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Nosocomial measles infection in a pediatric hospital during a community-wide epidemic
Nosocomial measles infection in a pediatric hospital during a community-wide epidemic M a r t h a Elisa Rivera, MD, Wilbert Henry Mason, MD, L a w r e n c e Alan Ross, MD, a n d Harry Tucker Wright, Jr., MD, MPH From the Department of Pediatrics, Division of Infectious Diseases, Childrens Hospital of Los Angeles and University of Southern California School of Medicine, Los Angeles
From Jan. I, 1988, through Dec. 31, 1988, a total of 89 cases of measles were observed at Childrens Hospital of Los Angeles, and 37 patients were admitted to the hospital. Of the 37 patients, six were not initially thought to have measles, which resulted in exposure of 107 patients and 24 personnel. Of the exposed patients, measles d e v e l o p e d in four. One nosocomially infected infant died of pneumonia. Another exposed patient was subsequently admitted to another hospital with unrecognized measles, which led to exposure of an additional eight patients. Of seven employees in whom measles developed, two required hospitalization because of pneumonia. Two hundred eleven e m p l o y e e days were lost because of measles exposure or infection. Infection control interventions included prophylaxis of exposed patients, e m p l o y e e education, and measles immunization for susceptible personnel. Of 1103 hospital personnel considered susceptible to measles, 800 received monovalent measles vaccine. No secondary cases of measles occurred in hospital personnel who received appropriate prophylaxis. We conclude that infection control programs aimed at mandating measles immunity in hospital employees at risk should be instituted. (J PEDIATR4991;119:183-6)
Despite the introduction of measles vaccine in the United States in 1963, outbreaks continue to occur, especially in large urban areas. 1 Such an outbreak has occurred in Los Angeles County since 1988. 2 Although measles transmission in recent years has occurred mainly in schools or at home, 4 as many as 3% to 5% of cases have resulted from nosocomial transmission to susceptible patients and employees in a variety of medical settings. 3, 5-12 We describe the impact of a measles epidemic in Los Angeles County on a children's hospital and how infection control measures were implemented to impede the spread of measles to both susceptible patients and employees.
BACKGROUND In 1988 a measles outbreak occurred in Los Angeles County; a provisional total of 513 cases was reported to the Los Angeles County Public Health Department between Jan. 1, 1988, and December 31, 1988. 2 Sixty-three percent of the patients reported were younger than 5 years, and 42% were 15 months of age or younger. At Childrens Hospital of Los Angeles (CHLA), a 331-bed urban pediatric teaching hospital, 89 cases of measles were identified in 1988.
See related articles, pp. 187 and 322. METHODS
Submitted for publication June 15, 1990; accepted Feb. 21, 1991. Reprint requests: Martha E. Rivera, MD, Division of Infectious Diseases, Childrens Hospital of Los Angeles, 4650 Sunset Blvd., Box 51, Los Angeles, CA 90027.
9/20/28998
Epidemiologic investigation. Medical records of patients with suspected measles were reviewed for clinical or serologic confirmation of the diagnosis. Measles was diagnosed in patients having an acute febrile illness with morbilliform
183
! 84
Rivera et al.
