measles best practices - california hospital …...measles best practices may 21, 2019 welcome bj...

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Measles Best Practices

May 21, 2019

Welcome

BJ BartlesonVice President, Nursing & Clinical ServicesCalifornia Hospital Association

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Faculty

Dr. Kathleen Harriman, Chief, Vaccine Preventable Disease Epidemiology Section, Center for Infectious Diseases, California Department of Public Health since 2007. Prior to that, she worked for 15 years as an infectious disease epidemiologist at the Minnesota Department of Health, including supervising the statewide infection control program. She has been actively involved in both vaccine use policy and vaccine-preventable disease prevention and control policy at the state and national levels. She has also worked on a number of large vaccine-preventable disease outbreaks, and provides guidance on management of vaccine-preventable disease cases.

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Faculty (cont.)

Chelsea Driscoll is the Acting Chief of Policy and Planning for the Licensing and Certification Program in the California Department of Public Health, with over 19 years of policy experience in various topics including: public health, social services and public safety. She oversees Policy and Enforcement Branch, Professional Certification Branch, Research and Evaluation Branch and the Resource and Management Branch. Previously served in various policy roles within the program over the last nine years.

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Faculty (cont.)

Gail Blanchard-Saiger is the Vice President & Counsel of Labor and Employment for the California Hospital Association. In this role, she provides leadership for state and federal legislative and regulatory issues related to hospital human resources and labor relations. Ms. Blanchard-Saiger has over more than 15 years of experience as a labor and employment law attorney representing hospitals and health care systems. She is a member of the American Society for Healthcare Human Resources Administration and serves on its Advocacy Committee.

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Faculty (cont.)

Susie Benson, RN, MPH CIC Ms. Benson is the Manager, Infection Prevention & Regulatory Compliance with Enloe Medical Center in Chico, California.

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Faculty (cont.)

Diane Wynn, currently Vice President of Risk Services and Patient Safety at MemorialCare Medical Group. Has extensive operations experience and has recently served as the interim Chief Nursing Officer for one of our campuses. Starting her career as a bedside nurse, Ms. Wynn has worked in risk and patient safety for decades, always advocating to doing what’s best for the patient and family as the right thing to do. She has facilitated multiple projects and process improvements throughout the MemorialCare system.

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Kathleen Harriman, PhD, MPH, [email protected]

510-620-3767

Measles Control in Healthcare FacilitiesCHA Webinar – May 21, 2019

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Measles Background - 1• Measles is an acute viral disease characterized by fever, cough, coryza, conjunctivitis and a

descending maculopapular rash; most patients recover without complications, but measles can result in encephalitis and pneumonia, and in some cases, death + the late complication of subacute sclerosing panencephalitis (SSPE)

• Measles virus is transmitted by the airborne route and can remain suspended in the air and travel via air currents to infect people at some distance away from the infected person for up to two hours after the infected person has left the area

• Measles is one of (if the not the most) highly infectious diseases; 90% of susceptible persons who are exposed will become ill

• Measles R0 = 12-18; in comparison, the R0 for influenza = 1-3

• To achieve herd immunity for measles at least 90-95% of the population must be immune

Measles Background - 2• In the pre-vaccine era there were ~3 to 4 million measles cases in the United

States each year, including 48,000 hospitalizations and 400 to 500 deaths • The first measles-containing vaccine was licensed in the United States in 1963

and one dose of vaccine was recommended until 1989 • The last large measles outbreak in the US was from 1989-1991; during this time

there were over 17,000 cases and 70 deaths in California • This outbreak was primarily caused by low immunization rates among poorer

children who had limited access to vaccines• After this outbreak, two doses of vaccine were recommended and the federal

Vaccines for Children program began 1 dose: 93% effective 2 doses: 97% effective

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Measles Background - 3• Measles was declared eliminated from the US in 2000

• However, measles is still endemic in many areas of the world, including Europe, Asia and Africa

• The US is at continued risk of imported measles cases from infected travelers; there are >8 million visitors to California each year from countries other than Canada and Mexico

Current World Measles Situation• Measles incidence has been increasing worldwide The number of measles cases reported worldwide in the first three months

of 2019 has quadrupled compared with the same time last year

• Much of this increase is due to a few large outbreaks Philippines: >51,000 cases and 614 deaths since 2018o In 2019: >31,000 cases and 415 deaths Ukraine: >98,000 cases and 32 deaths since 2018o In 2019: >44,000 cases and 16 deaths Madagascar: >117,000 cases and >1,200 deaths since 2018

