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Dealing with an outbreak

In the physician's office where I work, a patient who "felt miserable" came in for evaluation of fever, cough, conjunctivitis, and coryza (rhinitis). Mr. B was diagnosed with a viral infection and told to call if the fever worsened. The next day, he called to report a facial rash that's starting to spread to his chest. The physician suspects measles, which is transmissible to others before the rash appears. Mr. B had been sitting in the waiting room with five other people before his appointment. What should we do?-M.L., ILL.

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Although measles (rubeola) was declared eliminated in the United States in 2000, it made a comeback in 2014. At the time this issue went to press, the CDC had reported 170 cases in 17 states and Washington, D.C., in 2015.1 Highly contagious, measles is easily transmitted via aerosolized droplets that can remain in the air for up to 2 hours.


According to our consultant, a hospital-based epidemiologist, you need to identify anyone who may have been exposed to the patient, including office staff and other patients and families who shared the waiting room with him before his appointment. Measles is a reportable disease, so your local health department should be notified immediately. The public health officer will help determine your next steps.


Based on the office records of patients and staff potentially exposed to the disease, try to determine who has presumptive evidence of immunity against measles as defined by the CDC, such as written documentation of adequate vaccination or lab evidence of immunity. Those vaccine-eligible persons who were exposed and may not be immune should receive a measles, mumps, and rubella vaccine within 72 hours postexposure; the vaccine is most effective during this timeframe. For anyone who can't receive the vaccine, administer immune globulin no more than 6 days postexposure. This should be done in collaboration with the public health department.


If the patient returns to the office for diagnostic testing, he needs to apply a mask before he enters to reduce the risk of transmission. Someone should go to Mr. B's car to give him a mask and tell him not to remove it. Staff caring for the patient, even those with presumptive immunity, should wear an N95 respirator and other personal protective equipment specified by the CDC (depending on the circumstances) to protect them from infection if the mask comes off or is removed.2


Finally, remember-even during an outbreak, privacy rules still apply. Telling patients or staff the name of the patient with measles would violate the privacy provisions of the Health Insurance Portability and Accountability Act.


For more information on managing a possible case of measles, see Combatting Infection on page 62.



1. Centers for Disease Control and Prevention. Measles (rubeola). 2015. [Context Link]


2. Centers for Disease Control and Prevention. Airborne precautions. [Context Link]



Going back to nursing

I voluntarily left active nursing practice 10 years ago to raise three children. Now that they're in school, I dream of returning to nursing, but my RN license has expired. How can I turn my dreams into reality?-K.P., ARK.


Because nursing licensure and the process of licensure renewal, endorsement, and reactivation are part of your state's nurse practice act, begin with your state's board of nursing. A list of nursing boards and contact information and other valuable information are available at the National Council of State Boards of Nursing website at


Review your state's nurse practice act to update your knowledge of current nursing practice specific to your state or U.S. territory. Study everything you can find on your board's website, including information about reentry into nursing (or reinstatement) that applies to your situation. Look for a "contact us" section that includes phone numbers of board personnel who can answer your questions.


You may be required to complete your state's recommended nurse refresher process. Many board-approved nurse refresher procedures include both theory and clinical practice requirements. Follow all rules and keep careful records of all requirements, dates (started/completed), and results/scores. As needed, inform your board of your progress. Be prepared to complete a background check and a license reactivation process and pay related fees. To prepare for clinical practice, make sure your immunizations, Basic Life Support training, and malpractice insurance are current, and update your resume.


Nursing practice is constantly changing and evolving. Update your nursing knowledge by participating in free or low-cost continuing-education (CE) programs. Check your state's CE requirements and specifications, and choose CE offerings that will augment any weak or outdated knowledge areas. Study peer-reviewed nursing journals and current comprehensive nursing practice and med-surg texts and drug handbooks. These resources will be invaluable as you complete refresher processes and reenter professional nursing practice. Best of luck and welcome back!