Measles is in this news. With the recent outbreak reported in Florida and new cases in Michigan, Orthodontic Products podcast host Alison Werner spoke to infection prevention expert Jackie Dorst, RDH, BS, about what you need to know to keep the orthodontic office staff and patients safe. 

In this episode, Jackie provides: 

  • A backgrounder on measles. Like COVID, RSV, and the common cold, measles is an airborne transmitted disease. But it has the distinction of being the mostly highly infectious of those airborne transmitted diseases. Jackie explains why we are seeing outbreaks now, given that measles was declared eradicated from the United States in 2000, and the role the MMR vaccination plays in preventing infection.
  • A list of symptoms, including the one orthodontic staff are uniquely positioned to spot. Like all respiratory diseases, a cough is often the first noticeable measles symptoms, along with runny nose and a high fever. But for the oral health community, including orthodontics, there is one symptom they are in a unique position to spot before any other symptoms are noticeable: oral lesions called Koplik spots. These lesions are often found inside the buccal mucosa, or on the soft palate. Jackie recommends orthodontic offices implement a quick oral soft tissue exam to spot these lesions and then isolate the patient if so.
  • A breakdown of who is at risk. While unvaccinated children and adults are at risk, Jackie points out that infant siblings present in your office are at an even higher risk as they do not receive their first vaccination dose until age 1. Jackie also warns that unvaccinated adult members of your staff who are pregnant and acquire an infection are at risk of complications.
  • A reminder of the steps you can take to protect staff and patients from airborne diseases. Jackie walks listeners through the precautions they should have in place. She explains the importance of making sure your HVAC is working at maximum efficiency and how a carbon dioxide monitor can help you monitor the effectiveness of your air filtration. She also explains why now is the time to check your staff vaccination status, especially if you have new hires.
  • Guidance on what to do if you have an exposure in your office. It’s important to notify patients if there is a chance they were exposed in your office. Jackie explains why the notification should go out to patients who were in your office within the last 5 days, not just those who were present on the day of the known exposure.
  • Information on where to learn more. Orthodontic practices should look to their local health departments to monitor community transmission in their area; but they can also get valuable data on community transmission from their local media. To learn more about measles in general and what healthcare providers should know more specifically, Jackie recommends visiting the measles page on the CDC website. OP 

Resources mentioned in this episode: 

Podcast Transcript

Alison Werner 0:06
Hello and welcome to the Orthodontic Products podcast. I’m your host Alison Werner. We have a special episode this week touching on a timely issue that may be affecting your community and your practice. Specifically the rise in measles cases in certain parts of the United States. To break down the current situation and what the orthodontic team needs to know to protect staff and patients is infection prevention expert Jackie Dorst. Jackie, thanks for joining me today.

Jackie Dorst 0:30
Thanks, Alison. It’s always good to share information with your viewers.

Alison Werner 0:35
Great. Well, so I know this is a topic that came up recently on the AAO Staff Club Facebook group. So some of our listeners may be aware of the outbreak in Florida and more recently, they there have been some cases in Michigan. Can you talk about what’s currently going on?

Jackie Dorst 0:52
Yes, the Michelle Ritterscamp with AAO, who manages the AAO staff club, had read about increasing numbers of measles cases in the United States. And she contacted me and she said, Is this a concern for ortho offices? And if so, is there some information that we should be sharing? And so I put together a short informational posting to include on the staff club webpage or a Facebook page with them about the current status of measles infections in the United States, and concerns for the orthodontic office and how we can manage these potential infections if they had an outbreak in their community. So it’s very timely information as this, it seems like daily that I’m getting updates from both CDC and in the news media about measles cases in different communities.

Alison Werner 1:49
Okay, so let’s talk about measles. It actually was declared eradicated in the US in 2000. But there have of course, been outbreaks since then they are increasing. So what do we need to know about measles?

