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Chronology of a hospital-wide measles outbreak: Lessons learned and shared from an extraordinary week in late March 1989
P R A C T I C E FORUM
C h r o n o l o g y of a h o s p i t a l - w i d e m e a s l e s o u t b r e a k : Lessons l e a r n e d a n d s h a r e d f r o m an e x t r a o r d i n a r y w e e k in late March 1989 Elliot L. Rank, PhD" Lee Brettman, MD b Harry Katz-Pollack, MD b Deborah DeHertogh, MD b David Neville, BS c Hartford, Connecticut
In March 1989, Mount Sinai Hospital, a communityhospital in Hartford, Connecticut, faced a potential hospital-wide outbreak of measles when eight cases of measles occurred among medical personnel during several days. This article describes the chronologyof events, from the initial discoveryof the outbreak to the evolutionof the hospital-wide containment program designed to protect patients and staff members. Measles IgG immune status was determined for 1249 employees during a 9-day period. Measles vaccine and immune serum globulin were administered to patients and employees.We offer advice from our experience for infection control practitioners who may face outbreak situations in their institutions. (AJIC AMJ INFECTCONTROL1992;20:315-8)
Measles, a highly infectious childhood exanthem, is preventable by the administration of trivalent measles-mumps-rubella vaccine or monovalent measles preparations. It is spread by a i r b o r n e droplets or direct contact with respiratory secretions. The incubation period ranges from 8 to 13 days to the onset of fever to 14 days for the development of the rash. Measles is communicable from the p r o d r o m e period until 4 days after the rash appears. Vaccine, available by the early 1960s, eliminated the cycle of epidemics. 1 Some vaccine preparations were deficient in specific measles antigenic components. Recipients acquired antibodies to measles but were still unprotected. 2 Typical and atypical measles have been documented in people previously i m m u n i z e d with these defective vaccines. 3-6 Adults are conFrom the Departments of Pathology,a MedicineP and Epidemiology,~ Mount Sinai Hospital, Hartford, Connecticut. Reprint requests: Elliot L. Rank, PhD, Mount Sinai Hospital, Department of Pathology, 500 Blue Hills Ave., Hartford, CT 06112.
17/49/36703
sidered n o n i m m u n e to measles virus if they were born after J a n u a r y 1, 1957, and received one of these vaccine preparations in childhood. 7' 8 FRIDAY: M A R C H 17, 1 9 8 9
A 20-year-old male hospital security guard saw his physician because of malaise, fever, and a body rash. The physician m a d e a clinical diagnosis of measles. SATURDAY: M A R C H 18, 1 9 8 9
A 32-year-old male medical resident was seen in the emergency room. Two weeks previously a diagnosis of pityriasis rosea, a mild rash of limited duration, h a d been made. The resident continued to work. His symptoms worsened but were attributed to a cold. The infectious disease physician (IDP) m a d e the diagnosis of measles. A 28-yearold female medical resident was seen in the emergency room for a rash attributed to a drug reaction. Two days earlier she had noted coryza and a sore throat. She received amoxicillin and continued to work. The IDP diagnosed measles.
315
AJIC 316
December 1992
R a n k et al.
