How a children's hospital handled a measles outbreak

Suspicions of a possible outbreak started to grow when it was discovered the children came from the same community and attended the same preschool. But what concerned Stinchfield the most back in April was the community in which the cases were being reported. Both children were of Somali descent and lived in a community where visits to their home country were common. Since early 2017, Somalia has experienced its worst measles outbreak in four years, with nearly 19,000 suspected cases reported as of late October. "We knew that it was going to spread quickly because immunization rates in our Somali children had been dropping for over a decade," Stinchfield said.

But scenarios such as the Minnesota outbreak are hardly unique. Sudden outbreaks of vaccine-preventable diseases such as measles have become more commonplace in the U.S. over the past decade. A study JAMA published in October examining measles outbreaks between 2001 and 2015, found that 10 of the past 13 outbreaks with 20 or more cases occurred after 2010 despite the disease being declared eliminated in the U.S. in 2000. The study also found that the proportion of imported measles cases decreased to 15% in 2015 from 47% in 2001, while the number of cases acquired in the U.S. went up during that time, with researchers citing failure to vaccinate as a likely cause.

Minnesota has one of the largest Somali immigrant communities in the country, with about 25,000 members, and once there was little concern about a measles outbreak among them even if a measles outbreak swept their home country.

That's because as recently as 2004, the rate for measles, mumps and rubella vaccinations among Minnesota-born Somali children was around 92%, higher than the rate among non-Somali kids in the state, according to the Minnesota Department of Health.

But the state saw a steep decline in MMR immunizations among Somali immigrants over the past decade. Experts believe the decrease was due to fears that the vaccine was responsible for an increased rate of autism among Somali-American children in Minnesota in recent years. Studies showed the incidence rate for autism among Somali-American children was no higher than the rate among white children in the state.

An immunization rate of 90% to 95% is regarded by many infectious disease experts as the minimum threshold for what is called "herd immunity," in which unimmunized individuals are protected because a large enough percentage of individuals have been vaccinated.

But by 2012, the immunization rate among Somali Minnesotans at 24 months of age had fallen to 46%.

Between April and August, healthcare professionals at Children's saw 53 of the 79 measles cases reported during that period in what became the state's largest single outbreak of the disease in 30 years. Among the reported cases, 74 involved children and 65 were of Somali descent.

A total of 23 cases, all children, were hospitalized for measles, and all were treated at Children's, while other area systems, such as Fairview Health Services, also saw and treated several who were exposed.

Such cases offer challenges both medically and logistically for many healthcare providers since clinical staff often lack experience diagnosing and treating measles.

"The real area where training is needed is in younger physicians who don't know they're dealing with a case of measles," said Dr. Amesh Adalja, senior associate at Johns Hopkins University's Center for Health Security. "Not necessarily an outbreak, but in an individual case, and it may get missed and allow the virus to spread."

Stinchfield said once it was determined that they were dealing with a measles outbreak, the hospital immediately activated its incident command system, which many facilities only use for large-scale disasters such as the Oct. 1 mass shooting in Las Vegas.

"It's a structure that really gives you clear authority, accountability and communication," Stinchfield said. "It just brings a lot of clarification to a very chaotic situation."

The emergency protocol designation allowed for the hospital and its 12 ambulatory clinics in the Twin Cities area to expedite the mobilization effort.

The hospital deployed its emergency management team to set up the emergency department for triage, and "pivot nurses" were stationed near hospital entrances to distribute face masks to all who entered. Visitors were required to keep their masks on until staff could verify their immunization status and that they were not infectious.

Stinchfield said the hospital resorted to such measures because of the highly contagious nature of measles, which will infect 90% of non-immunized individuals who are near an infected person.

Additional negative-pressure rooms, used to prevent cross-contamination between rooms, were created to accommodate the influx of infected patients being treated at the hospital. Information technology staffers set up phone banks that allowed nurses to alert the families of patients exposed to measles at the ED.

The immediate actions by Children's and other providers were credited with containing the spread of the outbreak, which ended by August with no fatalities. The disease can be life-threatening especially in young children.

But such efforts can be incredibly resource-intensive, according to Stinchfield, who estimated Children's spent $1.3 million in its response, which included just $280,000 in reimbursable expenses.

Though outbreaks each tend to play out differently—even if they involve the same disease—similarities can be drawn that can help hospitals standardize their approach and improve their response to such events.

"It's really important to standardize as much as possible what you're doing, especially if you're dealing with a large number of patients," said Dr. Jasjit Singh, a pediatric infectious disease specialist at Children's Hospital of Orange County in California. CHOC was one of several hospitals that received and treated children who were infected with measles at Disneyland in December 2014. The subsequent outbreak lasted until early April 2015 and resulted in 147 reported cases across seven states, Mexico and Canada.

