Are You Ready For A Measles Outbreak? Lessons from Minnesota 2017 Outbreak

Transcription

1 Are You Ready For A Measles Outbreak? Lessons from Minnesota 2017 Outbreak Presentation to MCAAP December 6, 2017 Immunization Initiatives Webinar

2 Disclosure The speakers have been asked to disclose any significant relationships with commercial entities that are either providing financial support for this program or whose products or services are mentioned during my presentations. They have no relationships to disclose. They will not discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration. They will discuss the use of vaccines in accordance with ACIP recommendations

3 Objectives List the actions you might take in case of a suspect measles case based on the Minnesota outbreak Discuss the outbreak investigation and response activities undertaken by the Minnesota Department of Health and what your role would be in collaboration with local health department, healthcare facilities, child care facilities and schools in affected settings. Explain the creative collaborations initiated to address vaccine confidence and increase immunization rates in the community undertaken in Minnesota and summarize ways you might implement them in your practice

4 4 2016

5 So how did we get in this situation? Source: MN Department of Health

6 6 2016

7 Could this be measles?

8 Could this be measles? Amoxicillin Allergy Rash

9 Could this be measles? Amoxicillin Allergy Rash Strep Rash

10 Could this be measles? Amoxicillin Allergy Rash Measles Rash Strep Rash

11 Fever, the 3 C s and Rash

12 Measles Rash

13 Measles Control in Minnesota Kathryn Como-Sabetti, MPH Epidemiology Supervisor, Emerging Infections Program

14 Measles Control: Childcare and School Exclusion CDC and the AAP recommend susceptible individuals exposed to measles be excluded from schools, childcare, and health care settings for 21 days from exposure. The purpose is to limit exposures if the individual becomes infectious with measles (before or with prodromal symptoms). MDH collaborates with impacted schools and childcare to implement exclusion. Excluded individuals are instructed to call either MDH (24/7 number provided) or health care provider before seeking health care

15 Minnesota Department of Health Approach to Exclusion Used MN Immunization Information Connection (MIIC) to determine MMR history. Children with one MMR before or within 3 days of first exposure were considered non-susceptible. Parent/guardians of children excluded were contacted by phone. Implemented blanket exclusions when >1 case was identified in the same childcare and around the same time. All susceptible/ exposed children excluded from the last day of exposure at the childcare. When 1 case, only children attending same day as the case attended and was infectious were excluded Used established relationships through annual immunization reporting requirements and years of enhanced outreach. Involved partners: Department of Human Services, Minnesota Department of Education, Minnesota Minority Childcare Association

16 Implementation: Complicating factors Record keeping for many childcare centers was poor Complex message: different recommendations for children within the same household, timing of vaccination Communication challenging: language barriers, delivering a message no one wants to hear Exclusion caused serious hardship for many families Legal consultation necessary

17 Exclusion Implementation: The Tale of Two Childcares 10 of 15 childcares where cases attended had >25% of children with no MMR vaccination Childcares where cases were often are open on weekends, some providing 24/7 care Children in childcares where cases attended often attended additional childcare centers and/or schools

18 Childcare A Compliant Childcare provided roster and vaccination history immediately MDH was able to implement prompt exclusions Only secondary cases, no 3 rd or 4 th generations

19 Childcare A Compliant Childcare provided roster and vaccination history immediately MDH was able to implement prompt exclusions Only secondary cases, no 3 rd or 4 th generations Text Key Color Key P Primary case Primary case DC Daycare 2 nd generation HH Household 3 rd generation C Community 4 th generation SC School 5 th generation th generation

20 Childcare B Non Compliance Approximately two weeks to receive full roster Cases reported to MDH and were not on the initial childcare roster Required intervention by licensing

21 Childcare B Non Compliance Approximately two weeks to receive full roster Cases reported to MDH and were not on the initial childcare roster Required intervention by licensing Text Key Color Key P Primary case Primary case DC Daycare 2 nd generation HH Household 3 rd generation C Community 4 th generation SC School 5 th generation th generation

22 Contacts: Exposures and Exclusions Total health care and child care exposures: 8,490 Schools involved : 6 Child care centers involved : 12 Total exclusions associated with this outbreak: 649 Excluded from health care: 63 Excluded from school/child care: 507 Excluded due to being a case: No legal orders were necessary >8490 exposed contacts identified ~700 (8%) Susceptible >600 excluded from public settings 155 received PEP

23 Measles Inpatients--Clinical Picture Miserable, lethargic, listless Oropharyngeal erythema, mouth sores Koplik spots Dehydrated, dysphagia, admitted for IVF Febrile, fever control Otitis Media, strep, pneumonia Need for oral or IV antibiotics Atelectasis, oxygen Viral co-infections Last night was a nightmare in seeing my kids so helpless puking, can t sleep, fever, crying, not drinking, not even able to cry tears

24 Implemented HICS System Day 1- Ramp up, ramp down as needed

25 Hospital Incident Command System- HICS

26 Measles Cases Children s Minnesota 2011 March Outbreak cared for 12 of the 21 cases August Outbreak cared for index case below who survived 15 days on a ventilator in PICU. Mom requests his picture shown

27 How does HICS help in a Measles outbreak? Adds organization to a chaotic situation Clarifies leadership structure Fosters clear communication, internally and externally Ensures event documentation Fully engages responders Allows clinicians to be clinicians Garners internal resources quickly Sets as an organizational priority Defines clear accountability Declares this is not business as usual people!

28 Measles Outbreak Status State: 79 total cases - 70 in Hennepin County - 73 confirmed unvaccinated - 74 in children - 65 Somali Minnesotan Children s: 42 tested at Children s 53 cared for at Children s - Median age 3 yrs (range 10 mos-14 yrs) 21 children hospitalized 100% at Children s One child re-hospitalized for pneumonia for 22 hospitalizations - Average length of stay 4 days (range 2 d-17 d)

29 Number Measles Confirmed Cases Measles Outbreak Children's Minnesota Confirmed Cases by Admission Status Collection Date Yes (Current) Yes (Past) No

30 Number Measles Ruled Out Cases 2017 Measles Outbreak Children's Minnesota Negative Results by Collection Date 181 tested and ruled out Collection Date

31 Children s Measles Exposures Children s: 745 pediatric total exposures - ED-M (638) - Clinic-M (64) - 7 th -M Med/Surg (20) - 7 th -M Hem/Onc (23) most received IVIG 173 PEP eligible PEP given (80%) 489 letters sent Just 2 people who were exposed got Measles and both were adults 1 HCW and 1 Mom who thought she had been vaccinated or had disease as a child

32 Measles Exposures Vaccine Status 2017 Measles Outbreak Children's Minnesota Exposures by MMR status 42% 26% 3% 29% 0 MMR Immunocompromised (any dose) 1 MMR 2 MMR

33 Measles Post-Exposure Prophylaxis

34 PEP Plan Setting up the call bank Time is of the essence

35 Management of ED patients Pivot nurse role was instrumental to limiting exposures Implemented universal masking of all patients/family Developed ED screening tool to be more inclusive of patients without a history of travel Added shortcut to state vaccine registry to triage form in EMR, required check at pivot/triage Immediately roomed patients in AII room that met screening criteria

36 Universal Masking Requirement