• The outbreaks in the Philippines and Ukraine have been sparked by vaccine hesitancy

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Number of Reported Measles Cases, October 2018-March 2019

https://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/

Ukraine Measles Outbreak• Ukraine’s measles vaccine coverage among 1 year olds dramatically dropped

from 97% in 2008 to 42% in 2016 The rate could have been worse because parents can buy certificates of vaccination from

doctors for school entry• Why did coverage drop? Vaccine shortages occurred amid delivery disruptions due to conflict in eastern Ukraine

where >10,000 people have died in fighting against Russian-backed separatists since 2014 However, the biggest reason is parent and physician concern about vaccine safety after

the widely reported death of a 17 year old boy in 2008 after he received measles vaccine manufactured in India

WHO investigated and insisted that the vaccine did not play a role in his death, but this hasn’t stopped the concern

• There are an estimated 80,000 Ukrainians and Russians in Sacramento County; immunization rates are lower in this population

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Philippines Outbreak• Measles is endemic in the Philippines but the current outbreak was sparked by

problems associated with a government led dengue vaccination program

• In April 2016, the previous government launched a mass vaccination program against dengue and ~830,000 school children received the vaccine

• In November 2017, the vaccine manufacturer announced that the vaccine could lead to severe cases of dengue in people who had not previously had the disease

• The announcement alarmed parents whose children had been vaccinated, and some politicians and the media linked deaths to the vaccine with little or no evidence, which led to many parents rejecting all vaccines

• The California Filipino population is estimated at 1.6 million, and is the largest group of Asian Americans in California, and is by far the largest U.S. Filipino population

United States Measles Cases by Year, 2010-2019*

*From January 1 to May 17, 2019, 880 cases of measles have been confirmed in 24 states. This is the greatest number of cases reported in the U.S. since 1994 and since

measles was declared eliminated in 2000.

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New York Measles Outbreaks• In 2018, measles outbreaks began in New York City and New York State when

travelers who were exposed to measles in Israel returned to the United States; over 1,300 measles cases were reported in Israel in 2018; an outbreak started by Israeli travelers who had visited Ukraine

• The US numbers are being driven by cases in New York City and New York state; since September 2018, 498 cases have been reported in Brooklyn and Queens and 278 cases have been reported outside of New York City, most in Rockland County

• Almost all cases have been ultra-Orthodox Jews; some yeshiva schools have vaccination rates as low as 60%

• Health officials and sociologists say the reasons for low vaccination rates among this group are complex but they are in part related to the wider global anti-vaccination movement

Current California Measles Situation

• As of May 15, 45 measles cases had been reported in California in 2019

• Most measles cases have received healthcare while infectious; often there several visits before measles is suspected because people with measles are usually quite ill and infectious before the rash appears

• Each visit to a healthcare facility by an infectious measles patient results in many exposures to patients, visitors, and staff – there are often hundreds of contacts

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County Total cases Pediatric cases (<18 years) Adult cases (18+ years)

Alameda 1 0 1

Los Angeles 10 1 9

Orange 2 1 1

Placer 3 2 1

Sacramento 3 2 1

San Francisco 1 0 1

San Mateo 4 1 3

Santa Clara 4 1 3

Santa Cruz 1 0 1

Other 16 3 13

Total 45 10 28

Reported Measles Cases in California, 2019*

*As of May 15, 2019

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What happens when there is a measles exposure in a healthcare facility?

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Pretty much this…

• Measles transmission in healthcare facilities is well documented, including in physician offices, emergency rooms, and hospital inpatient units

• Healthcare workers have been infected in recent U.S. measles outbreaks, including in California

Then What? Steps in a measles exposure investigation

1. Contact facility infection control staff, and notify the local health department if they haven’t already been notified

2. Determine if patient was immediately masked at or before facility entry and placed in an airborne infection isolation room (AIIR)? If no, an exposure investigation must be conducted All steps should be completed as soon as possible This is a team effort; steps should be completed concurrently

3. Define exposure area and exposure time period Determine the affected airspace (area in the facility where people were potentially

exposed)o There are no guidelines for this but knowledge of facility’s air handling system is helpfulo Most often, the affected area is defined as the combined waiting and exam room area

