A Series of Unfortunate Events: 1 Hospitalized Measles Case Leads to More Than 1,000 Exposures

September 4th, 2015

There are accidents and then there is the docking of the Hindenburg.

There are maddening, laborious measles exposure incidents in hospitals and then there is the epic disaster that unfolded in May of 2014 at Inova Health System in Fairfax, VA. A cautionary tale on steroids, here is what can happen if you are not prepared to deal with a 3-year-old child from India admitted with upper respiratory symptoms.

“It was a Sunday afternoon around three and our on-call infection preventionist got a call that we had a confirmed case of measles in our children’s hospital,” said Dana Cole, MPH, CIC, an infection preventionist at Inova who described the incident recently in Nashville at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). “He was admitted [directly] to our pediatric surgical unit so we were relieved he didn’t come through the ED.”

However, the first red light was already blinking about the timing of the call.

“He had been admitted to pediatric urgent care the Thursday prior to this phone call -- so he had been in the hospital four days,” she said.

A pediatric infectious disease consult had been done but the patient was put in droplet precautions, a step down from the airborne precautions warranted for measles. One confounder might have been that the child’s immunizations appeared up to date, but a rubeola IgM test was ordered as part of the differential diagnosis and the patient developed the classic rash on day three of admission. Again, infection prevention was not notified and the call that came in four days after the admission was a notification of confirmed measles by the health department.

“Another [factor] is that the Inova health care system does not currently require any proof of immunity or vaccination for vaccine preventable diseases with the exception of influenza,” Cole said, drawing a few gasps out of the APIC audience.

For the rest of this story see the October 2015 issue of Hospital Employee Health