The Journal of Pediatrics August 1991
89 Cases - M e a s l e s
37 H o s p i t a l i z e d
52
not H o s p i t a l i z e d
I 6 cases Inappropriately
31 cases Respiratory Isolation
Isolated
Unknown
I
J
78 P a t i e n t
I
3 Nosocomial Measles Cases w i t h No Subsequent Exposures
IE x p o s u r e s I
Exposures
Unknown # Hospital Personnel E x p o s e d
I
1 Nosocomial Measles Case J
Exl~
14 Patients
One 2 ~ M e a s l e s
Case
I
4 Measles Cases from Patient Exposure
2 Measles Cases from Household Exposure
15 P a t i e n t s
1 Unknown Source
Exposed
No 2 ~ M e a s l e s
Cases
Figure. Schematic representation of hospital exposures from cohort of 89 patients with measles. or maculopapular rash (persisting for 3 or more days), cough, coryza, conjunctivitis, or Koplik spots. Patients and employees were considered susceptible to measles if they were born after 1956 and had not had physician-diagnosed measles or received live measles vaccine after 12 months of age. The'same criteria for measles susceptibility were applied to patients who were immunodeficient as to those who were immunocompetent. A search of personnel records was undertaken to identify susceptible employees, that is, those born after 1956, with no documentation of immunization with live measles vaccine or physician-diagnosed measles. Measles exposure was considered to have occurred in patients and personnel when they were in contact with persons in whom measles was ultimately diagnosed and who were not in respiratory isolation at the time of contact. Patients and employees present on the same ward area (including contiguous units) with a patient with measles were considered exposed. 6 After the first case of nosocomial measles was recognized, the hospital infection control officer and the department of quality assurance developed a protocol aimed at controlling
the further spread of measles to susceptible patients and employees. Prophylaxis for exposed susceptible patients was carried out in three ways as recommended in the Report of the Committee on Infectious Disease of the American Academy of Pediatrics ~: h Monovalent measles vaccine was given to children 6 to 12 months of age. 2. Measles-mumps-rubellavaccine was given to children older than 12 months. 3. Patients from birth to 6 months of age who were exposed received intramuscularly administered 3`-globulin. 4. When live vaccines were contraindicated, 3`-globulin was administered intramuscularly. The infection control program for hospital employees included vaccination and education. Monovalent measles vaccine was recommended for exposed susceptible hospital personnel if exposure was within 72 hours. If the exposure was assessed to have been between 72 hours and 6 days, "7globulin was given intramuscularly in an effort to prevent or modify the infection.13 An extensive educational program was initiated that included instructions to hospital
Volume 119 Number 2
admitting personnel and ward staff on the recognition and appropriate isolation of patients with measles.
Nosocomial measles in a pediatric hospital
Table. Patients seen at Childrens Hospital of Los Angeles with measles-1988 No. of patients
RESULTS From Jan. I, 1988, to Dec. 31, 1988, a total of 89 cases of measles were observed at C H L A (Figure). Sixty-two percent of patients were _< 15 months of age (Table). The age and gender distribution and ethnic background were similar' to those in the community as reported by the Los Angeles County Department of Health Services. 2 Thirtyseven patients were admitted to the hospital; of these, six were not recognized as having measles at the time of admission. The admitting diagnoses of these six patients were sepsis, pneumonia, bacteremia, esophagitis, roseola infantum, and mastoiditis. Lack of appropriate respiratory isolation of these patients led to exposure of susceptible patients and employees. Seventy-eight patients susceptible to measles were exposed to five of the six patients who were not appropriately isolated. An accurate assessment of exposures to the sixth patient was not available; this patient was first seen in the prodromal stage without rash, and many of the exposed patients were discharged home before the diagnosis of measles was established. During the study period, seven hospital personnel had measles. Four cases resulted from exposure to patients, two occurred after household exposure, and a rotating surgical resident acquired the illness from an unknown source. A nurse had atypical measles after contact with a patient with acquired immunodeficiency syndrome with unrecognized measles, and a radiology technician was infected in the radiology suite by a child with unrecognized measles. These two hospital employees required hospitalization because of respiratory complications, including the nurse who had atypical measles. All hospital employees who acquired measles were born after 1956. The hospital employees who acquired measles subsequently exposed an additional 15 hospitalized patients, none of whom acquired measles. A 10-month-old girl hospitalized with intractable diarrhea of infancy was exposed in a waiting room area to a child with unrecognized measles. Measles-related pneumonia developed in the girl and she subsequently died. She exposed an additional 14 susceptible hospitalized patients, one of whom acquired measles. Therefore a total of 107 susceptible hospitalized patients are known to have been exposed to measles during 1988. A teenage girl exposed to measles before discharge from C H L A was admitted to another hospital with fever and uncontrolled diabetes mellitus. Her febrile illness was subsequently diagnosed as measles, and during the admission she exposed eight additional patients.
