Week in Review

Hospital staff catching measles on the job

At least 20 DHB staff have had measles this year – and at least six of them caught it on the job. Eloise Gibson reports. 

Hospital staff are catching measles at work, with at least 20 people working at five different District Health Boards confirmed as being infected this year.

At one point, the highly contagious virus was being transmitted inside Christchurch Hospital. However, there are no reports of patients catching it from staff, only the other way around. 

More than 1957 people have caught measles this year, 1581 of them in Auckland.

Health authorities divide the cases into at least 12 separate outbreaks, each one involving a different strain of the virus that has spread to a cluster of people who've somehow come into contact. Sometimes a strain will jump between cities on board an infected traveller - and Auckland has been implicated in other cities' cases.

During an outbreak in Canterbury during February and March, six Christchurch Hospital staff caught measles while they were working at the hospital - raising fears Christchurch could lose control of the outbreak.

Forty people, including the workers, eventually caught measles before the Canterbury outbreak ended. Despite all six of the infected Christchurch Hospital staff having had some contact with patients, none of them gave measles to patients, says Canterbury’s Medical Officer of Health, Cheryl Brunton. 

During Canterbury's outbreak, Julie Ann Ira from Canterbury Health Laboratories, a measles testing and surveillance lab, told a meeting on vaccine-preventable diseases in the Philippines that the Canterbury outbreak had spread in a hospital. “Outbreaks can rapidly get out of control if nosocomial (hospital-acquired) transmission occurs,” she told the meeting, adding that any non-immune staff should stand down for 21 days after being around someone with measles.

In a separate incident last month, a seventh Canterbury DHB worker, this one at Burwood Hospital, went to work while infectious with measles, which she caught after travelling outside of Christchurch. The hospital tracked down patients and staff who’d been near the woman and isolated those with no records of immunity. This time, no one else caught the virus. Health authorities and the hospital's infection control staff managed to prevent an outbreak - aided by the fact that most patients at Burwood are old enough to have had measles as children.

The other city to have had several infected health workers is Auckland, specifically Counties Manukau DHB.

Seven Counties Manukau staff were infected with measles between January 1 and October 1. (The DHB has not yet answered questions about whether the staff caught measles at work, or whether they’d infected patients. Newsroom will update this story).

Counties Manukau has been at the epicentre of Auckland’s ongoing measles outbreak, with the DHB's Middlemore Hospital setting up a dedicated children's measles ward to handle an influx of seriously ill children. 

Up until September, more than 80 percent of notified measles cases in 2019 had been from the Auckland metropolitan region, of which over two-thirds were from Counties Manukau DHB, Nikki Turner, the head of the Immunisation Advisory Centre, wrote in this week’s New Zealand Medical Journal.

“In the Auckland metropolitan region, particularly ... the Counties Manukau District Health Board area, numbers from two separate outbreaks quickly multiplied and overwhelmed the ability of public health services to control the spread,” wrote Turner. “As of September, rates of measles in New Zealand were the second-highest in the Western Pacific region at 152.4 per million, with only the Philippines having higher rates at 612.1 per million. Health authorities divide the cases into at least 12 separate outbreaks, which have sometimes jumped between cities on board an infected traveller – particularly travelers from Auckland.

Around the country, there were six other cases of measles-infected DHB workers in the nine months ending October 1: two at Auckland DHB, one at Northland DHB and three at Waitemata, which operates Waitakere and North Shore hospitals.

A Newsroom inquiry involving multiple official information requests to every DHB found only two had any figures on what proportion of their staff were immune to measles or other highly contagious illnesses, such as whooping cough.

Most DHBs will hire staff who decline to be vaccinated, leaving it to managers to assess and deal with any risk. The Ministry of Health leaves management of staff vaccinations to DHBs. “It's about ensuring that staff who choose not to or are unable to be vaccinated are not rostered on to work with high risk or very vulnerable patients,” the Ministry told Newsroom.

Even at Auckland DHB - one of the most proactive in the country when it comes to measuring and increasing worker vaccination rates - there is a sprinkling of staff who are not confirmed to be vaccinated from measles, working in patient contact roles across newborn intensive care, paediatric intensive care, accident and emergency and the maternity ward.

