factor for many measles outbreaks published in literature

12 21% HCW

13 Preventative Strategies: Vaccination National Immunisation Program schedule; 2 doses at ages 12 and 18 months NHMRC AIH 2013 recommendation Adults born 1966 who do not have documented immunity (i.e. 2 doses or serological evidence), should have 2 doses given 4 weeks apart **Healthcare workers (as above) should have their vaccination records reviewed to ensure that they have received 2 doses of MMR vaccine or have serological evidence of immunity to measles [history of measles not reliable]

14 Mandatory HCW Vaccination Category A = direct contact with patients/clients, deceased persons/body parts and/or blood/body substances/infectious material

15 Preventative Strategies: Outbreak Control Prompt diagnosis + isolation of infectious cases Public Health notification + timely and effective identification and management of contacts

16

17 Challenges of Prompt Diagnosis **Recognition of possibility of measles Most clinicians in developed countries have never seen a single case of measles! Index of clinical suspicion declined in countries where measles has been eliminated History Clinical history Poor reliability of history of measles and is not an acceptable criterion for evidence of measles immunity Vaccination history Secondary vaccine failure rate ~ 5% at years post immunisation (<5% if vaccination after 12 months of age) **Disease can occur even among individuals who meet accepted criteria for presumptive immunity Clinical presentation Classical measles **Clinical variants Modified measles infection in patients with pre-existing but incomplete immunity Previous measles vaccination PEP with serum Ig Prior history of measles [Atypical measles infection following killed virus vaccine; rare] [5% MMR recipients develop non-infectious rash ] Diagnostic testing Timely access to diagnostic tests Serology testing **Interpretation of serology False negative IgM IgM antibodies might not be detectable until 4 days or more after rash onset and usually fall to undetectable concentrations within 4-8 weeks of rash onset [False positive IgM may also occur]

18

19

20 Index case; Returned traveller History of measles Previous MMR vaccination 2 ED presentations with fever, cough, coryza and rash No IC precautions on 2 nd presentation

21 4 prisoners with fever + rash?measles Rash commencing in left thoracic area Flu-like illness with cough for 7 days prior to onset of rash, starting on elbow Fever and rash Flu-like illness for 2 days with transient spotty rash on chest Retrospect; index case 2 weeks previously, presented with respiratory tract infection + prescribed antibiotics -> drug rash

22 Current PH Recommendations

23 Single negative pressure room P2 (N95) mask October 2010

24 Clear definitions of susceptible contact and significant exposure within healthcare setting PEP recommendations (reflect AIH 10 th Edition 2013 and CDNA SoNG) Exclusion of work recommendations

25 Variable Infection Prevention and Control Guidelines Aus (CDNA 2015) Fijian Guidelines May 2006 Accommodation Single room with ensuite (NPV) Single room with ensuite; door closed, window open Susceptible HCW Should not provide care Canada 2013 Single room (AIIR) Should not provide care USA (CDC 2015) UK (HPA 2010) Scotland (NHS Scotland 2015) Airborne Droplet Contact + N95 + surgical mask Single room (AIIR) + N95 Standard isolation Isolation room Should not provide care +FFP3 respirator or hood for AGPs and/or if nonimmune + Eye protection + Surgical mask if risk of splash/spray + Gloves, apron No PPE required for immune HCW No PPE required for immune HCW

26 Orange County Health Care Agency (OCHCA) outbreak described 22 confirmed cases 7 primary (no known epidemiological link to source case) 15 secondary 5 of these were HCWs

27 None of the 5 HCW wore N95 respirators on initial examination of the measles patients 4/5 had evidence of immunity Only 2/5 presented with typical symptoms 3/5 continued to work while symptomatic No secondary cases occurred among those patients and staff who these HCWs exposed HCW risk of becoming infected regardless of presumptive evidence of immunity All HCW providing care to patients with suspected or confirmed measles should wear PPE

28 Take Home Messages MeV may be transmitted by contact, droplet and airborne routes Healthcare transmission has key role in current epidemiology of MeV Optimise our processes to minimise transmission Prevention of healthcare (nosocomial) transmission HCW immunisation mandatory Prompt diagnosis and appropriate management of infectious cases Education and local implementation of identification, isolation and inform PH notification and timely and effective identification and management of contacts

29 THANKS Key Australian References; Australian Guidelines for the Prevention and Control of Infection in Healthcare Communicable Diseases Network Australia (CDNA) National Guidelines for Public Health Units; Measles The Australian Immunisation Handbook 10 th Edition 2013; Measles ook10-home~handbook10part4~handbook

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