185
Age (mo) 0-6 7-12 13-15 >15 Gender Male Female Ethnicity Hispanic Black White Asian
10 33 12 34 89 54 35 50 23 12 4
Of our 107 exposed patients, 54 received prophylaxis: 3'globulin was given intramuscularly to 31 patients, and measles vaccine, monovalent or combined with mumps and rubella vaccines, was administered to 9 patients; an additional 14 patients received prophylaxis, but the type was not specified in the medical record. Measles was not recognized in the patients who received prophylaxis. Of the 53 patients who received no prophylaxis, 4 secondary cases of measles occurred, for an attack rate of 7.5%. A hospital-wide measles vaccination program was begun in September 1988. A complete search of personnel records revealed that 1108 employees were born after 1956, and these individuals were interviewed regarding measles susceptibility. Approximately 800 doses of monovalent measles vaccine were administered to hospital personnel. Susceptible employees who received measles vaccination within 72 hours from the time of exposure were permitted to continue their regular work schedule; however, susceptible employees were precluded from work if they did not receive active immunization within 72 hours. No secondary cases of measles occurred in personnel who received appropriate prophylaxis. The major cost associated with measles control was related to removing the exposed employees (17) from work during the incubation period for measles (days 8 to 18 after exposure) or when they had acquired measles (7). Their job descriptions included nurse (13), lab technician (2), radiology technician (2), clerical staff (5), respiratory therapist (1), and physician (1). Twenty-four hospital employees were furloughed from work either because of having measles or because of measles exposure and lack of appropriate prophylaxis. Two hundred eleven employee-days were lost because of measles exposure or acquisition of the disease.
18 6
Rivera et aI.
The estimated cost to the hospital for time lost by employees who were susceptible to measles or who acquired measles was $18,000. The estimated cost of vaccine and gammaglobulin was $10,750. After the hospital-wide vaccination program and educational activities, 10 children were admitted with measles. Despite educational efforts, one patient was admitted with unrecognized measles and was not appropriately isolated. Thirty-two susceptible patients were exposed to measles, but no susceptible hospital personnel were exposed and no case of measles occurred with these exposures. DISCUSSION Transmission of measles virus in medical settings appears to be an important factor in ongoing outbreaks. Airborne transmission of measles was documented in a physician's office more than an hour after the index case had left the location. 6 The frequency of measles cases transmitted in medical settings has increased from 0.7% of the total number of reported cases in 1980 to 5% in 1985, 6.8% in 1986, and 17% in 1990. 6, 11, 12 From 1980 through 1984, a total of 241 persons with measles in 30 states were identified as probably having acquired the infection in a medical facility. 9 In Los Angeles County, 30% of the measles cases identified in 1988 were acquired in medical settings) Patients who acquire measles while hospitalized tend to be very young children or adults. These age groups tend to have higher rates of complications and mortality) The introduction of measles in our hospital resulted in four cases of infection among patients, with one death, and seven cases among personnel, two of whom required hospitalization, Interhospital measles exposure also occurred. The secondary attack rate of measles within our institution in patients who did not receive prophylaxis was 7.5%. This low rate is likely related to mild exposure. To maintain optimal infection control, all patients hospitalized on the same or contiguous wards of an inadequately isolated patient with measles were deemed exposed. Many of these exposures were likely of low intensity. Hospital personnel born before t957 are generally considered to be immune to measles because of natural infection. Although recent data suggest that many health care workers born before 1957 lack serologic evidence of measles immunity,14 none of the employees who acquired measles in this study were born before 1957. This report demonstrates the serious consequences related to transmission of measles in a hospital setting. A number of factors contributed to this phenomenon, includ-
The Journal of Pediatrics August 1991