Determine when patient entered the area and when the patient left the facility or was placed in an AIIRo If number of air changes per hour (ACH) is unknown, exposure time is the time

the patient was in the area (not in an AIIR) + 1 houro If ACH of area is known, and is >12 + 35 minutes

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Next steps4. Identify all people (patients, visitors, and staff) in the affected airspace during

the exposure time If the exposure occurred in an outpatient facility, it is typically not possible to

identify people who accompanied the patient of record unless it’s a parent; this must be done later

5. Check the measles immunity status of exposed healthcare facility staff, ascertain whether immunization data are available for patients, and review list of patients to identify those at high-risk of infection or severe disease Pregnant women Severely immunocompromised people Infants <18 months of ageo If infants are identified, ensure availability of intramuscular immune

globulin (IMIG) for postexposure prophylaxis (PEP)o Hospitals typically don’t stock IMIG and it may need to be ordered

High-risk people

• Exposed people are considered high-risk when they are at risk for serious disease, they’re likely to have contact with people at risk for serious disease, or they’ve had an intense exposure to measles Additional evidence of immunity is required for exposed high-risk people Healthcare workers of any age Pregnant women Household contacts of a case of any age Persons of any age in settings with high-risk or unvaccinated persons

• Such persons must have documentation of two doses of measles-containing vaccine, or serological evidence of measles immunity (measles IgG+)

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Next steps• Healthcare facility employee exposures Per Cal OSHA Aerosol Transmissible Diseases Standard requirements and CDC

recommendations, healthcare facilities should know the measles immunity status of all employees who could potentially be exposed to measleso Immunity to measles may be made a condition of employment for employees and may

also be required for volunteers, and per the contract for contract employees o Immunity to measles may be tied to credentialing for non-employee physicians Exposed employees should receive post-exposure prophylaxis (PEP), if indicated Exposed employees without evidence of measles immunity should be furloughed

from work from day 5 after first exposure through day 21 after last exposure unless proof of immunity is provided via immunization record or IgG testing All exposed employees, regardless of measles immunity status, should be advised

to monitor themselves for measles symptoms for 21 days after last exposure and immediately isolate themselves and notify employer if any symptoms develop

Evidence of measles immunity in healthcare workers

• Documentation of vaccination with 2 doses of live measles virus-containing vaccine*, or

• Laboratory evidence of immunity†, or • Laboratory confirmation of disease, or• Birth before 1957§

*The first dose of MMR vaccine should be administered on or after age 12 months; the second dose of measles- or mumps-containing vaccine should be administered no earlier than 28 days after the first dose. †Measles IgG in serum; equivocal results should be considered nega ve.§Although most persons born <1957 will be immune to measles, not all will be. Healthcare facilities should consider vaccinating HCP born <1957 who lack evidence of measles immunity. In the event of an exposure, healthcare facilities should ensure that such persons have had 2 documented doses of MMR vaccine or serological evidence of immunity.

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Next steps6. Contact identified high-risk patients as soon as possible High-risk patients (or their parents) should be contacted by phone It should be determined:o If infants aged 12-18 months have received a dose of MMR vaccineo If pregnant women can produce records of two doses of MMR vaccineo If immunocompromised people are severely immunocompromised using IDSA

criteria (Rubin LG, et al. Clin Infect Dis. 2013;58(3):e44-100)o Whether anyone else was with the patient at the time of exposure, and whether

they are high-risk (as above), a healthcare worker, or potentially susceptible to measles

If PEP is indicated, is the patient still within the time window to receive it?

Next steps7. Contact all other potentially exposed patients If number of patients is manageable, other patients should also be contacted by

phone If the number of patients is too large for phone calls to be practical, a certified letter

may be sent; or in some healthcare systems, an emailo CDPH has template interview forms and letters

Query the patient about their risk status and ask about people who accompanied patient to facility and determine if they are high-risk (susceptible pregnant woman, or severely immunocompromised person), healthcare workers, unvaccinated infants or other people who are potentially susceptible to measleso If patient is woman of childbearing age, is she pregnant?o Is patient severely immunocompromised?o Was a high-risk person with the patient at the time of exposure?

