Community Health
Community Health & Population-Focused Nursing
January 17, 2016

Community Health
A.1 The CDC reported 159 people from 17 states and Washington DC to have measles from January 4 – April 2, 2015 (Clemmons, Gastanaduy, Fiebelkorn, Reddl, & Wallace, 2015). Among the cases 155 were U.S. residents and four were foreign visitors. 70% of the cases were connected to an outbreak that originated in Orange County, California in December 2014. The cases were part of a large multi-state outbreak connected to an amusement park in California ("Measles cases," 2016).

A 2. The incidence of measles has decreased substantially in regions where vaccination has been instituted and subsequently measles occurs predominantly in areas with low vaccination rates, particularly in the developing world. Worldwide, measles is a significant cause of morbidity and mortality. Before the introduction of the measles vaccine, over two million deaths occurred annually, the majority in children less than5 years of age. Prior to the availability of the vaccine, annual measles prevalence peaked at 85, 862 in Texas in 1958 ("Measles cases," 2016). Since the vaccine, cases have declined by 99.9% in Texas. Almost all cases and outbreaks of measles in Texas and the US since 2000 has occurred among persons exposed to imported cases from countries where measles is still endemic ("Measles," 2015) Since measles is still endemic in developing parts of the world and is dangerously contagious, this viral illness could readily passed into unvaccinated communities. Measles is a highly contagious virus caused by the rubeola virus. The illness is characterized by initial onset of fever, malaise, cough, coryza, and conjunctivitis (Kutty et al., 2013). A maculopapular rash, usually beginning on the face then becoming generalized, appears between days 3 and 7 after onset of illness. The average incubation period is 12 days from exposure to prodrome (pre-rash) and 14 days from exposure to rash (range 7 to 21 days). Infectivity begins as early as 4 days before onset of rash and could progress until 4 days after onset of rash. ("Measles cases," 2016) Transmission occurs via person to person contact and through contaminated air and is spread via airborne, droplet, and secretions ("Measles Immunisation," 2016). Droplets from respiratory secretions of an individual infected with measles can remain airborne for several hours. The illness may be transmitted in public places and outbreaks could easily occur in areas of crowding such as schools and densely populated communities. Risk factors include unvaccinated persons, international travelers, young or elderly age, and those who cannot be vaccinated because of medical conditions.
A 3. The population most at risk for contracting measles are those who have not been vaccinated. The impact on community would be concentrated in areas that the most members who have not been vaccinated. Local government health departments would be responsible for advising on the prevention of spread and care for those affected. Hospitals and schools would be especially susceptible due to the immunocompromised nature of the members found in hospitals and the developing immune systems of unvaccinated children in the schools. The most likely effect on schools and hospitals would be the increased diligence and work involved in identifying those who have the measles, those who don’t, those who are susceptible due to not being vaccinated, and then isolating them from the rest of the population until the outbreak has been contained and is no longer a risk. This would inevitably result in increased costs to all hospitals and schools. In schools particularly, unvaccinated children would be the most affected due to the resulting isolation from their peers. This could result in both psychological stress on children who have contracted measles as well as those who are unvaccinated, as well as possible increase in absence due to illness or isolation, which in turn also costs schools money due to increased absences. Texas has a school exclusion policy for children who are suspected or confirmed should be kept out of school for 4 days after the onset of the rash. Rules for exclusion are outlined in the Texas Administrative Code, found in Rule 97.7 ("Measles," 2015).

A 4. The diagnosing clinic or facility should immediately report the case to Austin/Travis County and Human Services Department Disease Prevention and Health Promotion department at (ATCHHSD) (512) 972-5555. Next the provider must complete and submit the required forms “the initial provider disease report” # EP1 and “the confidential disease report”, # EP2 located on the Texas Department of Health and Human Services website at http://www.dshs.state.tx.us/idcu/investigation/forms/.
A 5. Once they have been made aware of an outbreak, the Health Department must notify and collaborate with others in the community who are most at risk for being affected by the outbreak. For example, if the outbreak occurred in public school in Austin, TX, the department would notify the superintendent of Austin Independent School District. Major hospital systems in the area would also be notified, including St. David’s Hospital, Seton and Scott & White hospitals. A media campaign, press conference or statement may also be issued by the Health Department to ensure that the correct information is disseminated and to mitigate the spread of rumors and misinformation among the community. This may be done via local news outlets, newspapers and local governmental websites. A 6. Immunization is the only way to prevent measles. Measles vaccination is required for school entry in Texas unless an exemption is requested. Nurses play a key role in increasing immunization coverage to prevent occurrence of disease. Nurses in the community must collaborate with the public health department in Travis County and provide education on the importance on immunizations as well as offer MMR vaccinations to raise awareness. Once a case has been diagnosed, it is important to contain it as efficiently and quickly as possible to prevent a spread and subsequent outbreak. The cause of transmission should be traced from the identified case until it can be determined the initial cause. Those exposed would need to be followed up with and isolated until a period of quarantine has passed or in the cases of active measles, until the case is resolved. Vigilance and awareness would be required as well to ensure that those who may have been exposed indirectly are closely monitored and educated on the symptoms to ensure no new cases arise, and if they do, they are addressed immediately.

References
Clemmons, N. S., Gastanaduy, P. A., Fiebelkorn, A. P., Reddl, S. B., & Wallace, G. S. (2015). Measles- United States, January 4-April 2, 2015 [Special issue]. Morbidity and Mortality Weekly Report (MMWR), 64(14). Retrieved from http://www.cdc.gov/mmwr/pdf/wk/mm6414.pdf
Infectious Disease Control: MEASLES. (2015). Retrieved from http://www.dshs.state.tx.us/idcu/disease/measles/
Kutty, P., Rota, J., Bellini, W., Redd, S., Barskey, A., & Wallace, G. (2013). Measles. In S. W. Roush, & L. M. Baldy (Eds.), Manual for the Surveillance of Vaccine-Preventable Diseases (6th ed.). [Adobe]. Retrieved from http://www.cdc.gov/vaccines/pubs/surv-manual/index.html
Measles Cases and Outbreaks. (2016). Retrieved from http://www.cdc.gov/measles/cases-outbreaks.html
Measles [Press release]. (2015, November). Retrieved from World Health Organization: http://www.who.int/mediacentre/factsheets/fs286/en/
Measles immunisation: Time to close the gap [Editorial]. (2016). The Lancet Infectious Diseases, 16(1), 1-130. http://dx.doi.org/ http://dx.doi.org/10.1016/S1473-3099(15)00504-6