ing (1) misdiagnosis or delayed diagnosis of measles, which prevented rapid institution of control measures, (2) a greater number of patients with measles seeking medical attention and requiring hospitalization, and (3) the presence of a number of susceptible medical personnel who escaped natural measles infection and were either unvaccinated or inadequately vaccinated, The risk of nosocomial measles in a hospital can be reduced by (1) infection control programs mandating measles immunization in new hospital employees born since 1956 who lack documentation of prior immunization or disease, (2) effective outpatient triage and prompt isolation of patients with suspected measles in separate rooms so that they do not sit in open waiting rooms, and (3) identification of susceptible patients and employees as soon as a suspected case of measles is seen so that appropriate and timely prophylactic measures can be initiated. REFERENCES
1. Markowitz LE, Preblud SR, Orenstein WA, et al. Patterns of transmission in measles outbreaks in the United States, 19851986. N Engl J Med 1989;320:75-81. 2. Measles--Los Angeles County, California, 1988. MMWR 1989;38-:49-52. 3. Bloch AB, Orenstein WA, Ewing WM, et al. Measles outbreak in a pediatric practice: airborne transmission in an office setting. Pediatrics 1985;75:676-83. 4. Measles--United States, 1983. MMWR 1984;33:105-8. 5. Hayden GF, Orenstein WA. Measles and rubella viruses. In: Donowitz LG, ed. Hospital acquired infections in the pediatric patient. Baltimore, Williams and Wilkins, 1988:218-25. 6. Remington PL, Hail WN, Davis IH, eta]. Airborne transmission of measles in a physician's office. JAMA 1985;253: 1574-7. 7. Measles--Hawaii. MMWR 1984;33:702;707-1 I. 8. Dales LG, Kizer KW. Measles transmission in medical facilities. West J Med 1985;142:415-6. 9. Davis RM, Orenstein WA, Frank JA, et al. Transmission of measles in medical settings, 1980 through 1984. JAMA 1986; 25:1295-8. 10. Foulon G, Cottin JF, Matheron S, et al. Transmission and severity of measles acquired in medical settings. JAMA 1986; 256:1135-6. 11. Raad I1, Sherety R J, Rains CS, et al. The importance of nosocomial transmission of measles in the propagation of a community outbreak. Infect Control Hosp Epidemiol 1989; 10:1616. 12. Measles--Washington, 1990. MMWR 1990;39:473-6. 13. Measles. Report of the Committee on Infectious Diseases, ed 21. Elk Grove Village, 111.:American Academy of Pediatrics, 1988:277-89. 14. Smith E, Welch W, Berhow M. Measles susceptibility of hospital employees as determined by ELISA [Abstract]. Clin Res 1990;38:183A.
From Jan. I, 1988, through Dec. 31, 1988, a total of 89 cases of measles were observed at Childrens Hospital of Los Angeles, and 37 patients were admitted to the hospital. Of the 37 patients, six were not initially thought to have measles, which resulted in exposure of 107 patients and 24 personnel. Of the exposed patients, measles d e v e l o p e d in four. One nosocomially infected infant died of pneumonia. Another exposed patient was subsequently admitted to another hospital with unrecognized measles, which led to exposure of an additional eight patients. Of seven employees in whom measles developed, two required hospitalization because of pneumonia. Two hundred eleven e m p l o y e e days were lost because of measles exposure or infection. Infection control interventions included prophylaxis of exposed patients, e m p l o y e e education, and measles immunization for susceptible personnel. Of 1103 hospital personnel considered susceptible to measles, 800 received monovalent measles vaccine. No secondary cases of measles occurred in hospital personnel who received appropriate prophylaxis. We conclude that infection control programs aimed at mandating measles immunity in hospital employees at risk should be instituted. (J PEDIATR4991;119:183-6)
Despite the introduction of measles vaccine in the United States in 1963, outbreaks continue to occur, especially in large urban areas. 1 Such an outbreak has occurred in Los Angeles County since 1988. 2 Although measles transmission in recent years has occurred mainly in schools or at home, 4 as many as 3% to 5% of cases have resulted from nosocomial transmission to susceptible patients and employees in a variety of medical settings. 3, 5-12 We describe the impact of a measles epidemic in Los Angeles County on a children's hospital and how infection control measures were implemented to impede the spread of measles to both susceptible patients and employees.