Her symptoms included a fever of 104 ° F, lymphadenopathy, conjunctivitis, cough, malaise, and the measles rash. A medical student who rotated through the hospital was seen at another local hospital, where measles was diagnosed. The medical residents were sent home to prevent further exposure of hospital personnel and patients. Their serologic titers for antimeasles IgM antibody, performed within 36 hours, measured 1:25,000 and 1:5200. Titer results, determined later in the week, were positive for the medical student and the security guard. The epidemiology section of the Connecticut State Department of Health was advised of the potential for a hospital-wide outbreak of measles on the basis of the two cases found in our medical residents. The Department immediately released ampoules of vaccine to begin vaccinations. The hospital epidemiology team determined that one of the infected medical residents had visited every hospital area within the preceding 72 hours. Personnel in the proximity of the medical resident were telephoned late Saturday and asked whether they recalled having measles or receiving the measles vaccine. Recollection of personal histories for measles is an unreliable method. 9 Individuals born before January 1, 1957, were considered immune. The incubation period for measles was calculated for each person on the basis of the number of elapsed days since exposure to the infected medical residents. SUNDAY: MARCH 19, 1 9 8 9
Limited vaccinations began for staff members. Immunocompromised patients and patients with AIDS were given immune serum globulin. Monovalent measles vaccine was given to patients who had HIV antibody but did not have symptoms of AIDS. MONDAY: MARCH 20, 1 9 8 9
A containment strategy was devised by a task force that included representatives from the departments of medicine, infectious diseases, epidemiology, emergency, personnel, public relations, laboratory, management information services, nursing affairs, payroll, and finance. The primary goal was identification of employees who were immune to measles and able to care for high-risk patients in obstetric, oncology, and pediatric wards. It was presumed that nonimmune staff members and patients were in the incubation stage of measles. The following strategy was implemented: (1) measles immunity status was determined for all
employees born after January 1, 1957, (2) measles vaccine was administered to all employees born on or after January 1, 1957, (3) serologically immune staff members cared for patients known or presumed to be nonirnmune and those born before 1954, and (4) patients born after January 1, 1954, and uncompromised patients (all older than 35 years) were cared for by vaccinated, healthy, staff members younger than 35 years. Nonimmune staff members who showed signs of the prodrome were furloughed with pay. The viral serology laboratory at the Connecticut State Department of Health (VLCSDH) aided in testing employee sera. Patients treated in the obstetricsgynecology and pediatric clinics, the emergency department, day health, and the community health • center were sent letters warning of the possible exposure to measles. The hospital auditorium was transformed into a processing center. Phlebotomists and laboratory personnel drew blood for measles immunity testing. Nurses administered vaccine injections. The epidemiologists, social workers, and utilization review people counseled employees about contraindications to the vaccine such as pregnancy, allergies, and immunodeficiency. P r e g n a n t employees were exempted from vaccination; pregnancy tests were administered to all women with uncertain pregnancy status. Each employee labeled a blood tube and a request form with last name, first name, and middle initial; sex, age, social security number, and birth date were also recorded on the request form. In the laboratory, serum was decanted from the clotted blood specimens, necessitating relabeling of serum tubes. Approximately 250 sera were transported to the VLCSDH, where the serum tubes and their accompanying forms were realigned for identification purposes. Testing began the next morning. We learned that a 40-year-old male employee of our institution was f o u n d at another hospital to have measles. Because this person was born before January 1, 1957, we expanded the measles immunity testing to include all employees regardless of age. Three clinical cases of measles were diagnosed in hospital employees during the course of this day, all were in persons older than 35 years. There were eight measles cases related to our hospital. TUESDAY: MARCH 21, 1989
Employees from the night shift were vaccinated early in the morning. Hospital personnel were aware of the serious implications of the outbreak
Volume 20 Number 6
and reported for vaccination even if it was their day off. Counselors determined that m a n y employees were vaccinated because of fear of contracting measles and transmitting the disease to their families. In all, 450 employees were vaccinated on this day of operation. Confusion emerged over w h e t h e r employees with no direct patient contact needed a measles immunity test performed, because they posed no direct risk to patients. A positive titer result allowed the staff m e m b e r access to all hospital areas. A negative result, or no s e r u m titer, restricted that employee to confined hospital areas, with furloughs for those in w h o m cold symptoms were evident. Thus all subsequent employees were tested but w e never determined the n u m b e r of untested persons. Two hospital floors w e r e designated for the cohort of n o n c o m p r o m i s e d patients 35 years of age or older, to be cared for by healthy, vaccinated staff m e m b e r s younger than 35 years. Other floors were assigned for oncology, obstetrics, immunocompromised, and pediatric patients, w h o were paired with seropositive, staff m e m b e r s 35 years of age or older. Measles titer results for the first 250 sera w e r e k n o w n by early Tuesday afternoon and the cohort system was then put in place. Matching the measles immunity result to an employee n a m e on a department list was difficult. Initial lists were outdated, inaccurate, or incomplete. Volunteers scrutinized lists to locate specific names. The payroll and m a n a g e m e n t information services departments were delegated to create an accurate computer listing of all employees. The reasons were varied for not being able to match an employee's measles immunity result with a name on a department list. Lists contained misspelled names. Transcription errors occurred in labeling the second serum test tube. Computer input errors occurred in forming the data base master list. Married or divorced w o m e n were listed by their maiden names. Hyphenated surnames appeared b e c a u s e of ethnic custom, marriage, or personal preference. Nicknames were used rather than a formal names, or vice versa. First and last names were reversed on the request form. Identical names were encountered for related (without any added "junior" or "senior") and unrelated persons. Other names belonged to nonstaff people, including hospital visitors, patients whose samples were mixed in with the employee samples, medical students, students training in allied health fields, and contractual workers providing technical service.
