Issue
Number 561
October 28, 2005
UNPROTECTED PEOPLE: Reports of
people who have suffered or died
from vaccine-preventable diseases
Report #80:
PREVENTABLE MEASLES OUTBREAK IN INDIANA
RESULTS IN 34 CASES AND THREE HOSPITALIZATIONS IN SUMMER 2005
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October 28, 2005
UNPROTECTED PEOPLE #80: PREVENTABLE MEASLES OUTBREAK IN INDIANA RESULTS IN
34 CASES AND THREE HOSPITALIZATIONS IN SUMMER 2005
The Immunization Action Coalition (IAC) publishes articles about people who
have suffered or died from vaccine-preventable diseases and periodically
devotes an IAC Express issue to such an article. This is the 80th in our
series.
On October 28, CDC reported on a measles outbreak that occurred in Indiana
during May-June 2005 when an unvaccinated U.S. resident returned from
Romania with measles symptoms. The U.S. resident infected 34 persons in
Indiana, most of them unvaccinated children in a church community.
Containment of the outbreak involved the resources of health departments in
three states. A press summary that preceded the publication of the CDC
report highlights the serious problem that nonmedical vaccine exemption
poses in an age in which international travel is common and
vaccine-preventable diseases are prevalent in many parts of the world. The
press summary is reprinted below in its entirety.
"Measles is a highly infectious and dangerous disease [that] is endemic in
most of the world. Relatively small numbers of unvaccinated persons can
produce outbreaks in the U.S. when ACIP vaccination recommendations are not
followed for vaccination of children, foreign travelers, and healthcare
workers. The seriousness of the Indiana outbreak underscores the need for
maintenance of high measles vaccination levels to prevent re-introduction of
measles transmission in the U.S.
"Over a four-week period in May-June 2005, a large measles outbreak occurred
in Indiana. While measles transmission was eliminated from the United States
in 2001 by high vaccination levels, globally measles causes 30 to 40 million
cases and 530,000 deaths annually worldwide. The source of the Indiana
outbreak was an unvaccinated teenager who had just returned from Romania
where a large measles outbreak is currently occurring. Most of the 34
Indiana cases were children whose parents had declined to have them
vaccinated. There were three hospitalizations, including one person who
required mechanical ventilation in the intensive care unit. Strenuous
containment efforts were required to prevent the outbreak from spreading
further. The Advisory Committee on Immunization Practices (ACIP) has
long-standing recommendations that children, foreign travelers, and
healthcare workers should be vaccinated against measles. Had these
recommendations been followed, the outbreak would not have occurred."
The report, "Import-Associated Measles Outbreak悠ndiana, May-June 2005"
appeared in the October 28 issue of MMWR. It is based, in part, on
contributions by the Tippecanoe County Health Dept., Lafayette, IN;
Immunology and Virology Laboratories, Epidemiology Resource Center,
Immunization Program, Indiana State Dept. of Health; Hamilton County General
Health District, Cincinnati Health Dept., OH; and Illinois Dept. of Health.
It was reported by health professionals at the Indiana State Dept. of Health
and the Epidemiology and Surveillance Division of NIP/CDC. It is reprinted
below in its entirety, excluding references and one figure.
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On May 29, 2005, the Indiana State Department of Health (ISDH) was notified
of suspected measles in a female Indiana resident aged 6 years who was
hospitalized in Cincinnati, Ohio, where she had been visiting relatives.
Serologic analyses performed by the Ohio State Department of Health
Laboratory and a private reference laboratory confirmed the diagnosis of
measles. The hospital in Cincinnati and the girl's parents told ISDH she had
been at a church gathering in northwestern Indiana on May 15 where a fellow
attendee had been ill. This fellow attendee was an adolescent girl aged 17
years, an Indiana resident who had not been vaccinated for measles and who
had worked during May 4-14 as a missionary in an orphanage and hospital in
Bucharest, Romania, where a large measles outbreak was subsequently
reported. The teen had returned to the United States with prodromal fever,
cough, conjunctivitis, and coryza, traveling on international and domestic
commercial airliners on May 14. The next day the teen attended the church
gathering along with others who had not been vaccinated because of
nonmedical exemptions. Family members recalled that the teen had a rash on
May 16; measles was diagnosed retrospectively, and the teen was identified
as the index patient. An outbreak investigation was conducted by ISDH and
CDC. This report summarizes (1) the results of that investigation, which
identified 34 persons with measles, including three who required
hospitalization, (2) the measures taken to control and prevent measles
transmission, and (3) recommendations to prevent future cases of measles.
Persons with measles were defined as having generalized maculopapular rash,
fever of 101 degrees F [or higher](38.3 degrees C [or higher]), and at least
one of the following: cough, coryza, or conjunctivitis. Measles cases were
either laboratory-confirmed or met the clinical case definition and were
linked epidemiologically to a patient with confirmed measles. Onset of rash
for the 34 persons identified with measles occurred during May 16-June 24.