BACKGROUND In 1988 a measles outbreak occurred in Los Angeles County; a provisional total of 513 cases was reported to the Los Angeles County Public Health Department between Jan. 1, 1988, and December 31, 1988. 2 Sixty-three percent of the patients reported were younger than 5 years, and 42% were 15 months of age or younger. At Childrens Hospital of Los Angeles (CHLA), a 331-bed urban pediatric teaching hospital, 89 cases of measles were identified in 1988.
See related articles, pp. 187 and 322. METHODS
Submitted for publication June 15, 1990; accepted Feb. 21, 1991. Reprint requests: Martha E. Rivera, MD, Division of Infectious Diseases, Childrens Hospital of Los Angeles, 4650 Sunset Blvd., Box 51, Los Angeles, CA 90027.
9/20/28998
Epidemiologic investigation. Medical records of patients with suspected measles were reviewed for clinical or serologic confirmation of the diagnosis. Measles was diagnosed in patients having an acute febrile illness with morbilliform
183
! 84
Rivera et al.
The Journal of Pediatrics August 1991
89 Cases - M e a s l e s
37 H o s p i t a l i z e d
52
not H o s p i t a l i z e d
I 6 cases Inappropriately
31 cases Respiratory Isolation
Isolated
Unknown
I
J
78 P a t i e n t
I
3 Nosocomial Measles Cases w i t h No Subsequent Exposures
IE x p o s u r e s I
Exposures
Unknown # Hospital Personnel E x p o s e d
I
1 Nosocomial Measles Case J
Exl~
14 Patients
One 2 ~ M e a s l e s
Case
I
4 Measles Cases from Patient Exposure
2 Measles Cases from Household Exposure
15 P a t i e n t s
1 Unknown Source
Exposed
No 2 ~ M e a s l e s
Cases
Figure. Schematic representation of hospital exposures from cohort of 89 patients with measles. or maculopapular rash (persisting for 3 or more days), cough, coryza, conjunctivitis, or Koplik spots. Patients and employees were considered susceptible to measles if they were born after 1956 and had not had physician-diagnosed measles or received live measles vaccine after 12 months of age. The'same criteria for measles susceptibility were applied to patients who were immunodeficient as to those who were immunocompetent. A search of personnel records was undertaken to identify susceptible employees, that is, those born after 1956, with no documentation of immunization with live measles vaccine or physician-diagnosed measles. Measles exposure was considered to have occurred in patients and personnel when they were in contact with persons in whom measles was ultimately diagnosed and who were not in respiratory isolation at the time of contact. Patients and employees present on the same ward area (including contiguous units) with a patient with measles were considered exposed. 6 After the first case of nosocomial measles was recognized, the hospital infection control officer and the department of quality assurance developed a protocol aimed at controlling
the further spread of measles to susceptible patients and employees. Prophylaxis for exposed susceptible patients was carried out in three ways as recommended in the Report of the Committee on Infectious Disease of the American Academy of Pediatrics ~: h Monovalent measles vaccine was given to children 6 to 12 months of age. 2. Measles-mumps-rubellavaccine was given to children older than 12 months. 3. Patients from birth to 6 months of age who were exposed received intramuscularly administered 3`-globulin. 4. When live vaccines were contraindicated, 3`-globulin was administered intramuscularly. The infection control program for hospital employees included vaccination and education. Monovalent measles vaccine was recommended for exposed susceptible hospital personnel if exposure was within 72 hours. If the exposure was assessed to have been between 72 hours and 6 days, "7globulin was given intramuscularly in an effort to prevent or modify the infection.13 An extensive educational program was initiated that included instructions to hospital
Volume 119 Number 2
admitting personnel and ward staff on the recognition and appropriate isolation of patients with measles.