Measles outbreak chronology
317
WEDNESDAY: MARCH 22, 1991
An account of the outbreak appeared in the local n e w s p a p e r ? ° The epidemiology team placed warning signs at each hospital entrance to indicate the presence of measles in the community and among the younger staff m e m b e r s of the hospital. Visitors were requested not to enter the hospital if they were suffering cold symptoms and were advised to consult their physicians about their o w n measles immunity status. The measles immunity results were reviewed for every batch of employee sera tested. We assumed that 10% to 15% of every b a t c h were seronegative (Mayo DR, VLCSDH, personal communication). The third batch of specimens showed a 30% seronegative rate and was retested. On retesting, seronegative percentages returned to normal. This delay deferred the w o r k assignments for a large n u m b e r of employees. The cohort assignment of employees and patients continued with the available results. THURSDAY: MARCH 23, 1991
Efforts were made to test the remaining employee sera. The next day was Good Friday. The VLCSDH laboratory would be closed through the weekend. All test results w e r e analyzed through the following day and cohort assignments were made. FRIDAY, MARCH 24, 1991
Hospital collection of employee sera continued through the following week. During a 9-day period, 1249 specimens w e r e tested for antimeasles IgG antibody. AFTERMATH
A second wave of measles cases was not seen. The cohort assignment continued until the incubation period passed the point b e y o n d which further measles transmission was no longer p o s sible. Staff m e m b e r s then returned to their usual positions. During the year, any employee rash was treated as a presumable case of measles until clinical and serologic assessments ruled this out. There were no further measles cases. CONCLUSIONS
The task force disseminated information to employees and quelled r u m o r s in an atmosphere of urgency; their input formulated the containment policy regarding employee assignments. Developments were discussed at scheduled meetings, with the IDP authorizing all final decisions. The primary goal was to protect susceptible
318
AJIC December 1992
R a n k et al.
patients a n d staff m e m b e r s . To t h a t end, m e a s l e s v a c c i n e was m a d e available a n d m e a s l e s i m m u n e testing b e g a n as a s e l e c t i o n m e c h a n i s m to determ i n e e m p l o y e e s c a p a b l e of c a r i n g for u n p r o t e c t e d patients. A n o m i n a l c o n t a i n m e n t p o l i c y to curtail a n o u t b r e a k m a y be as s i m p l e as the c r e a t i o n of a task f o r c e as a first r e s p o n s e . I n c l u d e t e l e p h o n e n u m b e r s of the i n f e c t i o n c o n t r o l p r a c t i t i o n e r , the IDP, a n d local, state, o r federal public h e a l t h officers. A c c u r a t e d e p a r t m e n t a l lists of e m p l o y e e n a m e s s h o u l d be u p d a t e d m o n t h l y a n d m a d e available to i n f e c t i o n c o n t r o l p r a c t i t i o n e r s to facilitate e m p l o y e e identification a n d r e s p o n s e in a n o u t b r e a k situation. Costs i n c u r r e d by the h o s p i t a l d u r i n g the outb r e a k i n c l u d e d f u r l o u g h s w i t h pay, staff r e d u c tions, i n c r e a s e d w o r k l o a d s , o v e r t i m e pay, a n d the m a t e r i a l costs for the s e r o l o g i c testing a n d vaccination programs. References
1. The National Advisory Committee. The measles epidemic: the problems, barriers, and recommendations. JAMA 1991;266:1547-52.