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Next steps

8. Attempt to determine the measles immunity status of exposed people Has exposed person been vaccinated against measles? Has exposed person had measles disease? Does exposed person meet any CDPH criteria for presumptions of

immunity? Patients without a presumption of immunity and or documentation of

MMR vaccination, but who think they were vaccinated should be offered IgG testing to determine measles immunity status Patients should be queried about people who were with them when the

exposure occurred, and as such people should also be evaluated as above

Presumptions of immunity for people who are not high-risk*• CDC presumptions of immunity for people who are not high-risk Birth prior to 1957; or Documentation of at least 1 dose of measles-containing vaccine; or Serologic evidence of immunity

• Additional CDPH criteria for presumptions of immunity for people who are not high risk (unless known to be unvaccinated) Born outside the U.S. prior to 1970 AND moved to the U.S. in 1970 or later; OR Born in any country in 1970 or later and attended a U.S. primary or secondary

school; OR Served in the U.S. armed forces; OR Entered the U.S. >1996 with an immigrant visa or have a green card

*These criteria do NOT apply to healthcare workers

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Next steps9. If PEP is indicated, and it is within the time window for the indicated PEP, it is the

healthcare facility’s responsibility to arrange for PEP administration Unvaccinated people >12 months of age should receive MMR vaccine if it is <72 hours of

exposure Exposed infants <12 months of age and unvaccinated children <66 pounds should

receive intramuscular immune globulin (IMIG) if it is <6 days of exposure Susceptible pregnant women should receive intravenous immune globulin (IVIG) if it is

<6 days of exposureo If woman thinks she was vaccinated but doesn’t have records, measles IgG testing for

immunity may be done if there is time to get back results and still give IVIG if needed Severely immunocompromised people should receive IVIG regardless of their measles

immunity status if it is <6 days of exposure

It is common for healthcare facilities to be learn about case confirmation when there is very little, if any, time left in the PEP window, which is why

time is of the essence in measles exposure investigations

Next steps• It’s important to note that measles IgG testing in commercial laboratories may

not be sensitive enough to detect adequate antibody levels in all immune people If tested person is IgG negative and is likely to have been vaccinated, blood should

be retested in the CDPH Viral and Rickettsial Diseases Laboratory • Public health should be notified of all high-risk patients, visitors and staff in

case further actions are needed such as quarantine or exclusion from high risk settings

• Susceptible contacts who did not receive timely PEP Home quarantine and exclusion from high-risk settings (childcare settings with

unvaccinated infants, healthcare settings)• Susceptible contacts who received timely PEP Exclusion from high-risk settings Infants <12 months of age, pregnant women, severely immunocompromised

people, household members of case without documented immunity

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Don’t let this happen to you: Arizona measles outbreak, 2008• In February 2008, an infected Swiss traveler sparked a measles outbreak in

Arizona involving 14 cases, seven of whom were infected in healthcare facilities; measles was not suspected until after the index patient had been hospitalized, unisolated, for two days

• Ten cases didn’t receive a prompt measles diagnosis after rash onset and only one was masked and isolated promptly

• 8,231 people were potentially exposed; 4,793 were hospital or clinic patients and 2,868 were HCP

• 25% of 7,195 HCP who were screened lacked evidence of measles immunity; 1,583 underwent IgG testing and 121 (11%) of 1,077 HCP born >1957 and 18 (4%) of 506 HCP born <1957 were seronegative, including one who developed measles

• The two hospitals involved spent ~$800,000 responding to and containing the seven measles cases in their facilities

Chen et al. J Infect Dis. 2011 Jun 1;203(11).

Lessons learned from investigating healthcare facility measles exposures

• Rapid identification and isolation of suspect measles cases is key• Good documentation and high levels of healthcare worker measles immunity minimize

the amount of follow-up necessary in the event of an exposure Record review for possibly hundreds of staff Serologic testing and PEP for many people; furlough of susceptible healthcare workers

• Healthcare workers should have evidence of measles immunity, even those born <1957 should have documentation of immunity if exposed CDC does not recommend measles IgG testing of healthcare workers with 2 documented

doses of MMR vaccine

• Healthcare workers with evidence of measles immunity have been infected All healthcare workers exposed to a patient with measles should self-monitor for symptoms All healthcare workers providing care for measles patients should wear an N95 respirator

• Measles symptoms may be modified in persons with a history of measles vaccination

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Measles resources• CDPH measles page https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/measles.aspx

• CDPH measles toolkit http://izcoordinators.org/outbreaks/measles-toolkit/ Username: Measles Group Password: Vaccinate!

