Re: Measles epidemic exposes inadequate vaccination coverage in Pakistan
The North West of England is experiencing an unprecedented measles outbreak1 with 918 confirmed cases since January 2012. The impact on primary care has been vast but our experience suggests it could have been mitigated significantly by more rigorous isolation of suspected cases and by adherence to national policy for occupational health MMR vaccination2.
Non-immune health care workers (HCWs) exposed to measles can acquire and transmit infection to patients. They require exclusion from work from day’s 5-21 post-exposure3 thus depleting the NHS of valuable staff time. If immune status is unknown urgent serology is required before return to work. In the current North West outbreak at least 16 health care workers have developed measles and significant numbers of staff have been excluded from work.
In our experience few acute or community trusts have robust MMR vaccination programmes in place. They don’t appear to consider MMR an essential vaccination and when they do occupational health departments are stretched to deliver it. In primary care occupational health provision is primitive and neither GPs nor PCTs appear to see MMR vaccination as their responsibility. MMR vaccine costs £7 per dose with a similar cost for immunity testing – however this is relative to the cost of a member of staff being off for three weeks and potential transmission to vulnerable patients. Ultimately GP practices have a duty to protect their staff under health and safety legislation4.
Measles is highly infectious and viral particles can remain viable in the air for up to two hours5. Face to face contact or 15 minutes close proximity contact (e.g. in a GP or hospital waiting area) requires risk assessment for immunoglobulin prophylaxis6. In the North West outbreak failure to isolate suspect cases (i.e. patients with rash illness of possible infective origin) in GP or hospital waiting rooms has led to a significant number of secondary cases and to labour intensive contact tracing exercises. But why aren’t suspect cases isolated? It is a basic infection control principle but despite frequent communication with hospitals and GP Practices awareness has remained stubbornly low. Surprisingly some A&E departments don’t have an isolation room defined. Understandably measles may just be one of a myriad of competing priorities but we need improved systems at local level to engage and communicate with GP Practices and A&E Departments for communicable diseases.
Worryingly we suspect our experience would be replicated more widely. Why is measles so difficult? Let’s deliver MMR vaccination to our staff and protect our patients in waiting areas. Surely we can do better than this?
Kenneth Lamden consultant in health protection, Cumbria and Lancashire Health Protection Unit, Chorley, PR7 1NY, UK. Kenneth.lamden@hpa.org.uk
Roberto Vivancos regional epidemiologist, HPA North West, Liverpool L1 1JF.
Rosemary McCann consultant in health protection, Greater Manchester Health Protection Unit. Manchester M30 0NJ.
Sam Ghebrehewet consultant in health protection, Cheshire and Merseyside Health Protection Unit, Liverpool L1 1JF.
Competing interests:
No competing interests
15 February 2013
Kenneth H Lamden
Consultant in Health Protection
Roberto Vivancos, Rosemary McCann, Sam Ghebrehewet
Cumbria and Lancashire Health Protection Unit
York House, Ackhurst Business Park, Chorley, Lancashire PR7 1NY, UK
Rapid Response:
Re: Measles epidemic exposes inadequate vaccination coverage in Pakistan
The North West of England is experiencing an unprecedented measles outbreak1 with 918 confirmed cases since January 2012. The impact on primary care has been vast but our experience suggests it could have been mitigated significantly by more rigorous isolation of suspected cases and by adherence to national policy for occupational health MMR vaccination2.
Non-immune health care workers (HCWs) exposed to measles can acquire and transmit infection to patients. They require exclusion from work from day’s 5-21 post-exposure3 thus depleting the NHS of valuable staff time. If immune status is unknown urgent serology is required before return to work. In the current North West outbreak at least 16 health care workers have developed measles and significant numbers of staff have been excluded from work.
In our experience few acute or community trusts have robust MMR vaccination programmes in place. They don’t appear to consider MMR an essential vaccination and when they do occupational health departments are stretched to deliver it. In primary care occupational health provision is primitive and neither GPs nor PCTs appear to see MMR vaccination as their responsibility. MMR vaccine costs £7 per dose with a similar cost for immunity testing – however this is relative to the cost of a member of staff being off for three weeks and potential transmission to vulnerable patients. Ultimately GP practices have a duty to protect their staff under health and safety legislation4.
Measles is highly infectious and viral particles can remain viable in the air for up to two hours5. Face to face contact or 15 minutes close proximity contact (e.g. in a GP or hospital waiting area) requires risk assessment for immunoglobulin prophylaxis6. In the North West outbreak failure to isolate suspect cases (i.e. patients with rash illness of possible infective origin) in GP or hospital waiting rooms has led to a significant number of secondary cases and to labour intensive contact tracing exercises. But why aren’t suspect cases isolated? It is a basic infection control principle but despite frequent communication with hospitals and GP Practices awareness has remained stubbornly low. Surprisingly some A&E departments don’t have an isolation room defined. Understandably measles may just be one of a myriad of competing priorities but we need improved systems at local level to engage and communicate with GP Practices and A&E Departments for communicable diseases.
Worryingly we suspect our experience would be replicated more widely. Why is measles so difficult? Let’s deliver MMR vaccination to our staff and protect our patients in waiting areas. Surely we can do better than this?
1. Vivancos R, Keenan A, Farmer S, Atkinson J, Coffey E, Dardamissis E et al. An ongoing large outbreak of measles in Merseyside, England, January to June 2012. Euro Surveill. 2012;17(29):pii=20226.http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20226
2. Department of Health. Immunisation against infectious diseases. TSO, 2006. https://www.wp.dh.gov.uk/immunisation/files/2012/07/Chap-21-dh_122643.pdf
3. Health Protection Agency. National measles guidelines – local and regional services, 2010. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1274088429847
4. Health and Safety Executive. Control of substances hazardous to health (Fifth edition) Approved Code of Practice and guidance, 2005. http://www.hseni.gov.uk/l5_control_of_substances_hazardous_to_health.pdf
5. Atkinson W, Wolfe C (Skip), Hamborsky J, editors. Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition. 12th ed. The Public Health Foundation; 2011.
6. Health Protection Agency. Post exposure prophylaxis for measles: revised guidance, May 2009. 2009. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1238565307587
Kenneth Lamden consultant in health protection, Cumbria and Lancashire Health Protection Unit, Chorley, PR7 1NY, UK. Kenneth.lamden@hpa.org.uk
Roberto Vivancos regional epidemiologist, HPA North West, Liverpool L1 1JF.
Rosemary McCann consultant in health protection, Greater Manchester Health Protection Unit. Manchester M30 0NJ.
Sam Ghebrehewet consultant in health protection, Cheshire and Merseyside Health Protection Unit, Liverpool L1 1JF.
Competing interests: No competing interests