2. Merz DC, Scheid A, Choppin PW. ImPortance of antibodies to the fusion glycoprotein of paramyxoviruses in the prevention of spread of infection. J Exp Med 1980;151: 275-88. 3. Edmonson MB, Addiss DG, McPherson T, Berg JL, Circo SR, Davis JP. Mild measles and secondary vaccine failure during a sustained outbreak in a highly vaccinated population. JAMA 1990;263:2467-71. 4. Hersh BS, Markowitz LE, Hoffman RE, et al. A measles outbreak at a college with a prematriculation immunization requirement. Am J Public Health 1991;81: 360-4. 5. Sekla L, Stackiw W, Eibisch G, Johnson I. An evaluation of measles serodiagnosis during an outbreak in a vaccinated community. Clin Invest Med 1988;4:304-9. 6. Leibovici L, Sharir T, Kalter-Leibovici O, Alpert G, Epstein LM. An outbreak of measles among young adults. J Adolesc Health Care 1988;9:203-7. 7. Annunziato D, Kaplan MH, Hall WW, et al. Atypical measles syndrome: pathologic and serologic findings. Pediatrics 1982;70:203-9. 8. Centers for Disease Control. Measles prevention: recommendations of the immunization practices advisory committee (ACIP). MMWR 1989;38(S-9):1-17. 9. Scott RM, Buffer AB, Schydlower M, Rawlings P. Ineffectiveness of historical data in predicting measles susceptibility. Pediatrics 1984;73:777-80. 10. ffohnson J. Six Mount Sinai workers diagnosed as having measles. The Hartford Courant C1. 1989 March 22.
Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Mary Castle White, RN, MPH, PhD, 155 Mareton Ave., San Francisco, CA 94112.
C h r o n o l o g y of a h o s p i t a l - w i d e m e a s l e s o u t b r e a k : Lessons l e a r n e d a n d s h a r e d f r o m an e x t r a o r d i n a r y w e e k in late March 1989 Elliot L. Rank, PhD" Lee Brettman, MD b Harry Katz-Pollack, MD b Deborah DeHertogh, MD b David Neville, BS c Hartford, Connecticut
In March 1989, Mount Sinai Hospital, a communityhospital in Hartford, Connecticut, faced a potential hospital-wide outbreak of measles when eight cases of measles occurred among medical personnel during several days. This article describes the chronologyof events, from the initial discoveryof the outbreak to the evolutionof the hospital-wide containment program designed to protect patients and staff members. Measles IgG immune status was determined for 1249 employees during a 9-day period. Measles vaccine and immune serum globulin were administered to patients and employees.We offer advice from our experience for infection control practitioners who may face outbreak situations in their institutions. (AJIC AMJ INFECTCONTROL1992;20:315-8)
Measles, a highly infectious childhood exanthem, is preventable by the administration of trivalent measles-mumps-rubella vaccine or monovalent measles preparations. It is spread by a i r b o r n e droplets or direct contact with respiratory secretions. The incubation period ranges from 8 to 13 days to the onset of fever to 14 days for the development of the rash. Measles is communicable from the p r o d r o m e period until 4 days after the rash appears. Vaccine, available by the early 1960s, eliminated the cycle of epidemics. 1 Some vaccine preparations were deficient in specific measles antigenic components. Recipients acquired antibodies to measles but were still unprotected. 2 Typical and atypical measles have been documented in people previously i m m u n i z e d with these defective vaccines. 3-6 Adults are conFrom the Departments of Pathology,a MedicineP and Epidemiology,~ Mount Sinai Hospital, Hartford, Connecticut. Reprint requests: Elliot L. Rank, PhD, Mount Sinai Hospital, Department of Pathology, 500 Blue Hills Ave., Hartford, CT 06112.