• CDPH healthcare worker immunization and immunity testing recommendations https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization

/HCWIZRecs.pdf

• CDPH measles posters, etc. http://eziz.org/resources/measles/

• CDC measles page https://www.cdc.gov/measles/index.html

Outbreak Reporting Requirements

Chelsea Driscoll, Acting Chief of Policy and Planning, Licensing and Certification ProgramCalifornia Department of Public Health

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Requirements to Report Outbreaks and Unusual Infectious Disease

Health facilities licensed by CDPH Licensing and Certification (L&C) are required to report outbreaks and unusual infectious disease occurrences to the local public health officer and their respective District Office (DO)

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Requirements to Report Outbreaks and Unusual Infectious Disease (cont.)

• Outbreaks• Unusual Disease• Unusual Occurrences

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Examples of Reportable Incidents: • Single case of colonization or infection with a novel

multi-drug resistant organism (MDRO) that was never previously or only rarely encountered in California, such as: – Candida auris– pan-resistant MDRO

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• Single case of measles in a patient not placed into airborne isolation precautions upon facility entry, or a healthcare worker or other employee

• Single cases of healthcare-associated legionellosis • Cluster or suspected transmission of any MDRO

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• Outbreak or increased incidence of disease due to any infectious agent occurring in residents or persons working in the facility, such as: – Staphylococci – Clostridium difficile

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• Intra-facility infectious disease outbreak of influenza, gastroenteritis, pneumonia, or respiratory syncytial virus

• Foodborne infectious disease outbreak • Clusters of positive tuberculosis test conversions

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The examples are not an all inclusive list. Rather, it should be used as a guide when making a determination on whether or not to report an occurrence. If in doubt, report.

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Role of the Agency• The local public health department recommends control

actions and may conduct an epidemiologic investigation• The DO makes a determination on regulatory follow-up

action, which may include an onsite survey. • The CDPH Healthcare-Associated Infections (HAI)

Program is available to local public health authorities and L&C for consultation on infection control and containment measures.

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If you have any questions, please contact your respective L&C District Office or the HAI Program ([email protected]).

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Questions

Online questions:Type your question in the Q & A box, press enter

Phone questions:To ask a question, press *1

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HR and Employee Health Considerationsfor Measles

Gail M. Blanchard-Saiger, Vice President & Counsel, Labor & Employment, CHA

LA County Department of Public Health Letter

• On Tuesday, April 30, the Los Angeles Department of Public Health (LA DPH) released a letter to all hospital administrators in its jurisdiction, with requirements and recommendations for steps for hospitals to take with their employees and contractors related to measles immunity.

• This letter included new requirements for hospitals when they had a suspected or confirmed case of measles.

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LA County Department of Public Health Letter (cont.)

When there is a suspected or confirmed case of measles:• Submit to LA DPH a line list of individuals, including

other patients, family members, staff and contractors, who were present at the facility and potentially exposed to sharing air space while a patient with suspected or confirmed measles was present and for up to two hours afterwards. This needs to be submitted within one working day.

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• Develop a list of all staff and contractors, not just health care workers, with their measles immunization/immune status

• Immunization status would be considered: 2 doses of the Measles, Mumps, and Rubella (MMR)

vaccine; or Laboratory evidence of immunity (measles lgB positive)

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• If the individual cannot provide satisfactory documentation of 2 doses of live measles (MMR) immunizations or laboratory evidence of immunity (measles lgB positive) to LA DPH, he or she will be excluded from work until his or her immunity can be established or they no longer present a substantial risk of developing measles and transmitting it to others, which could be for up to 21 days after their last exposure

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Survey of Hospitals in LA County

• May 3-6, CHA surveyed hospital HR and Employee Health staff for hospitals in LA County

• 44% of respondent hospitals do not require measles immunity as a condition of employment If there were an exposure of measles, they may have

many staff without immunity who might not be cleared to work

Even where it is required for a condition employment currently, most hospitals have tenured staff that were not subject to that requirement when hired

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Survey of Hospitals in LA County (cont.)

