Epidemiologic Notes and Reports Rubella in Hospitals -- California

During the first 26 weeks of 1982, 441 rubella cases were reported in Los Angeles, California. This is the highest number reported in that city during the first 26 weeks of any of the past 5 years, and represents 25.9% of the 1,703 cases reported in the entire United States during that period. Sixty-four (14.5%) of the 441 cases occurred among hospital staff, their household contacts, or hospitalized patients. Sixteen hospitals reported one or more cases, including two hospitals with six or more cases. The rest occurred in the community.

The largest outbreak occurred at a comprehensive-care facility in Los Angeles County with a daily census of 1,217 and a staff of 8,622; it illustrates many problems encountered during hospital rubella outbreaks and with hospital programs to control rubella. This hospital is divided into four units, each with its own physical plant: pediatric, obstetrical-gynecological, psychiatric, and general medical-surgical. Professional and support staff in these four distinct units have limited contact and interchange. Between January 21 and February 21, 1982, 19 rubella cases were reported among hospital personnel of the general medical-surgical unit (Figure 1), and one hospital staff member transmitted the infection to his wife. No clinical cases were identified among patients. The outbreak's source case was not identified. All cases met the clinical case definition of macular or maculopapular rash lasting 2-5 days, low grade or no fever (temperature 38.9 C (102 F)) and at least two of the following signs or symptoms: posterior auricular or occipital adenopathy, arthralgia, coryza, or conjunctivitis. Diagnosis was confirmed for 12 of the cases on the basis of a 4-fold or greater rise in rubella hemagglutination-inhibition (HI) antibody titers between acute- and convalescent-phase serum specimens.

The patients' ages ranged from 22 to 63 years, with a median of 29 years; three were over 50 years of age. Eleven (55%) were female. Of the 19 hospital staff members with rubella, all of whom worked in the medical-surgical unit, 14 worked primarily in the pulmonary services division, three worked in medical intensive care, one worked in surgery, and one worked in the epidemiology office. The 19 patients were employed in the following job categories: six nurses, five physicians, four respiratory therapists, one nurse epidemiologist, one physical therapist, one clerk, and one ward aide. Two cases occurred in women in their first trimester of pregnancy and were diagnosed by a 4-fold or higher rise in rubella HI antibody titers. Both women elected to have therapeutic abortions.

Nine pregnant contacts of these 19 cases were identified (eight were personnel and one was the wife of a staff member with rubella). Six of these had documented rubella immunity before the onset of this outbreak, and their fetuses were considered not to be at risk of developing congenital rubella syndrome (CRS). The remaining three had documented evidence of no rubella antibodies before the outbreak; two of these susceptible women were in the first trimester, and one was later in her pregnancy. None of these three susceptibles developed serologic evidence of rubella infection. To date, no cases of CRS related to the hospital cases have been identified.

In January 1980, the hospital had initiated a policy requiring all new personnel working in high-risk hospital units (pediatric and obstetrical-gynecological) to demonstrate immunity to rubella.* Rubella immunization was recommended but not required for persons working in the other two units. Seven cases occurred among persons hired after January 1980. Six had been serologically tested at the time of employment, and all lacked detectable rubella antibody. Of the 11 cases among persons hired for the medical-surgical unit before January 1980, two had been serologically tested before this outbreak and also lacked detectable rubella antibody. None of these eight known susceptibles who developed rubella worked in units subject to the mandatory immunization policy.

On January 29 and February 3, immunization clinics were held for personnel of the medical-surgical unit. Three hundred forty of the approximately 2,500 personnel in this unit were immunized at those clinics. Reported by PN Heseltine, MD, M Ripper, P Wohlford, Los Angeles County--University of Southern California Medical Center, S Huie, MPH, BP Weiss, MPH, SL Fannin, MD, MA Strassburg, DPH, Los Angeles County Dept of Health Svcs, J Chin MD, State Epidemiologist, California Dept of Health Svcs; Hospital Infections Program, Center for Infectious Diseases, Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This report demonstrates the potential for rubella outbreaks among hospital personnel and their contacts. In the United States, more than 10 such outbreaks have been reported in the medical literature (1); many more have doubtless occurred. The potential for further hospital outbreaks exists as long as an estimated 10%-20% of hospital personnel lack detectable rubella antibody (2,3). *Immunity to rubella is defined as a documented history of rubella vaccination on or after the first birthday or documented presence of detectable rubella antibody.