17/49/36703
sidered n o n i m m u n e to measles virus if they were born after J a n u a r y 1, 1957, and received one of these vaccine preparations in childhood. 7' 8 FRIDAY: M A R C H 17, 1 9 8 9
A 20-year-old male hospital security guard saw his physician because of malaise, fever, and a body rash. The physician m a d e a clinical diagnosis of measles. SATURDAY: M A R C H 18, 1 9 8 9
A 32-year-old male medical resident was seen in the emergency room. Two weeks previously a diagnosis of pityriasis rosea, a mild rash of limited duration, h a d been made. The resident continued to work. His symptoms worsened but were attributed to a cold. The infectious disease physician (IDP) m a d e the diagnosis of measles. A 28-yearold female medical resident was seen in the emergency room for a rash attributed to a drug reaction. Two days earlier she had noted coryza and a sore throat. She received amoxicillin and continued to work. The IDP diagnosed measles.
315
AJIC 316
December 1992
R a n k et al.
Her symptoms included a fever of 104 ° F, lymphadenopathy, conjunctivitis, cough, malaise, and the measles rash. A medical student who rotated through the hospital was seen at another local hospital, where measles was diagnosed. The medical residents were sent home to prevent further exposure of hospital personnel and patients. Their serologic titers for antimeasles IgM antibody, performed within 36 hours, measured 1:25,000 and 1:5200. Titer results, determined later in the week, were positive for the medical student and the security guard. The epidemiology section of the Connecticut State Department of Health was advised of the potential for a hospital-wide outbreak of measles on the basis of the two cases found in our medical residents. The Department immediately released ampoules of vaccine to begin vaccinations. The hospital epidemiology team determined that one of the infected medical residents had visited every hospital area within the preceding 72 hours. Personnel in the proximity of the medical resident were telephoned late Saturday and asked whether they recalled having measles or receiving the measles vaccine. Recollection of personal histories for measles is an unreliable method. 9 Individuals born before January 1, 1957, were considered immune. The incubation period for measles was calculated for each person on the basis of the number of elapsed days since exposure to the infected medical residents. SUNDAY: MARCH 19, 1 9 8 9
Limited vaccinations began for staff members. Immunocompromised patients and patients with AIDS were given immune serum globulin. Monovalent measles vaccine was given to patients who had HIV antibody but did not have symptoms of AIDS. MONDAY: MARCH 20, 1 9 8 9
A containment strategy was devised by a task force that included representatives from the departments of medicine, infectious diseases, epidemiology, emergency, personnel, public relations, laboratory, management information services, nursing affairs, payroll, and finance. The primary goal was identification of employees who were immune to measles and able to care for high-risk patients in obstetric, oncology, and pediatric wards. It was presumed that nonimmune staff members and patients were in the incubation stage of measles. The following strategy was implemented: (1) measles immunity status was determined for all
employees born after January 1, 1957, (2) measles vaccine was administered to all employees born on or after January 1, 1957, (3) serologically immune staff members cared for patients known or presumed to be nonirnmune and those born before 1954, and (4) patients born after January 1, 1954, and uncompromised patients (all older than 35 years) were cared for by vaccinated, healthy, staff members younger than 35 years. Nonimmune staff members who showed signs of the prodrome were furloughed with pay. The viral serology laboratory at the Connecticut State Department of Health (VLCSDH) aided in testing employee sera. Patients treated in the obstetricsgynecology and pediatric clinics, the emergency department, day health, and the community health • center were sent letters warning of the possible exposure to measles. The hospital auditorium was transformed into a processing center. Phlebotomists and laboratory personnel drew blood for measles immunity testing. Nurses administered vaccine injections. The epidemiologists, social workers, and utilization review people counseled employees about contraindications to the vaccine such as pregnancy, allergies, and immunodeficiency. P r e g n a n t employees were exempted from vaccination; pregnancy tests were administered to all women with uncertain pregnancy status. Each employee labeled a blood tube and a request form with last name, first name, and middle initial; sex, age, social security number, and birth date were also recorded on the request form. In the laboratory, serum was decanted from the clotted blood specimens, necessitating relabeling of serum tubes. Approximately 250 sera were transported to the VLCSDH, where the serum tubes and their accompanying forms were realigned for identification purposes. Testing began the next morning. We learned that a 40-year-old male employee of our institution was f o u n d at another hospital to have measles. Because this person was born before January 1, 1957, we expanded the measles immunity testing to include all employees regardless of age. Three clinical cases of measles were diagnosed in hospital employees during the course of this day, all were in persons older than 35 years. There were eight measles cases related to our hospital. TUESDAY: MARCH 21, 1989