Jackie Dorst 2:04
Well, measles is caused by a virus. It is an airborne transmission of the virus. And it is the most highly infectious of airborne transmitted diseases. You know, we learned about R-naughts the infectivity during the pandemic, and it has an R naught of that estimated between between 15 and 18, and is used as the standard really for how infectious are airborne diseases. Measles is a childhood disease that is vaccine preventable. The vaccine is very effective, over 90% protection from it. But we have to have vaccination of 95% of the population to provide that herd immunity. So with the pandemic, interrupting socially and healthcare wise vaccination rates, we’ve seen a drop in the vaccinations and even prior to that, for whatever reason, there have been communities where vaccination levels have dropped below that 95%. And since 2000, there have been a few years where there was an incidence of measles back diseases with it, and believe the year was 2014. Just to give you an example, Alison, that there was one child who visited Disneyland in California that was infected with measles. And within 14 days, there were over 800 cases of measles that cropped up because of that one child, the zero patient, if you will, being at Disneyland. So we’ve seen, you know, just a few cases, again of this vaccine preventable diseases until 2019. And then in 2019, it was is if the herd immunity was lost, we dip down in enough communities that there was a peak in infections. And in 2019, there were actually 1,274 infections and the health the public health, you know, was concerned. And then what happened? We had the pandemic and all of the respiratory protections that was implemented with wearing masks, hand hygiene, fresh air in the office and air filtration to prevent COVID transmission prevented respiratory diseases in general, both influenza, colds, RSV, and potentially measles with it, and we didn’t see another incident. Now, as we’ve exited the pandemic, we’re in our new normal with it now. People have dropped precautions, right. And we’re getting out socially and we’re going to sporting events and entertainment events where there’s crowds of people and traveling a lot more internationally. And yes, measles was supposed to have been eradicated from the United States in 2000, but not globally. And that’s where we’ve seen, there are other countries where there are higher rates, such as in India and in England, that we’re seeing higher rates of measles transmission. And with travel, then you can have patients come back to the United States that acquire an infection. Unvaccinated people, even adults are at risk of an infection, but especially infants. An infant under one year old, they don’t receive their, their measles vaccine, their MMR vaccines, measles, mumps, and rubella. All three vaccines are given when the baby’s one year old. Younger than that they have their mother’s protection with it, and their immune system hasn’t developed enough for them to produce antibodies with it. So that’s why that vaccinate vaccination is scheduled for the one year mark on it. And babies could get infected during that international travel with it. So highly infectious airborne disease.

Alison Werner 6:10
So what are some of the symptoms that people should be looking out for?

Jackie Dorst 6:15
Well, like all virus, respiratory diseases, that cough, you can have a cough with it, runny nose, oh my gosh, that is one of the first symptoms that you’ll see. And high fever, fever will run up to 104, possibly 105 with a measles infection. But for us in the orthodontic world, in oral health, one of the first symptoms will be lesions inside the mouth. Before they might even develop the cough or the fever, there is a unique oral lesion called a Koplik spot. And I think you’ve got some photos of it that you can bring up with us for our viewers to see with it. And they’ll usually be on the inside of the buccal mucosa, or on the soft palate. So that’s one of the things that I would encourage ortho offices, if you hear of a one or two cases, even in your community, start doing that oral exam, you know, when we look at a patient’s mouth, the first thing they’re going to look at is the alignment of the teeth. And are there any brackets off? And you know, are we changing archwires today? Or are you due for a new aligner with it? But look on the inside of the cheek, look at the soft palate, do that quick oral soft tissue exam. And if you see any of those Koplik dots, then definitely that’s an alert. I would segregate the patient into another room even not even in the open bay area. Because this virus with it being an airborne disease, it can stay suspended in the air for up to two hours after an infected patient is even sitting in the reception room for 15 minutes or in the open bay. So you would want to segregate them immediately. And then dismiss them and reschedule them for another appointment and just say, you know, we are suspicious of this, looks like we’re not definite, please go see your doctor. And because we don’t have I airborne isolation rooms in our ortho office. So you don’t want to put the rest of the team or other patients at risk.

Alison Werner 8:23
Okay. And then what are the complications with measles?