Nosocomial measles in a pediatric hospital
Table. Patients seen at Childrens Hospital of Los Angeles with measles-1988 No. of patients
RESULTS From Jan. I, 1988, to Dec. 31, 1988, a total of 89 cases of measles were observed at C H L A (Figure). Sixty-two percent of patients were _< 15 months of age (Table). The age and gender distribution and ethnic background were similar' to those in the community as reported by the Los Angeles County Department of Health Services. 2 Thirtyseven patients were admitted to the hospital; of these, six were not recognized as having measles at the time of admission. The admitting diagnoses of these six patients were sepsis, pneumonia, bacteremia, esophagitis, roseola infantum, and mastoiditis. Lack of appropriate respiratory isolation of these patients led to exposure of susceptible patients and employees. Seventy-eight patients susceptible to measles were exposed to five of the six patients who were not appropriately isolated. An accurate assessment of exposures to the sixth patient was not available; this patient was first seen in the prodromal stage without rash, and many of the exposed patients were discharged home before the diagnosis of measles was established. During the study period, seven hospital personnel had measles. Four cases resulted from exposure to patients, two occurred after household exposure, and a rotating surgical resident acquired the illness from an unknown source. A nurse had atypical measles after contact with a patient with acquired immunodeficiency syndrome with unrecognized measles, and a radiology technician was infected in the radiology suite by a child with unrecognized measles. These two hospital employees required hospitalization because of respiratory complications, including the nurse who had atypical measles. All hospital employees who acquired measles were born after 1956. The hospital employees who acquired measles subsequently exposed an additional 15 hospitalized patients, none of whom acquired measles. A 10-month-old girl hospitalized with intractable diarrhea of infancy was exposed in a waiting room area to a child with unrecognized measles. Measles-related pneumonia developed in the girl and she subsequently died. She exposed an additional 14 susceptible hospitalized patients, one of whom acquired measles. Therefore a total of 107 susceptible hospitalized patients are known to have been exposed to measles during 1988. A teenage girl exposed to measles before discharge from C H L A was admitted to another hospital with fever and uncontrolled diabetes mellitus. Her febrile illness was subsequently diagnosed as measles, and during the admission she exposed eight additional patients.
185
Age (mo) 0-6 7-12 13-15 >15 Gender Male Female Ethnicity Hispanic Black White Asian
10 33 12 34 89 54 35 50 23 12 4
Of our 107 exposed patients, 54 received prophylaxis: 3'globulin was given intramuscularly to 31 patients, and measles vaccine, monovalent or combined with mumps and rubella vaccines, was administered to 9 patients; an additional 14 patients received prophylaxis, but the type was not specified in the medical record. Measles was not recognized in the patients who received prophylaxis. Of the 53 patients who received no prophylaxis, 4 secondary cases of measles occurred, for an attack rate of 7.5%. A hospital-wide measles vaccination program was begun in September 1988. A complete search of personnel records revealed that 1108 employees were born after 1956, and these individuals were interviewed regarding measles susceptibility. Approximately 800 doses of monovalent measles vaccine were administered to hospital personnel. Susceptible employees who received measles vaccination within 72 hours from the time of exposure were permitted to continue their regular work schedule; however, susceptible employees were precluded from work if they did not receive active immunization within 72 hours. No secondary cases of measles occurred in personnel who received appropriate prophylaxis. The major cost associated with measles control was related to removing the exposed employees (17) from work during the incubation period for measles (days 8 to 18 after exposure) or when they had acquired measles (7). Their job descriptions included nurse (13), lab technician (2), radiology technician (2), clerical staff (5), respiratory therapist (1), and physician (1). Twenty-four hospital employees were furloughed from work either because of having measles or because of measles exposure and lack of appropriate prophylaxis. Two hundred eleven employee-days were lost because of measles exposure or acquisition of the disease.
18 6
Rivera et aI.