Singh said having an outbreak plan and conducting drills are important, but an essential component to a successful response is for a hospital to adopt a policy that calls for patients to be immediately isolated upon any suspicion that they may have an infectious disease and not to wait for confirmation before going into action.

"I think sometimes there's a hesitation where a clinician may say they're not sure if this is measles and maybe they have to ask a couple of other people," Singh said. "You can always back down from your isolation, but if you haven't done it upfront and it does turn out to be measles, then you may have potentially exposed staff or other patients while you were waiting for that confirmation."

Many healthcare providers have taken steps in recent years to improve their approach to infectious disease threats both in logistics and in the regular training of staff to handle such events. Much of that increased focus comes from lessons they learned in emergency preparedness during the Ebola outbreak in West Africa that killed thousands from 2013 to 2016.

Only a small number of Ebola cases were treated in the U.S. But fears of patients with the deadly contagious disease visiting their facilities prompted hospitals throughout the country to develop and routinely drill action plans in the rare likelihood that such an event took place.

Many hospitals made significant investments in purchasing supplies, retrofitting rooms with proper air filtration, and training staff for a crisis that never came. A study published in March in the journal Infection Control and Hospital Epidemiology found that acute-care hospitals spent on average more than $80,000 preparing for potential Ebola cases for a total of more than $361 million from 2014 to 2015.

But the experience in some ways helped hospitals and the public think more broadly about infectious disease. Hospitals have always had plans in place to respond to such events. But Ebola prompted providers to conduct more mock drills to ensure staff readiness and to test the emergency plan's effectiveness before it's actually needed.

"Ebola, I think, woke people up a little bit," said Dr. Jonathan Grein, infection control officer at Cedars-Sinai Medical Center in Los Angeles and medical director of the hospital's Special Pathogens Response Team, which cares for patients with highly infectious, highly deadly diseases like Ebola and Middle East respiratory syndrome. In 2016, Cedars-Sinai was selected to become one of 10 U.S. regional treatment centers for Ebola and other infectious diseases.

Grein said improving the hospital's overall readiness to handle infectious disease cases began with educating front-line staff on the importance of promptly identifying and isolating such patients, as well as communicating well with clinicians, public health officials and the community to establish a well-orchestrated, coordinated response.

In the aftermath of the measles outbreak, Stinchfield said the system made a greater effort to raise awareness within the immigrant Somali community about the importance of immunizing their children with the MMR vaccine and to assuage their concerns about its safety.

The decline in Somali-American children's MMR immunization rate sprang from fear that the vaccine was linked to an increased prevalence of autism cases in the community around 2008. But also around that same time, there was a concerted effort by anti-vaccination groups in the state to perpetuate such claims within that community.

Countering the vaccine skepticism within the Somali-American community would require a more thoughtful approach than simply running public service announcements if there was any hope such an effort would be more effective than past efforts

Children's and Minnesota's Department of Health have conducted a series of community outreach initiatives to encourage parents to vaccinate their children and dispel fears over MMR, including meeting with religious leaders. "Now, we spend a great deal of time meeting with imams in the community and ask them to partner with us, and they have been great," Stinchfield said.

Along with visiting mosques, the hospital and state health department launched a social media campaign to target younger parents, and established a group of Somali healthcare professionals who worked at the hospital to help the emergency preparedness team connect with community leaders.

Upon listening to their concerns, it became clear that any talks with the community had to focus more on dispelling the myth that MMR caused autism instead of discussing the severity of measles, a disease many parents already knew well from past exposures in Somalia.

"There are many articles that say the best way to get over the myth about MMR is to stop talking about it," Stinchfield said. "That was not the case for the Somali community—they're afraid of measles, but they know measles."

So the team brought in autism specialists to discuss autism with community leaders and answer their questions about its causes.

Such efforts led to an immediate boost in MMR immunizations within the community. On a typical week about 2,000 doses of MMR vaccine are distributed to children in Minnesota, according to Stinchfield. For three straight weeks during the outbreak at least 10,000 doses a week were being given for a total of 42,000 additional doses distributed throughout the entire outbreak.

"Now after this outbreak we have seen a significant sea change in the views of the Somali community," Stinchfield said. She said the experience showed her the importance of being culturally sensitive to every community that Children's serves and to have a constant presence in those communities.

"We as traditional, Caucasian healthcare leaders have to just be quiet and listen," Stinchfield said. "As healthcare professionals I think you have to be able to listen to make sure we are not using just one single template for all people."