Lecture By: DR.SATTI MOHAMMED SALEH MEEQAT HOSPITAL MEDICAL DIRECOR INFECTION CONTROL DIRECTOR CBAHI SIT MEMBER

1. DR.SATTI MOHAMMED SALEH
MEEQAT HOSPITAL MEDICAL DIRECOR
INFECTION CONTROL DIRECTOR
CBAHI SIT MEMBER
Control of outbreak of Measles
in Rehab Center in Medina
, June 2015
Effective Infection Control,
Teamwork and Preparedness

2. Measles is an acute viral respiratory illness. It is
characterized by a prodrome of fever (as high as
105°F) and malaise, cough, coryza, and
conjunctivitis -the three “C”s -, a pathognomonic
enanthema (Koplik spots) followed by a
maculopapular rash. The rash usually appears
about 14 days after a person is exposed
MEASLES

3. THE VIRUS
Measles is caused by a single-stranded,
enveloped RNA virus with 1 serotype. It is
classified as a member of the genus
Morbillivirus in the Paramyxoviridae family.
Humans are the only natural hosts of measles
virus

4. Background
Background
Background
Background
In the decade before the live measles
vaccine was licensed in 1963, an average
of 549,000 measles cases and 495
measles deaths were reported annually in
the United States

5. • Europe, Asia, the Pacific, and Africa. An
estimated 20 million people become infected
with measles worldwide each year, of whom
146,000 die.

6. TRANSMISSION
• Measles is one of the most contagious of all
infectious diseases; approximately 9 out of 10
susceptible persons with close contact to a
measles patient will develop measles. The virus is
transmitted by direct contact with infectious
droplets or by airborne spread when an infected
person breathes, coughs, or sneezes. Measles virus
can remain infectious in the air for up to two hours
after an infected person leaves an area

7.  AIRBORNE
 INFECTIVITY PERIOD, 4 DAYS PRIOR TO ONSET OF RASH TO 4
DAYS AFTER
 OUTBREAK MAY LEAD TO EPIDEMIC WITH MANY DEATH

8. INCUBATION PERIOD
 7 – 14 DAYS

9. AT RISK
 UNVACCINATED CHILDREN
 MALNOURISHED
 PREGNANT WOMEN
 IMMUNE SUPPRESSION
 OVER CROWDING IN RESIDENTIAL
CAMPS OR HOUSING

10.  PRODROMAL PHASE
 MALAISE
 ANOREXIA
SIGNS AND
SYMPTOMS
 FEVER
 CLASSIC TRIAD OF CONJUNCTIVITIS, COUGH, CORYZA (THE 3 C's)

13. OTHERS
 MYALGIA
 PHOTOPHOBIA
 PERI ORBITAL OEDEMA

14. SIGNS
 KOPLIK SPOTS
 RASH
 MODIFIED MEASLES
 ATYPHICAL MEASLES

15. KOPLIK SPOTS

16. CASE DEFINITION
1. SUSPECTED CASE
- FEVER WITH RASH
2. PROBALBLE CASE
(CLINICAL CASE DEFINITION)
NO LAB SUPPORT
3. CONFIRMED CASE
- LABORATORY CONFIRMED
- EPIDIMIOLOGICALLY LINKED TO
CONFIRMED CASE

17. PEOPLE AT HIGH RISK FOR COMPLICATIONS
• People at high risk for severe illness and complications
from measles include:
• Infants and children aged <5 years
• Adults aged >20 years
• Pregnant women
• People with compromised immune systems

18. COMPLICATIONS
• Common complications from measles include otitis media,
• bronchopneumonia,
• laryngotracheobronchitis,
• and diarrhea.
• Even in previously healthy children, measles can cause serious illness
requiring hospitalization.
• One out of every 1,000 measles cases will develop acute encephalitis,
which often results in permanent brain damage

19. DIAGNOSIS AND LABORATORY TESTING
• Healthcare providers should consider measles in
patients presenting with febrile rash illness and
clinically compatible measles symptoms, especially
if the person recently traveled internationally or
was exposed to a person with febrile rash illness.
Healthcare providers should report suspected
measles cases to their local health department
within 24 hours

20. LABORATORY CONFIRMATION
• Laboratory confirmation is essential for all sporadic
measles cases and all outbreaks.
• Detection of measles-specific IgM antibody
• and measles RNA by real-time polymerase chain
reaction
• (RT-PCR) are the most common methods for
confirming measles infection

21. HEALTHCARE PERSONNEL
• Healthcare personnel should have documented
evidence of immunity against measles,
according to the