A measles audit and vaccination push in March - when the Christchurch DHB outbreak was still ongoing - managed to get measles immunisation rates to 99 percent in the highest-risk areas of the hospital, including cancer care, NICU, paediatric intensive care, accident and emergency, and the maternity ward. Cancer care - the most dangerous area for measles, because of the extremely high death rate for patients who catch measles - has full measles coverage among its staff. However, there remains at least one un-immunised staff member in each of the newborn intensive care, paediatric intensive care, accident and emergency and the maternity ward. Meanwhile, 14 percent of staff in Auckland DHB’s Starship children’s emergency department are not recorded as being immunised from whooping cough (though the hospital says it is missing some vaccination records, meaning its real vaccination coverage would be slightly higher).

The only DHB that had complete figures was Waitemata, and they were from 2017. At last count, 11 percent of DHB staff were not immunised against measles and 48 percent weren’t vaccinated against whooping cough, though the DHB says it has since improved those rates. (No newer figures were available).

No other DHB knew its rates - though several have been trying to increase staff vaccination uptake. 

Associate Health Minister Julie Anne Genter says New Zealand does not have a problem with measles spreading in its hospitals. Genter cited an estimate by the Ministry of Health that 1 percent or less of measles cases have involved hospital workers. The Ministry says it has had no reports of staff giving measles to patients. “There doesn’t appear to be an issue with measles spreading in hospitals,” Genter told Newsroom in an email. “In terms of un-immunised staff, immunisation isn’t compulsory in New Zealand. However, the Government expects that employers (including those who employ healthcare workers) should take all reasonable steps to encourage susceptible workers to be immunised.”

National MP Shane Reti, a GP and his party’s associate health spokesperson, said Genter’s statement that there wasn’t a problem “was wishful thinking on several levels”.

“While there may be no recorded cases, we can’t really tell if hospital workers have passed it on to patients,” he said. “Because they are working with immunocompromised patients, they (health workers) have higher risk of passing it on. And what about hospital workers themselves? They have the same risk of encephalitis (brain swelling) and other complications as anyone.”

Reti disagreed with leaving it to DHBs to decide on their staff immunity policies. He said the Health Ministry should make it mandatory to require a blood test showing immunity to measles, whooping cough and other diseases that can be vaccinated against on employing new staff, and that hospitals should require new staff to be vaccinated if they weren’t immune. However, he stopped short of saying he would require existing staff to be vaccinated, saying he would want to consult with the nurses union and others.

Rostering was not the right way to deal with non-immune staff, said Reti. “Rostering is complicated enough as it is. People would want to know why you’re being rostered off that area, and that affects someone’s privacy."

Intriguingly, three of the infected Christchurch Hospital staff were recorded as being at least partially vaccinated: two of them had had both the recommended doses of the measles vaccine, and one was partially vaccinated with one dose.

That’s a significantly higher rate of measles acquisition among the vaccinated than you'd expect from the general population. Nationwide, less than 7 percent of measles cases so far have been in people with records of being fully vaccinated. It is possible to have two doses of the vaccine and still get measles, but it should be unlikely in countries where the vaccines are properly stored and administered.

In the population at large, the real chances of a fully vaccinated person getting measles in New Zealand are even less than the 7 percent of cases suggests. The numbers are skewed by the fact that vaccinated people make up a larger share of the population than the unvaccinated, so they will be exposed to measles in much higher numbers.

For the unvaccinated, however, measles is so contagious that there’s a 9/10 chance someone will catch the virus if they are exposed to it. Simply being inside the same supermarket is considered a health risk. Those least likely to be protected include babies too young for the vaccine, people with low immunity, and an estimated 15-25 percent of those New Zealanders who were born between 1985 and 2005, who haven't received full vaccination.

Of the roughly 600 people hospitalised by this outbreak, more than a hundred were babies. Some of the infants almost died, and two pregnant women lost their unborn babies during the second trimester of pregnancy. Children with low immunity, such as those having chemotherapy, have a 50 percent risk of death if they get measles.

Unless there is a medical reason for not vaccinating, the Ministry of Health recommends hospital workers should be fully vaccinated from measles and several other illnesses, but this is not compulsory even for new employees at many DHBs. At least two DHBs - Lakes, and Waikato - have chosen to impose proof of immunity as a condition for new employees. One Waikato nurse representative indicated to Newsroom last week she did not think nurses would oppose a requirement for measles and whooping cough vaccinations being extended to existing staff. Some DHBs are moving to requiring blood tests to prove whether someone's immune or not, in case someone has records of being fully vaccinated but it hasn't worked successfully. 

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