1. Measles victim leaves house despite warning
The Register-Guard
Measles victim leaves house despite warning
Lessons Learned From A Measles Outbreak
Juventila Liko, MD, MPH
Oregon Public Health Division
Martha deBroekert, RN, BSN
Lane County Public Heatlh
Four people exposed to measles have agreed to be quarantined for 21 days.

2. Objectives Review Oregon’s recent measles trends
Summarize control measures necessary to limit disease spread in an unimmunized population
Present pre-outbreak policies needed to control disease outbreaks

3. Reported Measles Cases, Oregon, 1920-2007
16,000
12,000
8,000
4,000
Cases
Reported Measles Cases, Oregon,
Vaccine Licensed
1 Dose School
Immunization
Requirement
2 Dose School
Immunization
Requirement

4. Incidence of Measles Oregon vs. Nationwide, 1995-2007
U.S.

5. Age Distribution of Measles Cases, Oregon, 1997-2007

6. Reported Measles Cases by Country of Importation, Oregon, 2000-2007

7. High Population Immunity in Oregon
First dose coverage > 89% for month-old children
First dose coverage > 96% for children attending preschool
Second dose coverage > 96% for kindergarteners
Second dose coverage > 98% for 7th
graders

8. Adults at Increased Risk for Measles
College students
International travelers
Health-care personnel
All persons who work in medical facilities should be immune to measles
2 doses

9. Measles Basics Control measures
Post-exposure vaccination within 72 hours provides protection
IG for immunosuppressed, pregnant or infants within 6 days of exposure
In health care
Exclude susceptibles from day 5 through day 21 after exposure

10. Oregon Measles Outbreak, June 2007
21 year old healthy unvaccinated male
Prodrome on 5/20/2007
Rash onset on 5/25/07
Hx Tokyo x 2mos; arrived in Oregon 5/22/07
Hospitalized on 5/26/07 and initially not isolated

11. Challenges Delayed isolation of the index case at the hospital
Shared ventilation among case’s room and other
hospital units
Limited documentation of measles immunity among
health care workers
Inappropriate discharge of case into community while
still infectious
Airline exposures
Exposures among a community of unimmunized
peers
Withholding of information and non-compliance with
voluntary home isolation

12. Possible airflow exposure in the hospital ?
Single air handling system
Air flow had a mixture of about 20% outside air and 80% recyclable air
90-95 % effective filtration; no HEPA filter
On the same flow system: PCU/ER (where case was housed but not isolated), Cardiac Unit and Mother Baby Unit

13. Measles Disease in Health-Care Workers
HCWs at higher risk for measles
-13-fold elevated risk among HCWs
- Nosocomial transmission in 5% of cases
Of these, 38% among HCWs
- 84% unvaccinated
- 28% hospitalized
- 3 died
- Nosocomial transmission in 14% of cases with known source
2005
- Impact of an infected employee to the hospital: $113,647

14. Recommendations: 3 Tiers of contact investigation at the hospital:
HCWs in direct contact; patients in the waiting room and ER; HH contacts and close friends
HCWs in units affected by the air flow
High-risk patients( pregnant moms, babies, immunocompromised) affected by the air flow
- Review vaccination status
- Get titers if documentation incomplete
- Exclude non-immune from days 5-21 after exposure

15. Potential Exposures on Airplane

16. Possible second case of measles eyed
The Register-Guard
Possible second case of measles eyed
Public Health officials diagnosed a young man on May 29
with measles and urged him to stay home until he got well.
Both men came from families who do not believe in measles
vaccinations, and "who don't think measles are a big deal.“
That night, the man caught a hip-hop show and went
drinking afterward at a downtown bar. The next night,
he went out for sushi.

17. Measles victim leaves house despite warning
The Register-Guard
Measles victim leaves house despite warning
Quarantine is hitherto the surest means of hindering the spread of the disease. Peter Panum, M.D, 1846
Voluntary Home Confinement order created
Old bill did not work very well in Oregon
- very weak & fragmented
- failed to provide tools that would be essential in addressing outbreaks
- did not contemplate group quarantine
New bill (HB 2185) went into effect on 1/1/2008
- strengthens and clarifies PH authority
- clearly describes procedures, standards and conditions
- better “due process” and recognition of individuals rights
- contemplate group quarantine

18. Lane County Measles Outbreak June 2007

19. Impact of Two Measles Cases in 2007
LHD
- ICS
- 2 cases & 1 suspect
-168 contacts investigated
-90% were immune
- 4 shots given
- $50,000
State
- AOC
- $20,000
Hospital
- ICS
titers (in a 2 wk period)
- 97% of HCWs were immune
-Cost of titers $40,000
-10 HCWs on furlough for several days
-3 HCWs on furlough for 21 days
- 63 shots given
- Now immunity to measles required
- Infection education module updated
- Isolation & transferring process reviewed
-$100,000

20. Recommendations
Consider using quarantine orders and the new quarantine process as outlined in the new bill (HB 2185) to minimize the risk of spreading the virus
Consider taking legal action when cases are non-compliant with public health investigation
Develop education materials with clear, relevant messages targeting vaccine-hesitant communities affected by the outbreak
Continue efforts to ensure networking with the alternative medical community
Expand use of digital communications for public information
Continue to promote measles vaccination among healthcare workers in Oregon

21. SUMMARY
The limited extent of this outbreak highlights the high level of population immunity achieved in Oregon.
This outbreak and its impact could have been limited by adherence to ACIP recommendations for measles vaccination of high-risk adults.

22. Lane County Public Health Depart.
Acknowledgements
Lane County Public Health Depart.
Paul Cieslak, MD
Martha Skiles, MPH
Michelle Barber, MS
Maria Grumm, RN, MPH
Maureen Cassidy, MPH Cathy Stone, BS, MT, CIC
Charles LeBaron, MD
Susan Reef, MD
Susan Redd, MD
Preeta Kutty, MD
John M. Kobayashi, MD

23. THANK YOU