Employees from the night shift were vaccinated early in the morning. Hospital personnel were aware of the serious implications of the outbreak
Volume 20 Number 6
and reported for vaccination even if it was their day off. Counselors determined that m a n y employees were vaccinated because of fear of contracting measles and transmitting the disease to their families. In all, 450 employees were vaccinated on this day of operation. Confusion emerged over w h e t h e r employees with no direct patient contact needed a measles immunity test performed, because they posed no direct risk to patients. A positive titer result allowed the staff m e m b e r access to all hospital areas. A negative result, or no s e r u m titer, restricted that employee to confined hospital areas, with furloughs for those in w h o m cold symptoms were evident. Thus all subsequent employees were tested but w e never determined the n u m b e r of untested persons. Two hospital floors w e r e designated for the cohort of n o n c o m p r o m i s e d patients 35 years of age or older, to be cared for by healthy, vaccinated staff m e m b e r s younger than 35 years. Other floors were assigned for oncology, obstetrics, immunocompromised, and pediatric patients, w h o were paired with seropositive, staff m e m b e r s 35 years of age or older. Measles titer results for the first 250 sera w e r e k n o w n by early Tuesday afternoon and the cohort system was then put in place. Matching the measles immunity result to an employee n a m e on a department list was difficult. Initial lists were outdated, inaccurate, or incomplete. Volunteers scrutinized lists to locate specific names. The payroll and m a n a g e m e n t information services departments were delegated to create an accurate computer listing of all employees. The reasons were varied for not being able to match an employee's measles immunity result with a name on a department list. Lists contained misspelled names. Transcription errors occurred in labeling the second serum test tube. Computer input errors occurred in forming the data base master list. Married or divorced w o m e n were listed by their maiden names. Hyphenated surnames appeared b e c a u s e of ethnic custom, marriage, or personal preference. Nicknames were used rather than a formal names, or vice versa. First and last names were reversed on the request form. Identical names were encountered for related (without any added "junior" or "senior") and unrelated persons. Other names belonged to nonstaff people, including hospital visitors, patients whose samples were mixed in with the employee samples, medical students, students training in allied health fields, and contractual workers providing technical service.
Measles outbreak chronology
317
WEDNESDAY: MARCH 22, 1991
An account of the outbreak appeared in the local n e w s p a p e r ? ° The epidemiology team placed warning signs at each hospital entrance to indicate the presence of measles in the community and among the younger staff m e m b e r s of the hospital. Visitors were requested not to enter the hospital if they were suffering cold symptoms and were advised to consult their physicians about their o w n measles immunity status. The measles immunity results were reviewed for every batch of employee sera tested. We assumed that 10% to 15% of every b a t c h were seronegative (Mayo DR, VLCSDH, personal communication). The third batch of specimens showed a 30% seronegative rate and was retested. On retesting, seronegative percentages returned to normal. This delay deferred the w o r k assignments for a large n u m b e r of employees. The cohort assignment of employees and patients continued with the available results. THURSDAY: MARCH 23, 1991
Efforts were made to test the remaining employee sera. The next day was Good Friday. The VLCSDH laboratory would be closed through the weekend. All test results w e r e analyzed through the following day and cohort assignments were made. FRIDAY, MARCH 24, 1991
Hospital collection of employee sera continued through the following week. During a 9-day period, 1249 specimens w e r e tested for antimeasles IgG antibody. AFTERMATH
A second wave of measles cases was not seen. The cohort assignment continued until the incubation period passed the point b e y o n d which further measles transmission was no longer p o s sible. Staff m e m b e r s then returned to their usual positions. During the year, any employee rash was treated as a presumable case of measles until clinical and serologic assessments ruled this out. There were no further measles cases. CONCLUSIONS
The task force disseminated information to employees and quelled r u m o r s in an atmosphere of urgency; their input formulated the containment policy regarding employee assignments. Developments were discussed at scheduled meetings, with the IDP authorizing all final decisions. The primary goal was to protect susceptible
318
AJIC December 1992
R a n k et al.