• Of those hospitals that do not require measles immunity as a condition of employment, 43% do not document measles immunity

• If there were a measles exposure, even if it was only suspected and the case was not confirmed, they would have significant work to do to document immunity and provide to the county within one working day

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Other Local Health Jurisdictions

• As of today, CHA is not aware of other local health jurisdictions (City or County Public Health Departments) that have issued similar requirements in writing

• However, it is likely that other counties would take a similar approach and at least one has taken that approach verbally

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Enloe Medical Center

Susie Benson, RN, MPH CIC Manager, Infection Prevention & Regulatory ComplianceEnloe Medical Center

May 2019

Devising Our Measles Readiness “Checklist” – for CHA Webinar

Diane Wynn, RN, MSNVice President, Risk Management Services

Dana Platt, RN, MSHCAExecutive Director, Clinical Risk & Patient Safety

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What/Where is MemorialCare?Southern California

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Measles Readiness Checklist and ConsiderationsWho, what, when, where, why, how, which…

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6 BIG KEYS• Establishing leadership oversight• Assessing workforce status• Ensuring vaccine and titer availability or “triaging”

plan• Determining approach to vaccination/titer gaps• Communication, communication, communication• Creating patient-facing guides and resources

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Establishing Leadership Oversight

Initiatives Key Activities/PlanEstablish a Planning Group and Cadence

• Create a cross functional system-wide team including: Physician Leaders, Human Resources, Epidemiology, Employee

Health, Pharmacy, Lab, Nursing, Emergency Department Group scheduled for weekly call and prn Led by system-wide patient safety/risk

• Team review and completion of checklist needs and adds• Coordinating communication needs for leaders, staff,

physicians (“question of the day influx”)

“Aim. Plan. Do. Study. Act.”

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Assessing Workforce Protection Status

Initiative Key Activities/PlanEvaluate immunization/immunity of workforce to ensure both availability of “staff” and protection of patients during an outbreak

• Evaluate titer/immunization status of workforce Reports by entity Actual lists

• Obtain physician immunity status / lists from Medical Staff or central verification location Question on accuracy as self-report through

credentialsConsiderations for contract “staff”

• Review and consider planning needs for outsourced services, registry, dialysis, travelers

• Don’t forget locum physicians

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Ensuring Supply of Titer Reagents and Vaccines

Initiatives Key Activities/PlanVaccine and Reagent availability

• Work with Pharmacy and Lab leaders to assess and sync to policy/approach plan

• Merck vaccine manufacturer Assess ability to obtain: currently no shortage, and do

not anticipate one; however many facilities across U.S. have started to stock up on vaccine from the distribution centers so they are now releasing it in “batches”

• Titer reagent availability

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How to Approach Titers and (re) Vaccinations

Initiative Key Activities/PlanDetermination of approach to protection

• Considerations on how to think this through Will you make it recommended or mandatory? Free of charge to physicians? Thoughts on making this a requirement for employment (ex. we

have a “mandatory flu protection program – vaccine or mask”)Organize entity teams to facilitate titer/vaccination for non-immune or “under-immunized” staff and physicians

• Review plans location by location (e.g. based on local employee health staffing/resources) Consideration of modified duty / return-to-work staff

• Consideration of priority “first” areas (e.g. ED, urgent care, clinics, pediatrics, etc.)

• For physicians, create logistics for titer if requested (+/-)

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Communication, Communication, Communication

Initiatives Key Activities/Plan

Employee Communication

• How to communicate/disseminate, examples Letters to employees – individualized and general Intranet resource center Town halls, etc.

Physician Communication

• As above• Broader communication needs to physician

community Coordination via established medical staff governance Letter from physician leaders to all providers

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Designing Patient‐Facing Communication

Initiative Key Activities/PlanED/urgent care/other “front door” communication

• Consideration of signage / posters design• Assess readiness to recognize measles signs

and symptomsPublic service announcements/ resources

• Considerations on how to make resources available Website resources

https://www.memorialcare.org/blog/measles-and-importance-immunization

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Designing Patient‐Facing Communication (cont.)

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Questions

Online questions:Type your question in the Q & A box, press enter

Phone questions:To ask a question, press *1

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Speaker Contact Information

BJ Bartleson, Vice President, Nursing & Clinical ServicesCalifornia Hospital Association(916) [email protected]

Gail Blanchard-Saiger, Vice President & Counsel, Labor and EmploymentCalifornia Hospital Association(916) [email protected]

Thank You and Evaluation

Thank you for participating in today’s webinar. An online evaluation will be sent to you shortly.

For education questions, contact Jaime Welcher at (916) 552-7527 or [email protected].

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measles best practices - california hospital …...measles best practices may 21, 2019 welcome bj...

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