Research Article|Articles in Press

Healthcare Associated Measles outbreak in pediatric wards in a tertiary care hospital; challenges and Swiss cheese model enforcement for patient safety

Published:March 02, 2023DOI:



      Measles is one of the most contagious of all infectious diseases, for example, up to nine out of ten susceptible people with close contact to a measles patient will develop measles. In countries where measles is rare, transmissions in healthcare facilities have been a key factor in amplifying outbreaks


      describe the hospital transmission of measles among unvaccinated children in pediatric service, challenges faced and recommendations for healthcare settings by applying the Swiss cheese model.


      Between December, 9th 2019 and January 24th 2020, multiple exposures to measles cases occurred. The incident and factors that led to the outbreak are described. The MF-NCR sequence analysis was also conducted on the three strains isolated from the cases.


      The outbreak extended from December 9th 2019 to January 24th 2019, which resulted in 110 exposed individuals (85 HCWs and 25 patients). Eleven (44%) children exposed were vaccinated, 14 (56%) were not yet vaccinated and the measles status of 10 (11.8%) HCWs was not known at the time of the outbreak. Two infants acquired measles in the hospital, and both required ICU care. Three infants and one HCW received immunoglobulin. The phylogenetic tree of the MF-NCR sequencing confirmed that all three cases had 100% identical Measles strain.


      In countries where measles elimination goals are achieved, a multifaceted approach to prevent measles transmission in healthcare is vital to maintain patient safety.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. CDC, Measles (Rubeola), for healthcare providers, Diagnosing and Treating Measles, National Center for Immunization and Respiratory Diseases, Division of Viral Diseases, Page last reviewed: November 5, 2020

        • Pillsbury A
        • Chiew M
        • Bag S
        • Hope K
        • Norton S
        • Conaty S
        • Sheppeard V
        • McIntyre P.
        The changing epidemiology of measles in an era of elimination: lessons from health-care-setting transmissions of measles during an outbreak in New South Wales, Australia, 2012.
        Western Pac Surveill Response J. 2016; 7 (Oct 19PMID: 28246577; PMCID: PMC5330218): 12-20
        • Shakoor S
        • Mir F
        • Zaidi AK
        • Zafar A.
        Hospital preparedness in community measles outbreaks-challenges and recommendations for low-resource settings.
        Emerg Health Threats J. 2015; 8 (Apr 15PMID: 25882388; PMCID: PMC4400300): 24173
      2. Global measles and rubella strategic plan: 2012-2020, World Health Organization, 2012,, ISBN 978 92 4 150339 6

        • Awaidy Salah T.Al
        • Omer Iyad
        Efforts for measles elimination in the Gulf Cooperation Council countries 2015–2019: A review.
        Journal of Emergency Medicine, Trauma and Acute Care. Jan 2021; 2020 (VolumeIssue)
        • Alkindi Nawal
        • Maskari Zaina
        • Kindi Hanan
        • Al-Jardani Amina
        Serostatus of Measles, Mumps, Rubella and Varicella in Healthcare Workers in Oman.
        Global Journal of Immunology and Allergic Diseases. 2017; 5
      3. WHO Measles Outbreak Toolkit, September 2022,

        • CDC
        Interim infection prevention and control recommendations for measles in healthcare settings.
        Centers for Disease Control and Prevention, Atlanta, GA2019 (Updated July2019)
        • Stone SP
        • Cooper BS
        • Kibbler CC
        • Cookson BD
        • Roberts JA
        • Medley GF
        • Duckworth G
        • Lai R
        • Ebrahim S
        • Brown EM
        • Wiffen PJ
        • Davey PG.
        The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection.
        J Antimicrob Chemother. 2007; 59 (MayEpub 2007 Mar 26. PMID: 17387116): 833-840
        • Bodewes Rogier
        • Reijnen Linda
        • Zwagemaker Florian
        • Kohl Robert H.G.
        • Kerkhof Jeroen
        • Veldhuijzen Irene K.
        Rob van Binnendijk, An efficient molecular approach to distinguish chains of measles virus transmission in the elimination phase, Infection.
        Genetics and Evolution. 2021; 91 (VolumeISSN 1567-1348)104794
        • Gil Horacio &
        • Fernandez-Garcia Aurora &
        • Mosquera Maria &
        • Hübschen Judith &
        • Castellanos Ana &
        • Manchón Fernando &
        • Masa-Calles Josefa &
        • Echevarría Juan.
        Measles virus genotype D4 strains with non-standard length M-F non-coding region circulated during the major outbreaks of 2011-2012 in Spain.
        PLOS ONE. 2018; 13e0199975
        • Barrett Peter
        • et al.
        A national measles outbreak in Ireland linked to a single imported case, April to September, 2016.
        Euro surveillance: bulletin European sur les maladies transmissible = European communicable disease bulletin. 2018; 23 (vol)1700655
        • Chen Sanny Y.
        • Anderson Shoana
        • Kutty Preeta K.
        • Lugo Francelli
        • McDonald Michelle
        • Rota Paul A.
        • Ortega-Sanchez Ismael R.
        • Komatsu Ken
        • Armstrong Gregory L.
        • Sunenshine Rebecca
        • Seward Jane F.
        Health Care–Associated Measles Outbreak in the United States After an Importation: Challenges and Economic Impact.
        The Journal of Infectious Diseases. 2011; 203 (VolumeIssue1 JunePages): 1517-1525
        • Sá Machado R
        • Perez Duque M
        • Almeida S
        • Cruz I
        • Sottomayor A
        • Almeida I
        • R Oliveira J
        • Antunes D
        Measles outbreak in a tertiary level hospital, Porto, Portugal, 2018: challenges in the post-elimination era.
        Euro Surveill. 2018; 23 (MayPMID: 29790461; PMCID: PMC6152427): 18-00224
        • Popescu Saskia v.
        Swiss Cheese Model - How infection prevention really works.
        Infection Control Today. 2021; 25 (January/FebruaryVolNo)