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January 12, 2018

How Children's Minnesota contained the state's largest measles outbreak in 30 years—with no fatalities

Daily Briefing

    When measles broke out in the Twin Cities' Somali community last spring, Children's Minnesota hospital in St. Paul deployed a rapid response strategy typically used for "large-scale disasters" to diagnose, contain, and treat those affected by the outbreak—without any fatalities, Steven Ross Johnson reports for Modern Healthcare.

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    A resurgence of vaccine-preventable disease

    Outbreaks of vaccine-preventable diseases have become more common in the United States in recent years: a JAMA study published last October found 10 measles outbreaks with at least 20 cases occurred between 2010 and 2015. Further, the study noted that imported measles has become less common while U.S.-acquired measles has become more common.

    The resurgence of measles comes after the often deadly disease was declared eliminated in the United States in 2000. Researchers said failure to vaccinate was likely a cause of the shift.

    Detecting a budding outbreak

    Children's Minnesota last spring confirmed the first case of the outbreak in a toddler, according to Patricia Stinchfield, an infectious disease NP at the hospital. When the toddler was diagnosed, the hospital realized that some children who had been seen a few days earlier—who were from the same local Somali community and attended the same preschool—might have had measles as well, Stinchfield said.

    Somalia since early 2017 has been experiencing its worst measles outbreak in four years, Ross Johnson reports, and it's common for Somali immigrants in the Minnesota community to visit home.

    Further, vaccination rates among Somali children had been falling over the last decade, a decline that experts attribute to anti-vaccination efforts and the misconception that the Measles Mumps Rubella (MMR) vaccine is linked to autism. Overall, the local Somali community in Minnesota has an immunity rate of 46% among 24-month-olds—falling far short of the 90% or 95% required for a community to have "herd immunity," Ross Johnson reports.

    Acting fast

    Once officials determined they were facing a measles outbreak, Children's Minnesota immediately activated its incident command system, Stinchfield said.

    While facilities typically reserve the system for large-scale disasters, such as a mass shooting, the hospital opted to launch it because officials knew that given the declining immunization rates and extremely contagious nature of the illness, the outbreak "was going to spread quickly," Stinchfield explained. According to Ross Johnson, the disease can spread to 90% of non-immunized individuals who are near an infected individual.

    The special protocol meant the hospital and its 12 ambulatory clinics could expedite the mobilization effort, Ross Johnson reports. "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."

    Under the system, the hospital sent an emergency management team to the ED for triage, while nurses were stationed near hospital entrances to hand out face masks. Visitors had to keep the masks on until their immunization status could be verified and staff could confirm they weren't infected. The hospital also used additional negative-pressure rooms to prevent cross-contamination from room to room. In addition, IT staff erected phone banks to help notify the family members of individuals exposed to the virus at the ED.

    The outbreak was declared over in August, with 79 cases reported, making it the state's largest single measles outbreak in three decades. There were no fatalities.


    According to Ross Johnson, many health care providers have amped up their infectious disease response in recent years, due in part to emergency preparedness efforts taken for Ebola—and while individual outbreaks may differ in the details, hospitals can benefit from certain standardized approaches.

    Jonathan Grein, infection control officer at Cedars-Sinai Medical Center in Los Angeles and medical director of the hospital's Special Pathogens Response Team, said, "Ebola, I think, woke people up a little bit." According to Grein, a hospital's preparation for infectious disease generally starts with teaching front-line-staff about the importance of spotting and isolating infected patients and communicating efficiently with local public health officials and community members to coordinate a response.

    Separately, Jasjit Singh—a  pediatric infectious disease specialist at Children's Hospital of Orange County, which treated children in a recent measles outbreak in California—said in the case of an outbreak, "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."

    He also noted the importance of immediately isolating patients. "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," Singh said.

    In addition, providers say early detection of infected persons is key to avoiding and containing an outbreak. Amesh Adalja, senior associate at Johns Hopkins University's Center for Health Security, said, "The real area where training is needed is in younger physicians who don't know they're dealing with a case of measles."

    Working with the community on prevention

    The Minnesota outbreak led Children's Minnesota to focus on boosting vaccination rates in the Somali community, Stinchfield said.

    To do that, Children's Minnesota and the Minnesota Department of Health launched several community outreach initiatives to encourage vaccination and dispel myths around the MMR vaccine. For instance, the team had autism specialists discuss autism with community leaders and answer questions about its causes. In addition, the health department launched a social media campaign aimed at younger parents.

    "Now after this outbreak we have seen a significant sea change in the views of the Somali community," Stinchfield said.

    She also noted that the experience helped her understand the importance of being culturally sensitive to every community the hospital serves and to have a regular presence in those communities. "As health care professionals I think you have to be able to listen to make sure we are not using just one single template for all people," she said (Ross Johnson, Modern Healthcare, 12/30/17).

    From outbreaks to hurricanes: How can your hospital prepare for disasters?

    Hospitals must be prepared for myriad disasters that can stress health care systems to the breaking point and disrupt delivery of vital health care services.

    Advisory Board has compiled step-by-step procedures for various threats your facility may encounter—though we hope you'll never need to use them.

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