Elsevier

Vaccine

Volume 37, Issue 14, 28 March 2019, Pages 1905-1909
Vaccine

Short communication
Hospital outbreak of measles – Evaluation and costs of 10 occupational cases among healthcare worker in Germany, February to March 2017

https://doi.org/10.1016/j.vaccine.2019.02.068Get rights and content

Highlights

  • During a nosocomial measles outbreak, 10 healthcare workers (HCW) contracted measles.

  • None of the affected HCW had direct contact to the index patient.

  • The economic impact of the outbreak is estimated to approximately 700,000€.

  • The cause of the outbreak was the fact that HCW were unvaccinated.

Abstract

After treatment of an inpatient with measles, an outbreak occurred within the unprotected healthcare workers (HCW) of a regional hospital in Hesse, Germany in February and March 2017. Overall, 10 HCW contracted measles. Remarkably, none of the affected HCW had direct contact to the index patient. One nosocomial transmission to a patient occurred. The economic impact of the outbreak is estimated to approximately 700,000€.

Medical institutions play a major role in the management of measles outbreaks, since the risk of exposure as well as nosocomial transmission to vulnerable patients and HCW is very high. To avoid outbreaks it is essential to have an easily accessible documentation of the immune-status of all HCW. The role of occupational medicine in identifying and closing vaccination gaps is of particular importance.

Introduction

Measles is a vaccine-preventable disease with one of the highest basic reproduction numbers (R0 = 15–18) and a contagion- and manifestation-index near 100%. Thus, anyone without immunity acquired by either vaccination or prior infection will contract measles and develop the characteristic symptoms: rash and fever. Prior to the onset of rash Koplik spots, which are pathognomonic for measles, might appear on the buccal mucosa [1].

Back in 1998, the World Health Organization (WHO) had already proclaimed the goal to eliminate measles in Europe which had to be postponed several times [2]. Germany still struggles to reach the elimination goal for measles [3], [4].

Recently, health-care facilities turned out to be major sites of acquisition of measles and numerous studies have shown that measles are transmitted from patients to health care workers (HCW) and from HCW to patients and colleagues [5], [6], [7]. The risk to contract measles has been estimated to be 2- to 19-times higher for HCW than for the general public [8].

Vaccinations for HCW are not mandatory in Germany. However, the “Infection Protection Act” with §23a regulates the use of data from vaccination documents and lab results of the immune status of HCW [9]. Despite this, data about the vaccination status are still not collected on a regular basis. The “German Standing Committee on Vaccination (STIKO)” at Robert Koch-Institute recommends one dose of MMR for HCW born after 1970 without vaccination, with only one vaccination in childhood or a vaccination status that is uncertain [10].

This article describes an outbreak of measles among HCW from February to March 2017 at a regional hospital in the German federal state Hesse.

Section snippets

Materials and methods: Chronology of the outbreak and measurements for controlling the outbreak

On January 31, 2017, a patient with laboratory confirmed measles was announced by a local health protection agency to hospital A (650 beds) for admission. Hospital A is one of three sites of a hospital composite being under one management. The other two sites in different cities (B and C) were not affected by the outbreak.

The patient (later defined as index case) was treated and cared for only by HCW with evidence of vaccination. During treatment, HCW wore personal protective equipment (coat,

Control measures related to HCW and strategy choice

Documentation of the immune status of HCW was scarce and divided into written files and an electronic database. The infection control team and the occupational health physician checked the available data; however, a reliable assessment of immunity to measles could only be given for less than 5% of the HCW. To ensure patients were only treated by measles-immune HCW, the following two strategies were therefore considered:

  • Checking vaccination certificates, performing MMR-vaccination in case of

Control measures related to patients

To detect nosocomial measles infections and avoid future nosocomial transmissions, measles-IgG and -IgM were determined for inpatients: first the test was performed for individuals treated in the intensive-care unit, the maternity ward and oncology ward. Later on, all other inpatients were tested as well. Patients with a measles IgG < 200 mIU/ml were offered the MMR-vaccine (no contra-indication provided), and a protective reverse isolation was implemented. Patients with an equivocal or

Characteristics of HCW

Overall, 1691 HCW are employed at Hospital A: 244 physicians, 769 nursing staff, 340 in other patient-related services and 338 in services not related to patients. The mean age was 42 years (17–69 years). Hospital B and C have 606 HCW, resulting in a total of 2297 HCW.

Serologic test results

Between February 16 and February 27, 2017, measles IgG were tested for 1443 (85.3%) of 1691 employees of hospital A. For 248 HCW (14.6%) the test was not performed due to absence during the time of the outbreak. Testing for

Discussion

This report describes a measles outbreak in a German hospital that could have been prevented. To protect non-immune patients from measles, vaccination of the HCW is of utmost importance. To guarantee immediate ability to act in cases of suspected measles infection admitted into hospitals and other medical facilities, the knowledge of the occupational health physician about the vaccination status of all HCW is indispensable.

A recent study calculated that if the vaccination coverage drops by only

Conflict of interest

Ute Hiller and Norbert Köneke: No conflict of interest.

Acknowledgement

The authors would like to thank Josephin Mosch for her editorial support.

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