The estimated cost to the hospital for time lost by employees who were susceptible to measles or who acquired measles was $18,000. The estimated cost of vaccine and gammaglobulin was $10,750. After the hospital-wide vaccination program and educational activities, 10 children were admitted with measles. Despite educational efforts, one patient was admitted with unrecognized measles and was not appropriately isolated. Thirty-two susceptible patients were exposed to measles, but no susceptible hospital personnel were exposed and no case of measles occurred with these exposures. DISCUSSION Transmission of measles virus in medical settings appears to be an important factor in ongoing outbreaks. Airborne transmission of measles was documented in a physician's office more than an hour after the index case had left the location. 6 The frequency of measles cases transmitted in medical settings has increased from 0.7% of the total number of reported cases in 1980 to 5% in 1985, 6.8% in 1986, and 17% in 1990. 6, 11, 12 From 1980 through 1984, a total of 241 persons with measles in 30 states were identified as probably having acquired the infection in a medical facility. 9 In Los Angeles County, 30% of the measles cases identified in 1988 were acquired in medical settings) Patients who acquire measles while hospitalized tend to be very young children or adults. These age groups tend to have higher rates of complications and mortality) The introduction of measles in our hospital resulted in four cases of infection among patients, with one death, and seven cases among personnel, two of whom required hospitalization, Interhospital measles exposure also occurred. The secondary attack rate of measles within our institution in patients who did not receive prophylaxis was 7.5%. This low rate is likely related to mild exposure. To maintain optimal infection control, all patients hospitalized on the same or contiguous wards of an inadequately isolated patient with measles were deemed exposed. Many of these exposures were likely of low intensity. Hospital personnel born before t957 are generally considered to be immune to measles because of natural infection. Although recent data suggest that many health care workers born before 1957 lack serologic evidence of measles immunity,14 none of the employees who acquired measles in this study were born before 1957. This report demonstrates the serious consequences related to transmission of measles in a hospital setting. A number of factors contributed to this phenomenon, includ-
The Journal of Pediatrics August 1991
ing (1) misdiagnosis or delayed diagnosis of measles, which prevented rapid institution of control measures, (2) a greater number of patients with measles seeking medical attention and requiring hospitalization, and (3) the presence of a number of susceptible medical personnel who escaped natural measles infection and were either unvaccinated or inadequately vaccinated, The risk of nosocomial measles in a hospital can be reduced by (1) infection control programs mandating measles immunization in new hospital employees born since 1956 who lack documentation of prior immunization or disease, (2) effective outpatient triage and prompt isolation of patients with suspected measles in separate rooms so that they do not sit in open waiting rooms, and (3) identification of susceptible patients and employees as soon as a suspected case of measles is seen so that appropriate and timely prophylactic measures can be initiated. REFERENCES
1. Markowitz LE, Preblud SR, Orenstein WA, et al. Patterns of transmission in measles outbreaks in the United States, 19851986. N Engl J Med 1989;320:75-81. 2. Measles--Los Angeles County, California, 1988. MMWR 1989;38-:49-52. 3. Bloch AB, Orenstein WA, Ewing WM, et al. Measles outbreak in a pediatric practice: airborne transmission in an office setting. Pediatrics 1985;75:676-83. 4. Measles--United States, 1983. MMWR 1984;33:105-8. 5. Hayden GF, Orenstein WA. Measles and rubella viruses. In: Donowitz LG, ed. Hospital acquired infections in the pediatric patient. Baltimore, Williams and Wilkins, 1988:218-25. 6. Remington PL, Hail WN, Davis IH, eta]. Airborne transmission of measles in a physician's office. JAMA 1985;253: 1574-7. 7. Measles--Hawaii. MMWR 1984;33:702;707-1 I. 8. Dales LG, Kizer KW. Measles transmission in medical facilities. West J Med 1985;142:415-6. 9. Davis RM, Orenstein WA, Frank JA, et al. Transmission of measles in medical settings, 1980 through 1984. JAMA 1986; 25:1295-8. 10. Foulon G, Cottin JF, Matheron S, et al. Transmission and severity of measles acquired in medical settings. JAMA 1986; 256:1135-6. 11. Raad I1, Sherety R J, Rains CS, et al. The importance of nosocomial transmission of measles in the propagation of a community outbreak. Infect Control Hosp Epidemiol 1989; 10:1616. 12. Measles--Washington, 1990. MMWR 1990;39:473-6. 13. Measles. Report of the Committee on Infectious Diseases, ed 21. Elk Grove Village, 111.:American Academy of Pediatrics, 1988:277-89. 14. Smith E, Welch W, Berhow M. Measles susceptibility of hospital employees as determined by ELISA [Abstract]. Clin Res 1990;38:183A.