This outbreak shows that rubella among hospital personnel can have a substantial health impact. Cases occurred among staff members of all ages and both sexes, including two cases in health workers not generally considered to provide direct patient care. Only one case outside hospital personnel was documented, although further spread may have occurred to other contacts. Two therapeutic abortions occurred as a direct result of the outbreak.

Despite a large rubella outbreak in the community and some staff contact between units, only one of the four units was affected. This unit was not covered by the mandatory rubella vaccination policy; the mandatory policy in effect in two other units might have prevented transmission in those units.

The Immunization Practices Advisory Committee (ACIP) recommends that "health-care providers should carefully review the rubella immunity status of young adults and vaccinate those who do not have documented immunity. To protect susceptible female patients and female employees, persons (both male and female) working in hospitals and clinics who might contract rubella from infected patients or who, if infected, might transmit rubella to pregnant patients should be vaccinated against rubella, unless there are contraindications" (4). This is supported by the American College of Obstetricians and Gynecologists (5). The American Hospital Association Advisory Committee on Infections within Hospitals also recommends that susceptible health-care personnel of both sexes and all ages who have contact with female patients of childbearing age should be immunized. It also states that "the hospital has a responsibility to protect its patients from infection. The need for this protection would appear to be sufficient reason for a policy obliging personnel who come in contact with pregnant patients to be tested for susceptibility to rubella and to be immunized if susceptible" (6).

Currently, four states have laws or regulations requiring proof of immunity to rubella in some hospital personnel. Special emphasis should be given to physicians who previously have not participated fully in voluntary vaccination efforts directed at health professionals (7, 8). Among persons for whom immunization is not required, vaccine acceptance has been suboptimal and disappointing. Mandatory programs are generally more effective (9). Routine serologic testing for all personnel with unknown immunity is not essential, since harmful effects from vaccinating immune persons are unknown. Additionally, problems frequently occur in followup and vaccination of those identified as susceptible.

Identifying exposed pregnant personnel and patients during rubella Mandatory programs are generally more effective (9). Routine serologic testing for all personnel with unknown immunity is not essential, since harmful effects from vaccinating immune persons are unknown. Additionally, problems frequently occur in followup and vaccination of those identified as susceptible.

Identifying exposed pregnant personnel and patients during rubella outbreaks among medical and paramedical personnel uses considerable time and money and results in time lost from work. Prevention can be accomplished by ensuring that all hospital personnel who might be at risk of exposure to patients infected with rubella or who might have contact with pregnant patients, be immune to rubella.

References

1. Greaves WL, Orenstein WA, Stetler HC, Preblud SR, Hinman AR, Bart KJ. Prevention of rubella transmission in medical facilities. JAMA 1982;248:861-4.

2. Rubella testing and immunization of health personnel. California Morbidity 1978; 37(suppl):1-4.

3. Dales LG, Chin J. Public health implications of rubella antibody levels in California. Am J Public Health 1982;72:167-72.

4. ACIP. Rubella prevention. MMWR 1981;30:37-42, 47.

5. ACOG Technical Bulletin. Rubella--a clinical update. Number 62. Chicago: American College of Obstetricians and Gynecologists, July 1981.

6. Advisory Committee on Infections within Hospitals of the American Hospital Association. Recommendations for the control of rubella within hospitals, 1981. Chicago: American Hospital Association, 1981.

7. Orenstein WA, Heseltine PN, LeGagnoux SJ, Portnoy B. Rubella vaccine and susceptible hospital employees. Poor physician participation. JAMA 1981;245:711-3.

8. Polk BF, White JA, DeGirolami PC, Modlin JF. An outbreak of rubella among hospital personnel. N Engl J Med 1980;303:541-5.

9. Chappell JA, Taylor MA. Implications of rubella susceptibility in young adults. Am J Public Health 1979;69:279-81.

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