patients a n d staff m e m b e r s . To t h a t end, m e a s l e s v a c c i n e was m a d e available a n d m e a s l e s i m m u n e testing b e g a n as a s e l e c t i o n m e c h a n i s m to determ i n e e m p l o y e e s c a p a b l e of c a r i n g for u n p r o t e c t e d patients. A n o m i n a l c o n t a i n m e n t p o l i c y to curtail a n o u t b r e a k m a y be as s i m p l e as the c r e a t i o n of a task f o r c e as a first r e s p o n s e . I n c l u d e t e l e p h o n e n u m b e r s of the i n f e c t i o n c o n t r o l p r a c t i t i o n e r , the IDP, a n d local, state, o r federal public h e a l t h officers. A c c u r a t e d e p a r t m e n t a l lists of e m p l o y e e n a m e s s h o u l d be u p d a t e d m o n t h l y a n d m a d e available to i n f e c t i o n c o n t r o l p r a c t i t i o n e r s to facilitate e m p l o y e e identification a n d r e s p o n s e in a n o u t b r e a k situation. Costs i n c u r r e d by the h o s p i t a l d u r i n g the outb r e a k i n c l u d e d f u r l o u g h s w i t h pay, staff r e d u c tions, i n c r e a s e d w o r k l o a d s , o v e r t i m e pay, a n d the m a t e r i a l costs for the s e r o l o g i c testing a n d vaccination programs. References
1. The National Advisory Committee. The measles epidemic: the problems, barriers, and recommendations. JAMA 1991;266:1547-52.
2. Merz DC, Scheid A, Choppin PW. ImPortance of antibodies to the fusion glycoprotein of paramyxoviruses in the prevention of spread of infection. J Exp Med 1980;151: 275-88. 3. Edmonson MB, Addiss DG, McPherson T, Berg JL, Circo SR, Davis JP. Mild measles and secondary vaccine failure during a sustained outbreak in a highly vaccinated population. JAMA 1990;263:2467-71. 4. Hersh BS, Markowitz LE, Hoffman RE, et al. A measles outbreak at a college with a prematriculation immunization requirement. Am J Public Health 1991;81: 360-4. 5. Sekla L, Stackiw W, Eibisch G, Johnson I. An evaluation of measles serodiagnosis during an outbreak in a vaccinated community. Clin Invest Med 1988;4:304-9. 6. Leibovici L, Sharir T, Kalter-Leibovici O, Alpert G, Epstein LM. An outbreak of measles among young adults. J Adolesc Health Care 1988;9:203-7. 7. Annunziato D, Kaplan MH, Hall WW, et al. Atypical measles syndrome: pathologic and serologic findings. Pediatrics 1982;70:203-9. 8. Centers for Disease Control. Measles prevention: recommendations of the immunization practices advisory committee (ACIP). MMWR 1989;38(S-9):1-17. 9. Scott RM, Buffer AB, Schydlower M, Rawlings P. Ineffectiveness of historical data in predicting measles susceptibility. Pediatrics 1984;73:777-80. 10. ffohnson J. Six Mount Sinai workers diagnosed as having measles. The Hartford Courant C1. 1989 March 22.
Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Mary Castle White, RN, MPH, PhD, 155 Mareton Ave., San Francisco, CA 94112.