22. POST-EXPOSURE PROPHYLAXIS
• People exposed to measles who cannot readily
show that they have evidence of immunity against
measles should be offered post-exposure
prophylaxis (PEP) or be excluded from the setting
(school, hospital, childcare). MMR vaccine, if
administered within 72 hours of initial measles
exposure, or immunoglobulin (IG), if administered
within six days of exposure, may provide some
protection or modify the clinical course of disease

23. MMR VACCINE AS POST-EXPOSURE
PROPHYLAXIS
• If MMR vaccine is not administered within 72 hours of exposure as PEP, MMR
vaccine should still be offered at any interval following exposure to the disease
in order to offer protection from future exposures. People who receive MMR
vaccine or IG as PEP should be monitored for signs and symptoms consistent
with measles for at least one incubation period.
• If many measles cases are occurring among infants younger than 12 months of
age, measles vaccination of infants as young as 6 months of age may be used
as an outbreak control measure. Note that children vaccinated before their first
birthday should be revaccinated when they are 12 through 15 months old and
again when they are 4 through 6 years of age.
• Except in healthcare settings, unvaccinated people who receive their first dose
of MMR vaccine within 72 hours after exposure may return to childcare, school,
or work.

24. IMMUNOGLOBULIN (IG) AS POST-EXPOSURE
PROPHYLAXIS
• People who are at risk for severe illness and complications from
measles, such as infants younger than 12 months of age, pregnant
women without evidence of measles immunity, and people with severely
compromised immune systems, should receive IG. Intramuscular IG
(IGIM) should be given to all infants younger than 12 months of age who
have been exposed to measles. For infants aged 6 through 11 months,
MMR vaccine can be given in place of IG, if administered within 72
hours of exposure. Because pregnant women might be at higher risk for
severe measles and complications, intravenous IG (IGIV) should be
administered to pregnant women without evidence of measles immunity
who have been exposed to measles. People with severely compromised
immune systems who are exposed to measles should receive IGIV
regardless of immunologic or vaccination status because they might
not be protected by MMR vaccine

25. POST-EXPOSURE PROPHYLAXIS FOR
HEALTHCARE PERSONNEL
• If a healthcare provider without evidence of
immunity is exposed to measles, MMR
vaccine should be given within 72 hours, or
IG should be given within 6 days when
available. Exclude healthcare personnel
without evidence of immunity from duty from
day 5 after first exposure to day 21 after last
exposure, regardless of post-exposure
vaccine

26. ISOLATION
• Infected people should be isolated for four days after they develop a rash.
Healthcare providers should follow respiratory etiquette and airborne precautions
in healthcare settings. Regardless of presumptive immunity status, all healthcare
staff entering the room should use respiratory protection consistent with airborne
infection control precautions (use of an N95 respirator or a respirator with similar
effectiveness in preventing airborne transmission). Because of the possibility,
albeit low, of MMR vaccine failure in healthcare providers exposed to infected
patients, they should all observe airborne precautions in caring for patients with
measles. The preferred placement for patients who require airborne precautions is
in a single-patient airborne infection isolation room (AIIR).
• People without evidence of immunity who have been exempted from measles
vaccination for medical, religious, or other reasons and who do not receive
appropriate PEP within the appropriate timeframe should be excluded from affected
institutions in the outbreak area until 21 days after the onset of rash in the last case
of measles

27. TREATMENT
• There is no specific antiviral therapy for measles. Medical
care is supportive and to help relieve symptoms and
address complications such as bacterial infections.
• Severe measles cases among children, such as those who
are hospitalized, should be treated with vitamin A. Vitamin A
should be administered immediately on diagnosis and
repeated the next day. The recommended age-specific daily
doses are
• 50,000 IU for infants younger than 6 months of age
• 100,000 IU for infants 6–11 months of age
• 200,000 IU for children 12 months of age and older

28. TREATMENT
 ANTIBIOTIC FOR
SECONDARY INFECTION

29. ‫السعودية‬ ‫العربية‬ ‫المملكة‬
‫الصحـــة‬ ‫وزارة‬
‫المنورة‬ ‫المدينة‬ ‫بمنطقة‬ ‫الصحية‬ ‫للشئون‬ ‫العامة‬ ‫المديرية‬
‫العام‬ ‫الميقات‬ ‫مستشفى‬
‫تاريخ‬ ‫من‬ ‫العام‬ ‫الميقات‬ ‫بمستشفى‬ ‫المنومة‬ ‫الحصبة‬ ‫حاالت‬ ‫عدد‬ ‫عن‬ ‫تقرير‬1/7/1436‫وحتى‬8/9/1436
‫الشهر‬‫الحاالت‬ ‫عدد‬
‫رجب‬14
‫شعبان‬20
‫رمضان‬2
‫الشهر‬‫الحاالت‬ ‫عدد‬
‫رجب‬14
‫شعبان‬20
‫رمضان‬2
‫المجموع‬=36
‫د‬/‫المهدي‬ ‫االمين‬ ‫محمد‬
‫مكاف‬‫العدوى‬ ‫حة‬