Jackie Dorst 8:27
Well, a measles infection, we think of it is a childhood disease and you know you’re sick for a week or so stay out of school. I was born before 1957, which is the year that the measles vaccine was introduced in it and we saw mass vaccination starting in the 60s with it. And CDC says that anyone born before 1957 is assumed to have acquired immunity having had that infection. And I remember when I had it, and one of the things is having ear complications with it. The infection can actually affect the ear and cause hearing loss that is a lifelong hearing loss or affects the eyes. I remember both with chickenpox and measles, my mom said, Hey, I’ve got to stay in a dark room, you’re not gonna play outside in the bright sunshine, while you have that ocular eye infection. And of course, it’s the rash over the full body. The high temperature can be a risk with it. And it can be there are fatalities with it. Not a lot. It’s you know, maybe one in 1000 and it’s usually from complications such as developing pneumonia. So initially, the cough, runny nose with it and the high fever and of course, like any viral infection, the aches and pains, the fatigue with it, but those oral lesions are a real early symptom that we can identify in our orthodontic practices.

Alison Werner 9:57
Okay, so you talked about the oral exam and those are only And so what can staff do? What can the ortho team be doing to protect staff and patients?

Jackie Dorst 10:08
Well, let’s go back to what we learned during the pandemic. And it’s about protecting against all of those airborne diseases. And I’m going to call in CDC refers to them as ILI, influenza like illnesses. So flu, RSV, colds, all of those diseases that can be transmitted in the air, then we want to take precautions. So number one, how is your heating and air conditioning system working is it at its maximum efficiency, you want to have at least six air changes per hour. When have you change your your filter on the heating and air conditioning system. We learned that a MERV 13, minimum efficiency reporting value, provides at least 50% filtration of point three micron size particles. And that should be changed on a regular basis. I can’t give you how often, it depends on how busy your ortho practice is. If you’re working four days a week, and you’re seeing 200 patients a day, you probably need to change your filter more frequently than an office that works three days a week and maybe sees 40 to 60 patients. So what’s the traffic in your office how you know that you need to change that filter. And I would suggest at least once a quarter if not once a month, depending on the traffic with it, and then you want as much fresh air coming into the building as possible. And we use an indirect way of measuring that looking at the carbon dioxide. Because the more densely populated we have the office, more patients the team members in the office. If that carbon dioxide where we’re exhaling each time gets above 800 parts per million, then the risk of acquiring an airborne infectious disease is greater normal outdoor carbon dioxide levels are at 400 parts per million. So keeping a simple co2 monitor that you can buy online, in the reception room and in the open bay area is a good way to monitor, Do we have enough fresh air in our office. And then I would definitely check with the vaccination status of all your employees. I think that’s important. We’ve had new team members join our offices as we had some maybe early retirements during the pandemic, if you have a team member who was not vaccinated as a child, then they’re going to be at high risk of acquiring infection, and especially for say, young women in their 20s and 30s who could possibly be pregnant. If they were not vaccinated and acquire a measles infection, then it could affect their developing fetus. So again, recommending they go get that vaccine. It’s one of the vaccines recommended for all healthcare providers by CDC in the US. And even if they haven’t been previously vaccinated, if you had an outbreak in your community and a patient was identified as infectious, then go get that vaccine right now because even you having that vaccine before you develop signs or symptoms can help reduce symptoms or even prevent an infection. So it wouldn’t be too late to say, oh, I’ve already been exposed. The vaccine won’t do me any good.

Alison Werner 13:28
Okay. And then what should offices do if there is an exposure in their office?

Jackie Dorst 13:34
Because the disease is so highly infectious, let’s say you do have that patient come in, and you do the oral exam and you see the lesions and you go, I would go ahead and notify patients that, you know, there has been a measles outbreak in the community, and it’s been identified in within your office because of the risk. You want to notify patients. And if those patients have any unvaccinated family members or patients that were in your office within the last five days or so, because again, patients can be infectious before they show signs or symptoms, and then they’re highly infectious for that three to five days afterwards. I would say, Please watch for symptoms. And if you do observe symptoms, please immediately go for a measles vaccine, see your physician and go from measles vaccination. And I would say watch for symptoms for 14 days, because the incubation period can be anywhere from 10 to 14 days with measles.

Alison Werner 14:40
Okay. And then just to go back to keeping the ortho team and patients say, what are the masking what what do you recommend in terms of masking just to keep the practice safe?

