A rash case Infection control management of measles 23 th June 2013 PanCeltic Meeting Dr Jo Hargreaves Microbiology SpR University Hospital of Wales, Cardiff
Acknowledgements Dr Harriet Hughes Nicola Bevan, Occupational Health Virology Department Dr Eleri Davies Infection Control Team
Case presentation 2011 35 year old man from Welsh valleys Admitted via A&E on Friday evening Unwell for 5 days Anorexia, malaise, coryzal symptoms, dry cough, diarrhoea 1 day: fever, headache, photophobia Normally fit and well Occupation: I drink
Examination Fever 38.8 C Tachycardic Sats 98% on air Cardiovascular and respiratory exams NAD No signs of Chronic Liver Disease Slight neck stiffness Photophobia
Investigations Hb 16.4 WCC 8.3 Plts 156 U&E Alb 35 ALT 82 ALP 66 NAD CRP 174 CXR old rib fractures
Differential diagnosis Atypical pneumonia Exclude meningitis Viral illness
What was done next Cefotaxime + clarithromycin commenced Atypical pneumonia screen sent Urine legionella antigen sent CT + LP prominent cerebellar folia; inflammatory change within maxillary antrum LP: NAD No improvement over weekend CRP 330 BE -7, HCO3 17
Call to ID registrar 35 year old man admitted on Friday with fever, headache, diarrhoea and a cough. Not responding to cefotaxime and clarithromycin. Now has a rash.
Further history elicited Widespread rash developed over weekend Not left Wales for 16 years Mostly drinks at home + one pub 2 female partners in 3 years last UPSI casual partner 2-3 months previously One daughter aged 4 living locally No contacts with other children Unknown vaccination history No known contact with rash illness
Revised Differential Diagnosis Measles HIV seroconversion Secondary syphilis Atypical pneumonia
Clinical Diagnosis: Measles High clinical suspicion No epidemiological link Investigations Urgent buccal swab for measles PCR to Colindale Measles IgM (3 days after rash onset) HIV and syphilis testing Immediate actions Communication with A&E staff Infection control Public Health notified on clinical suspicion Occupational Health informed Measles PCR positive confirmed within 24 hours HPA National Measles Guidance Local & Regional Services, October 2010 HPA Post Exposure Prophylaxis for Measles guidelines
Why all the fuss? Airborne or droplet transmission Highly contagious Incubation period of 7-18 days; rash 2-4 days into illness Infective: 4 days before to 4 days after rash Healthcare worker incubating virus may transmit Vulnerable population Possible intervention Pre-emptive MMR x2 Post-exposure vaccination with MMR or HNIG
Urgently Identify and assess contacts for Post Exposure Prophylaxis Limited patient contact as isolated on admission HCW exposed as no PPE used Should have used respiratory precautions Identify high risk individuals for HNIG Has there been a significant exposure? Patient infectious from time of admission until day of meeting Immunocompetent: face-to-face contact or 15 minutes exposure Immunocompromised: very low threshold Is the exposed individual likely to be susceptible? Born before 1970: presumed natural immunity Born since 1970: assess susceptibility CCDC + WAG informed MDT Meeting Microbiology/Virology, Infection control, Public Health, Occupational Health, A&E Staff representative
Health Care Workers: the strategy Satisfactory evidence of protection Documentation of 2 MMRs and/or positive measles antibody test and/or born before 1970 Continue working Advised to report to OH if develop symptoms No evidence of protection Measles IgG testing Exclude from work from 5 th day after exposure Give 1x MMR Return to work after 21 days after final exposure or earlier if IgG positive at least 14 days after MMR given Complete course of MMR Exclude from work if ill with symptoms or rash until 4 days after onset of rash
Hospital contacts 18 tested immune 3 tested Non-immune 5 knew immune 4 Born before 1970 2 pregnant tested immune 8 knew immune 2 tested immune 10 Doctors 0 Other patients 32 Nurses Patient 2 Radiographers 2 Ambulance crew Born before 1970
Health Care Workers: the reality Infection control Poorly adherent to PPE Poor awareness of need for protection Not engaging with Infection Control to list contacts Occupational Health Low awareness of vaccination status amongst nursing staff Poor documentation within occupational health notes 7% of HCW tested were non-immune : reflects local rates Better awareness of vaccination status amongst doctors Anxiety regarding MMR Blame regarding potential staff shortages Already pressurized environment
Substantial Cost Our trust Contact tracing of 40+ hospital contacts Exclusion from work of 3 full time nurses Time of many teams Could have been worse
Recommendations at the time Consider increasing the frequency of Occupational Health review particularly for long term staff. Target high risk areas e.g. paediatrics, A&E, haematology Current drives to vaccinate HCWs against influenza could be used as a stepping stone to improving rates of vaccination for other communicable diseases. Consider having minor incident training.
Situation now Nearby large outbreak Public Health Wales National Advice for Measles Occupational Health Have been trying to vaccinate staff, but it is not mandatory Less than 10% are Ig G negative Well over 50% do not know their vaccination status Would like to test Ig G pre-employment No Data
Public Health Wales National Advice for MeaslesAdvice for Healthcare Workers (HCW) All HCW should be aware of their vaccination status. This is their responsibility. Those not aware, or who have not had 2 doses of measles vaccine, should seek vaccination as soon as possible. Immunocompetent HCW born before 1970 or who have a documented history of MMR x2 should be considered immune. Immunocompromised HCW should be assessed individually Health care workers in contact with a possible case of measles should discuss with their local Infection Control team and Occupational Health. ALL STAFF SHOULD BE ADVISED, if fever or symptoms of measles develop within 21 days of contact, irrespective of vaccine history, to stop work and report to OH immediately History of significant contact (see definitions) Born before 1970 OR documented history of MMR x2 No further action required. Offer MMR if requested by HCW Not pregnant AND not immunocompromised Send blood for urgent measles IgG testing (see separate algorithm) Offer prophylactic MMR within 3 days. MMR may be offered beyond three days to provide protection from subsequent exposures. Measles IgG POSITIVE No further action and no requirement for exclusion from work No documented history of 2x MMR AND born 1970 onwards Pregnant OR immunocompromised OR allergy to MMR Do not give MMR Send blood for urgent measles IgG testing (see separate algorithm) Assess need for HNIG (see separate guidance) Measles IgG NEGATIVE Exclude from work from 5th day after initial exposure to 21 days after final exposure May resume work earlier if measles IgG positive 14 days post MMR immunisation
Learning Points Only a brief encounter is needed to put others at risk of measles Education of front door staff is paramount Adherence to simple infection control principles is vital Isolate Use respiratory precautions HCW should know their own vaccination or immune status MMR vaccination of HCW should be undertaken Excellent communication between all teams is required during such incidents
Would you have done anything differently?