30. STEPS FOR OUTBREAK INVESTIGATION
1. VERIFY THE DIAGNOSIS
2. CONFIRM THAT OUTBREAK EXIST
3. SEARCH FOR ADDITIONAL CASES
4. CHARACTERISE CASES BY PERSON, PLACE AND TIME
5. (ALINE LISTING AND DRAW EPIDEMIC CURVE)
6. FORM ATENTATIVE HYPOTHESIS
7. INSTITUTE PRELIMINARY CONTROL MEASURES (HAND
HYGIENE, ISOLATION, ASSISTANCE NEEDED, COHORING,
etc.,
8. TEST HYPOTHESIS
9. REFINE THE CONTROL MEASURES
10. MONITOR AND EVALUATE CONTROL MEASURES

35. W.H.O. RESPONSE
 END OF 2015
REDUCE BY 95 %
 MEASLES DEATH
 ACHIEVE MEASLES AND RUBELLA (CR'S)ELIMINATION GOAL
 BY END OF 2020
 ELIMINATE MEASLES AND RUBELLA IN 5 W.H.O. REGIONS

36. 5 CORE COMPONENTS
1. INCREASE VACCINATION COVERAGE
MMR
2. MONITOR DISEASE (SURVEILANCE)
3. OUTBREAK PREPAREDNESS
4. RAPID RESPONSE AND EFFECTIVE
TREATMENT
5. RESEARCH

37. CONTROL OF COMMUNICABLE
DISESES
( IMPORTANT MEASURES )
1- PATIENTS
2- CONTACTS
3- ENVIRONMENT.
A- MEASURES TOWARDS PATIENTS:-
1- EARLY DETECTION
2- CONFIRMATION
3- NOTIFICATION ( WRITTEN POLICY ).
4- ISOLATION

38. 1- EARLY DETECTION
2- INVESTIGATIONS
3- VACCINATIONS
4- CHEMOPROPHYLAXIS
5- OBSERVATION
6- TREATMENT
7- HEALTH EDUCATION.
B- Measures Towards Contact

39. PLAN
1. TEAM ORGANIZATION
2. VISIT THE CRC
3. MEETING WITH ADMINISTRATION
4. MEETING WITH DOCTORS AND NURSES
5. DISCUSS THE SCIENTIFIC FACTS
6. DISCUSS THE SERIOUS IMPLICATIONS
7. VIEW THE STRUCTURE AND PROCESS
FOLLOWED
8. TOUR THROUGH DIFFERENT
DEPARTMENTS WITH OBSERVATIONB,
DOCUMENTS REVIEW, INTERVIEW STAFFS.

40. PLAN AND CONTROL MEASURES
1. MEASURE TOWARDS PATIENTS
2. MEASURE TOWARDS CONTACTS
3. MEASURE TOWARD ENVIRONMENT

41. OUT BREAK CONTROL TEAM PLAN
1. MEASURES TOWARDS PATIENTS
a. FOR EARLY DIAGNOSIS AND ISOLATION
i. 3 ROOMS WITH HEPA FILTERS FOR SUSPEECTED CASES
ii. 5 ROOMS WITH HEPA FILTERS FOR PROBALE CASES
iii. TRAIN 2 DOCTORS AND NURSING DIRECTOR AND SUPERVISORS
iv. TASK FORCE FROM MEEQAT HOSPITAL
A. ICP
B. CETD NURSE
C. QUALITY NURSE
D. TRAINERS
2. TEACHING FOR BASIC IC STANDARD
3. PROVISION OF SUPPLIES NEEDED
4. ANY PATIENT WITH COMPLICATION OR CO MORBID DISEASE TO BE REFERRED
TO MEEQAT HOSPITAL
5. ISOLATE FOR INFECTIVITY PERIOD
6. CONCOMITANT DISINFECTION ANF DISINFECTION AND TERMINAL CLEANING
7. VISITORS CONTROL
8. CONTROL ALL ACTIVITIES
9. 24 HOURS NOTIFIVATION

42. EVIDENCE OF IMMUNITY
• written documentation of adequate vaccination:
• one or more doses of a measles-containing vaccine administered
on or after the first birthday for preschool-age children and adults
not at high risk
• two doses of measles-containing vaccine for school-age children
and adults at high risk, including college students, healthcare
personnel, and international travelers
• laboratory evidence of immunity
• laboratory confirmation of measles
• birth before 1957