Jackie Dorst 14:52
Well, I’ve had a there’s a debate and it’s just going to be an office policy at this time. Ortho offices need to watch for postings on their local health department about airborne diseases especially such as measles, and we’re going to see other emerging and reemerging diseases in the future. So you just need to stay aware of community transmission and your office, verify that you are current with your infection control standards with your know what your disinfectants are, are they effective against healthcare acquired infections. And speaking of that, EPA, which regulates disinfectants, now just published a new blood borne pathogens list that is called the EPA List S. And it combined about five different lists that EPA had. So you want to make sure that your, your disinfectant that you’re using is on that List S, you know, as a health care disinfect disinfectant. Review your airborne disease transmission precautions, and then screening patients with it. Wearing a mask is always from the respiratory disease system from October until April a wise precaution. It is a prevention with it. And it doesn’t have to be that N95 respirator mask. It can be a level two, or a level three. Both of those procedure masks provide the same level of particle filtration. With them, the only difference is a slight fluid increase with the level three on there. So it would be wise to wear that mask as a prevention for both the front desk team and the clinical team. Because this disease is not one that’s just transmitted in blood or saliva, it’s airborne. So the entire team needs to be protected. And many hospitals during the season are reimplementing mas protocols for both visitors, patients and staff during this time, especially during the community outbreak, so you have to use good professional judgment and keep up with community transmission of diseases in your area.

Alison Werner 17:05
Right. And they can find that information through their their local health department.

Jackie Dorst 17:10
The their local health department. And I have in my Google Alerts. That’s what I go through every morning what pops up in the entire United States and even globally on safety and infectious diseases. But the health department in both the media, the media has been good to alert about the outbreaks that are in Florida now. I know this morning, I saw three new cases that were just in Michigan. And when you have an outbreak there, it can spread like fire through a community because of the high infectivity and the airborne disease. So keeping up with your your local health department is one of the best ways to stay informed.

Alison Werner 17:52
Okay. And I know you wanted to make a recommendation to doctors to visit the CDC website page focused on measles. Should they Well,

Jackie Dorst 18:01
as the case has started reemerging. I thought I need to review what are signs and symptoms complications. And the CDC are this is another improvement that we’re seeing post pandemic with it. CDC is updating their website. I didn’t realize it but there are over 220,000 web pages in the CDC website. And if you’ve been looking for information, and especially during the pandemic, we will all spend maybe two or three hours trying to find a specific page with it. They are in the beta test. Now I was privileged to sit in on the initial introductory meeting for that last week. And it’s going to be a huge improvement. Much, much more user friendly, easy to locate information with it. And we won’t lose information as the CDC is revamping their website. Some of it that’s not that’s it will be archived. And it will still be available if you want to do a deep search on it. But it’s going to bring up the more relevant information and as things change that there’ll be posted with it. So I looked up measles on the CDC website, you’ll go to the main page, then go down to what health care professionals need to know. Click on that. And there is an educational video. And the same PowerPoint slides that were used in the video that came were posted in last fall. And it was from what’s called COCA and it’s the communication on for communities on issues of health for CDC that they put out and they do COCA calls routinely with emerging issues such as measles with it. And just reviewing those the PowerPoint slides, it took me about maybe five to 10 minutes to click through about 40 of those relevant slides. How the disease is transmitted, what are the symptoms? What’s the prevention with it? And what are the risks or complications with the disease? I think it’s wise for every doctor and for the clinical team to quickly review those slides. If they prefer to listen to the video, they have the option of listening to the video just to update themselves on measles, and the measles complications with it and how it could affect the orthodontic practice.

Alison Werner 20:26
Okay, well, we will provide a link to that measles website, as well as the direct page for the video and then a direct page or direct link for the for the PowerPoint slide, Jackie, as always, it’s great to see you and thank you so much for all this information.

Jackie Dorst 20:44
Well, thank you for sharing this information. I think it’s very timely Alison. And my hope is that this measles infection will just be a little blip. But it’s wise for us to share the information in case there are is a bigger spread with communities. And the orthodontic team knows how to care for patients safely and to prevent transmissions in their office. So thank you for sharing the information about the AAO’s orthodontic staff club and the AAO being proactive and sharing this information and for getting the information out. There are always emerging issues that we can do to be the best in our orthodontic practices.

Alison Werner 21:28
Exactly. All right. Well, thank you so much. As always, thank you for joining us. Be sure to subscribe to the orthodontic products podcast to keep up with the latest episodes. And be sure to check out orthodontic products to keep up with the latest industry news. Until next time, take care.