Measles: How doctors and EMTs deal with the outbreak

In the fight against measles, medical professionals and first responders are on the front lines.

They are immunized against the highly contagious virus, but some of their patients may not be. So they've adopted tactics to contain an outbreak that has grown to 225 cases over the past eight months.

These tactics include increasing communication with local hospitals, adjusting response and triage techniques and fighting the spread of misinformation with credible data and sources.

Community ambulance

When Hatzoloh EMS of Rockland County responded to the first measles case in the county last autumn, they were not aware they’d soon be responding at least once a week to suspected measles cases in a historically large outbreak that had swelled to 773 in the state, mostly in Brooklyn, Monsey and Spring Valley.

When that first call came in that a middle-aged patient was not feeling well, the private, volunteer ambulance corps, which primarily serves the Jewish community most affected by measles, did what was routine and took him to Westchester Medical Center.

It wasn’t until days later that Hatzoloh, which is based out of Monsey — the epicenter of the outbreak — was notified by the state Department of Health that the patient had measles.

“None of us had ever seen measles,” Hatzoloh Captain Joshua Hans said Tuesday morning at the main ambulance garage in Monsey, which also serves as the offices and training grounds. “I don’t think anybody in the EMS world was really thinking about measles in that case. That really put it on our radar.”

But a news report about a measles case at Newark Airport originating from Israel did cause first responders to ask this patient if he had any recent history of air travel. Israel is currently experiencing a large outbreak with more than 4,100 cases, according to the Israeli Ministry of Health.

When measles was confirmed, Hatzoloh first responders realized they would have to take the proper precautions, Hans said.

“We had to make certain changes in terms of what … our members were doing and what our response was,” he said. “As soon as that happened, we took a very strong approach to keep our members and families protected.”

The first step was ensuring every volunteer was immunized against the virus, which is so contagious it will infect 90% of unvaccinated people who come in contact with it. One dose of the measles, mumps, rubella (MMR) vaccine is 93% effective and two doses have an efficacy rate of 97%.

For many volunteers, that meant getting a titers blood test, which measures the level of measles antibodies in the blood. Those within the ranks of nearly 200 volunteers who couldn’t be immunized for whatever reason were taken off active calls and have not responded to a call since the end of September, Hans said.

Special rigs

After that, there were other protocols that needed to be instituted.

Hatzoloh designated certain ambulances for measles calls so they could be properly equipped with extra masks and other protective equipment. Those ambulances are then taken out of commission for two hours following the transport of a suspected measles patient, because that is how long the airborne virus can live in the air.

Besides the safety precautions, Hatzoloh members have also tried to stress the importance of immunizations to the community, and the ambulance group's rabbinical board is staunchly pro-vaccination and does not recognize any religious exemptions to vaccines.

“We try not to lecture people about their choices,” Hans said. “That’s not our role. Our role is to help treat people.”

But, he said the EMTs and paramedics will try to educate people.

“We try to work with anybody in the community, different segments of the community, to make sure the message is out there,” he said.

Blue alert

While communicating with the community has become a priority for many health professionals and first responders, so has communication with hospitals.

About 18 months ago, Montefiore Nyack Hospital started using a web-based application, Twiage, that allows emergency responders to communicate directly with the hospital. Other area hospitals, including Good Samaritan Hospital in Suffern and Westchester Medical Center, also use Twiage.

In the easy-to-use phone app, the EMT has an array of medical emergencies to choose from and once they click on the appropriate one, an alert is displayed on one of the triage boards – large monitors hanging in the emergency department – with the ambulance’s time of arrival, the type of emergency and the responding agency.

Alerts for acute patients come in red, lesser emergencies are yellow and routine ones are green.

Measles are blue.

Isolation is the newest section of the app, which was recently developed by Twiage for measles at the request of Dr. Jeffrey Rabrich, the hospital’s director of emergency medicine who was instrumental in getting Twiage in the first place.

Questions under the measles section include if the patient has recently been exposed to the virus and if they had been inoculated with the MMR vaccine. It also lists the symptoms – rash, runny nose, fever, cough, red and watery eyes – so first responders can check the appropriate boxes.

“The app helps in the general communications, so we know what's coming in,” Rabrich said Wednesday at the emergency department. "But now what this does, it asks the specific questions … we've determined are the important questions to screen someone as being potentially infectious for measles.”

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It also helps paramedics and emergency responders know whether they need to put on masks and take other protective measures, despite being immunized.

“It's protecting our people too,” said Glenn Albin, who uses the app as a nurse in the hospital and as a paramedic with Rockland Paramedics. He is also the assistant chief of the South Orangetown Ambulance Corps. "That's important also, because if an EMS provider gets sick, he's not out there providing services to Rockland County.”

Other Twiage features include photos, video, voice messages, a map linked to the phone’s GPS and a chat option.

"When we're in the field trying to take care of the patient, we may not have a lot of time," Albin said, shortly after finishing his overnight shift. “From an ambulance perspective it's a way to get better communication with the hospitals.”

For a busy hospital like Nyack, which sees about 55,000 patients annually, this makes communications in suspected measles cases especially critical. The hospital had an exposure in the first week of April and needed to notify 42 people that they were at risk for contracting the virus.

When the alert on the screen is blue, emergency department staff know to hold the patient in the ambulance at the loading bay until an isolation room is available and to ensure the patient is wearing a mask.

“Then you don't have an exposure to anyone else,” Rabrich said.

'A lot of noise'

It’s more difficult to minimize exposure at a walk-in urgent care clinic like MedRite, which sits at the edge of Monsey off Route 59 in Spring Valley and has already had seven patients visit with symptoms that were later confirmed measles.

But the staff of about 20 do their best to protect those who visit, triaging patients at the front door, which displays measles warning signs in English, Creole, Spanish and Yiddish.

“We set up policies and plans based on the recommendations of the Department of Health, how to approach patients walking in,” said clinical director Eliezer Gurkov, who is also a physician’s assistant.

Because patients are contagious up to four days before a rash shows, it’s not always apparent that a person has measles. So if a person is showing any of the early symptoms –  including a fever, cough, runny nose and red, watery eyes – the staff at MedRite immediately lock the doors, give the patient a mask, put them in isolation and take blood, nasal and urine samples to be tested by the state in an Albany lab.

As for the other patients in the waiting room, the staff takes down names, immunization status and birth dates before shifting operations to a waiting room in the rear of the office. The front office is closed for the following two hours until the virus is no longer in the air.

"It does disrupt the flow and the intensity of practicing medicine," Gurkov said Wednesday while standing in the front waiting room. "Especially in this setting."

Patients are urged to call before going to a clinic, physician, urgent care or hospital if they suspect or present early symptoms of measles.

And if they do come in, patients get a primer on vaccines.

“Every patient that comes in, we have a discussion about vaccines,” Gurkov said. “It's challenging because they have a lot of misinformation of vaccines in general and particularly of the measles infection and measles disease. I guess they don't remember what measles is because fortunately we didn't have to deal with it for years.”

A anti-vaccine symposium in Monsey on Monday attracted hundreds of attendees, most of them from the Orthodox Jewish community, which is where the outbreak has hit hardest.

He said there are not a lot of people visiting the clinic who refuse to vaccinate, but they are vocal.

"They make a lot of noise," he said. "You take a tin can, you put in a whole bunch of pennies, it doesn't make noise. You put in two pennies and it makes a lot of noise. Especially with measles, it's hard to contain."

Twitter: @ReporterRox