43. FOR CONTACTS:
1. EVIDENCE OF IMMUNITY (NONE)
2. VACCINATE ALL RESIDENTS WITH MMR
3. FOR THOSE WITH COMORBID DISEASE, UNDER
NUTRITION,IMMUNO SUPPRESSION, 2 DOSES, OF MMR (I MONTH
APART)

46. VACCINE RECOMMENDATIONS
• Children
• CDC recommends routine childhood immunization for MMR vaccine starting with the first
dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or
at least 28 days following the first dose.
• Students at post-high school educational institutions
• Students at post-high school educational institutions without evidence of measles
immunity need two doses of MMR vaccine, with the second dose administered no earlier
than 28 days after the first dose.
• Adults
• People who are born during or after 1957 who do not have evidence of immunity against
measles should get at least one dose of MMR vaccine

49. SURVEILLANCE
 EPIDEMIC CURVE
 FOLLOW UP DAILY BASIS
 COLLECT DATAAS NEEDED
 FOLLOW UP CMPLIANCE WITH IC POLICIES
 TO CONTINUE SURVEILLANCE FOR 2 WEEKS AFTER THE ONSET OF
RASH IN THE LAST CASE

52. HEALTHCARE PERSONNEL
• Healthcare personnel should have documented
evidence of immunity against measles,
according to the

53. GOALS OF MEASLES OUTBREAK
RESPONSE:
• - The primary goal of measles outbreak
response was to reduce morbidity and
mortality by providing appropriate case
management and vaccinating contacts.

54. SECONDARY GOALS ARE TO :
• - limit the spread of outbreak.
• identify high-risk groups/areas for implementing
strategies to improve vaccination
• assist in the identification and correction of
weaknesses in immunization and surveillance
• raise awareness in the community about the
disease and its prevention

55. POST-OUTBREAK ACTIVITIES
•
• After an outbreak, the Epidemic Response Team must carry out
a thorough evaluation of the following:
• cause of the epidemic
• surveillance of measles and detection of the outbreak
• preparedness for the epidemic
• management of the epidemic
• immunization program goals and operations

56. PREVENTING FUTURE
OUTBREAKS:
•
• There are 4 main keys in preventing measles outbreak:
• Suspecting measles as a possibility and properly
diagnosing patient.
• Instituting immediate airborne isolation.
• Measles immunization campaigns.
• Ensuring easily retrievable measles immunity records for
healthcare workers

57. IMPRESSION AND
RECOMMENDATIONS
• Overcrowded institutions which provide health care to persons with co morbid
diseases and decreased immune status should have a policy to combat all vaccine-
preventable diseases without waiting for disease to occur to start vaccination
• .
• All healthcare workers should be trained to adhere and implement infection control
measures.
•
• Hospital infection control departments should ensure that all healthcare workers are
screened and vaccinated against all vaccine-preventable diseases.

58. • All healthcare workers should have a file with the employee health
clinic and infection control unit documenting all their screenings and
vaccination as per CBAHI infection control standard e.g. all staff in Al-
Meqat General hospital have files documenting their vaccination status
and all received MMR during the last outbreak.
•
• In the event of an outbreak we should have a way for rapid laboratory
confirmation ( to be discussed with higher authority in MOH ).
•
• It is recommended to give 2 doses of MMR vaccine, one month interval
for all persons with co morbid or decreased immune status.
•
• Strengthening the surveillance system at CRC through staff training,
regular active surveillance visits and implementation of HESN program

59. • Improving overall levels of vaccine coverage in the population.
•
• If an outbreak is anticipated, supplementary immunization activities should be
considered.
•
• When an outbreak occurs that has not been predicted, or could not be prevented,
the response needs to be rapid, since measles is highly infectious and spreads
rapidly
•
• Discussing measles outbreak of CRC in the next meeting of early preparedness for
outbreak committee.
•
• Holding health education campaigns to raise public awareness about measles and
importance of vaccination

60. • The establishment of the outbreak Coordination Committee under the
chairmanship of HE Assistant General Director of Public Health. The
Outbreak Coordinating Committee should ensure that the following
actions are carried out:
• Prompt laboratory confirmation of the outbreak,
• ensuring adequate clinical management of cases,
• intensifying surveillance and notification of suspected cases
• investigating a confirmed measles outbreak,
• implementing control and preventive measures (including vaccination
activities),
• assessing the risk of a large outbreak with high morbidity and mortality,
• ensuring effective community involvement and public awareness.