The Unfortunate Return of Measles: What EMS Providers Need to Know

In the year 2000, not that long ago, measles was declared eliminated in the United States. Now, unfortunately, in 2014–15 it is back. What happened? And how do we respond?

Since 2000, just a few cases have occurred in the U.S., the result of visitors from foreign countries that do not have strong vaccine and immunization programs. These are referred to as “imported cases” and are reported to the public health department, where contact follow-up is conducted. In recent years cases have been brought to this country by travelers from England, France, Germany and India. In 2014 cases were imported from the Philippines and Vietnam.

Now more cases are occurring, the result of communities in the U.S. with unvaccinated people. Prevention of measles by vaccine has been available in this country since 1963. Prior to the availability of the vaccine, about 3–4 million people acquired measles each year. Of those, 400–500 died and more than 48,000 required hospitalization. Of the severely ill, up to 1,000 developed chronic disability as a result of acute encephalitis. Many people today are unaware of this significant data.

It was this type of data that led to the development of an effective vaccine and the passage of state laws requiring vaccination of children for entry to school. All 50 states have some requirements for vaccinations prior to entry to school, but many have exemptions. Also, studies have shown that people who are opposed to vaccinating their children tend to group together in communities. This can lead to outbreaks if one person develops measles within the group.

The most recent outbreak to make the news began from December 28, 2014 to February 13, 2015. This outbreak appears to have been started by a traveler who acquired the disease overseas and then visited Disneyland in California. This resulted in approximately 114 cases in seven states (California, Colorado, Nebraska, Utah, Oregon, Washington and Arizona). By February 27 the numbers had increased to 170 cases in 17 states and the District of Columbia. About 125 cases were related to exposure at Disneyland. Outbreaks in Illinois, Nevada and Washington were not.

What Is Measles?

Measles is caused by an RNA virus with only one serotype. Humans are the only known host for this virus. This illness presents with the “3 C’s”: cough, coryza and conjunctivitis. This is accompanied by fever, malaise and the development of a rash. The rash is often the last symptom to appear. It starts on the head and travels downward. The most significant sign for measles is the presence of Koplik spots (whitish-grey spots) that appear on the buccal mucosa.

Measles can be transmitted by air and is considered a highly communicable disease. The virus resides in the nose and throat and is transmitted by coughing and sneezing. It can survive up to two hours on a surface and in the airspace where an infected person coughed or sneezed. About 90% of persons exposed will develop the disease.

The incubation period is 7–21 days after exposure. Rash may not be present until 14 days. A patient is considered contagious from four days before until four days after the rash appears.

Prevention

Your best protection: If not already protected by having had the disease, get vaccinated. All fire/EMS personnel need to obtain their vaccine and health records for review to ascertain who needs the vaccine for pre-exposure protection. Vaccination for all healthcare providers is recommended by the Centers for Disease Control and Prevention (CDC), and that is being enforced by the Occupational Safety and Health Administration (OSHA). Also, the need for vaccine history and the vaccination of unprotected personnel is addressed in NFPA 1581: Standard on Fire Department Infection Control.

All employers of healthcare providers are required to offer the vaccine free of charge to employees. At this point employees and volunteers are permitted to decline but must sign a declination form. Declination forms are important, as they document that the employer made the offer to vaccinate. Remember that declination forms do not remove employee rights.

The vaccine is safe and effective. It’s a two-dose series vaccine, and the doses should be administered at least 28 days apart. After one dose, a person has a 93% level of protection. Two doses yield a 99% protective level. If you were born after 1957 and cannot provide proof of vaccination, you should receive one dose of vaccine. If you were born between 1963–67 and vaccinated, you need to be revaccinated with two doses of live-measles vaccine. This is because the vaccine administered during those years was a killed-virus vaccine and has been shown not to be effective.

The vaccine administered today is a live-virus vaccine combined with vaccines for mumps and rubella (MMR). As this is a live-virus vaccine, women of childbearing age are advised not to become pregnant for four weeks after each dose. This counseling should be documented in writing.

Secondary Protection

Get travel histories and assess signs and symptoms. If a patient presents with fever and a rash, have them wear a surgical mask. If you cannot mask the patient, place a surgical mask on yourself.

Under the emergency responder provisions of Part G of the Ryan White law, medical facilities must notify the designated infection control officer (DICO) if they receive a patient from emergency responders who has or is suspected of having an airborne- or droplet-transmissible disease. On November 2, 2011, the CDC published a specific list of diseases covered by this requirement, and it includes measles. Such notification provides an opportunity for the employers of emergency responders who have been exposed to measles to provide postexposure follow-up if necessary.

Postexposure Treatment

If a medical facility receives a patient known or suspected to have measles, a representative is required to notify the DICO for the transporting unit. The DICO will then interview the crew to determine if an unprotected exposure occurred.

If an unprotected exposure occurred, the MMR vaccine should be administered with 72 hours of the exposure event if there is no evidence of immunity. Immunoglobulin (IG) can be administered within six days. The recommended dose of IG given IM is 0.5 mL/kg of body weight. Individuals at high risk for developing measles (pregnant women, the immunocompromised) who have no evidence of immunity should be offered immunoglobulin in IV form. Immunoglobulin offers temporary protection, usually for 3–6 months.

Nonimmune healthcare workers will also need to be placed on work restriction from days 5–21 after exposure, even if postexposure medication is administered. If this is job-related, it’s covered by workers’ compensation. If it’s not job-related, the use of sick time will be required.

Cost

Protection by vaccination is a personnel benefit. It also serves to protect coworkers and patients we serve. Vaccination before an exposure occurs is cost-effective. Time off, workers’ compensation and replacement costs far outweigh the cost of vaccination for unprotected healthcare workers.

The practice of medicine tells us that we are to first do no harm. This applies not only to patients, but also to coworkers, family and self.

References

• Kutty P, Rota J, et al. Chapter 7: “Measles.” In: Roush SW, Baldy LM, eds. Manual for the Surveillance of Vaccine-Preventable Diseases. Atlanta: Centers for Disease Control and Prevention, 2008.

• Zipprich J, Winter K, Hacker J, et al. Measles Outbreak—California, December 2014–February 2015. MMWR, 2015 Feb 27; 64(6): 53–54.

• Centers for Disease Control and Prevention. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practice (ACIP), https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.

• Ryan White HIV/AIDS Treatment Extension Act of 2009. Public Law 111-87, October 30, 2009.

• Centers for Disease Control and Prevention. Implementation of Section 2695 (42 U.S.C. 300ff-131) of Public Health Law 111-87: Infectious Diseases and Circumstances Relevant to Notification Requirements. Federal Register, 2011 Nov 2; 76(212): 67,736–43.

• National Fire Protection Association. NFPA 1581: Standard on Fire Department Infection Control Program.

Katherine West, RN, BSN, MSEd, is an infection-control consultant with Infection Control/Emerging Concepts in Manassas, VA, and a member of the EMS World editorial advisory board. She's also a featured speaker at EMS World Expo, Sept. 15–19 in Las Vegas. Visit EMSWorldExpo.com.