Of the 34 cases, 33 (97%) were in church members who acquired disease either
through direct exposure to the index patient or household exposure to a
person with measles who had been exposed to the index patient. The remaining
case was in a phlebotomist, with rash onset on June 24, who worked in an
Indiana hospital where one of the measles patients had been admitted;
however, exposure of the phlebotomist to any of the patients in the outbreak
was not identified. The phlebotomist had received 1 dose of
measles-containing vaccine (MCV) as a child, according to a school record.
Among the measles patients, 33 were residents of Indiana and one resided in
Illinois. Patients ranged in age from 9 months to 49 years (median age: 12
years); vaccination with MCV was documented for two (6%) persons, one who
had received 1 dose, and one who had received 2 doses. Of the 34 cases, 14
(41%) were laboratory confirmed either by serologic testing that detected
measles-specific IgM antibodies, polymerase chain reaction analysis of urine
specimens, or both; the other 20 cases were in patients with rash illness
who were linked epidemiologically to the confirmed cases. Three (9%) of the
34 patients were hospitalized, two (aged 6 and 45 years) with dehydration
and one (aged 34 years) with pneumonia who required 6 days of ventilator
support. Among the 31 nonhospitalized patients, complications included 16
cases of diarrhea and two cases of otitis media.
The outbreak was controlled by multiple actions taken by state and local
health departments in Indiana, Ohio, and Illinois. These measures included
(1) voluntary isolation of patients, (2) tracing of potentially exposed
patient contacts by local and state health departments in all three states
and by staff members at hospitals in Indiana and Ohio, (3) administering
vaccine and immunoglobulin to susceptible contacts, (4) voluntary home
quarantine among those who refused vaccination, (5) checking immune status
of healthcare workers, (6) alerting hospitals to the measles outbreak and
urging physicians to report all suspected cases, and (7) increasing media
attention to health risks posed to the community by persons who refuse
vaccination.
Editorial Note
The measles outbreak described in this report was the largest in Indiana
since 1990 and the largest in the United States since 1996. The outbreak
resulted from a gathering of church members who had not been vaccinated for
measles and could have been prevented if the index patient had been
adequately vaccinated before traveling to Romania.
Measles is a highly infectious acute viral illness that can cause severe
pneumonia, diarrhea, encephalitis, and death. Although an effective vaccine
has been available since 1963, an estimated 30-40 million measles cases and
530,000 deaths from measles occur annually worldwide. Ongoing measles
transmission has been eliminated in the United States by high vaccination
levels. Of 540 measles cases in the United States during 1997-2001, 362
(67%) were linked to imports (i.e., 196 imported cases, 138 cases
epidemiologically linked to imported cases, and 28 cases associated with an
imported measles virus genotype), and most measles cases could have been
prevented.
Because the disease is endemic or epidemic in many parts of the world, the
Advisory Committee on Immunization Practices (ACIP) recommends that all
persons who travel internationally be vaccinated for measles to reduce the
risk for infection among travelers. ACIP further recommends that all
preschool children in the United States receive 1 dose of MCV and all
school-aged children receive 2 doses of MCV. Although all states require 2
doses of MCV for children attending school, nonmedical exemptions are
permitted by certain states, including Indiana. Persons choosing a
nonmedical exemption from vaccination are approximately 22 times more likely
to acquire measles than persons who are vaccinated. Parents and persons who
opt out of vaccination should be aware of the risk that this practice places
upon their children and their community. Communities of persons who have not
been vaccinated can make intensive measles-containment activities necessary.
ACIP also recommends that persons who work in medical facilities be
vaccinated for measles. The Indiana outbreak, in which a hospital worker
contracted measles, demonstrates the need for healthcare facilities to be
aware of the vaccination status of their workers and require written
documentation of vaccination history.
The Indiana outbreak could have been prevented by adherence to long-standing
ACIP recommendations calling for measles vaccination of (1) international
travelers, (2) children, and (3) healthcare workers. The serious illnesses
that resulted from this outbreak and the size and scope of activities and
resources required to contain it underscore the need to adhere to
theserecommendations to sustain elimination of measles in the United States.
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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5442a1.htm
To access a ready-to-print (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5442.pdf
To receive a FREE electronic subscription to MMWR (which includes new ACIP
statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
To read more IAC Unprotected People Reports, go to:
http://www.immunize.org/stories
DISCLAIMER: The Immunization Action Coalition (IAC) publishes Unprotected
People Reports for the purpose of making them available for our readers'
review. We have not verified this report's content, for which the authors
are solely responsible.
DO YOU KNOW OF PUBLISHED ARTICLES ABOUT UNPROTECTED PEOPLE? Please let us
know if you find articles or case reports about people who have suffered or
died from vaccine-preventable diseases that have appeared in the general or
scientific media. Send information about articles or case reports to IAC
Express by email to admin@immunize.org
or by fax to (651) 647-9131.
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