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Measles Outbreak Among Internationally Adopted Children Arriving in the
United States, February--March 2001
On February 16, 2001, the Texas Department of Health was notified about a
child aged 10 months adopted from orphanage A in China who was taken to a
Texas hospital with fever, conjunctivitis, coryza, Koplik spots, and a
maculopapular rash. Measles was confirmed by serologic testing. Public
health authorities in Texas notified CDC, which then collaborated with
health officials in other states to contact other recently adopted children
from China and their adoptive families. This report summarizes the results
of multistate contact investigations that identified 14 U.S. measles cases
and outlines measures taken in the United States and China to control and
prevent measles transmission.
The index patient had traveled with prodromal fever on international
(China to Los Angeles) and domestic (Los Angeles to Houston) flights on
commercial airlines and had been part of a cohort of adopted children from
China who had resided in orphanage A. These children and their adoptive
families had spent >2 weeks together in China while the families were
visiting the orphanage and completing the immigrant visa process. The index
patient potentially exposed multiple persons during the communicable period,
including members of 63 families who had traveled to China to adopt
children, representatives from 16 international adoption agencies who
accompanied the families, staff at the local medical facility in China at
which the patient was examined as a requirement for a U.S. immigrant visa,
staff at the U.S. Consulate, passengers and crew members of the
international and domestic flights on which the patient traveled, and
adoption-agency representatives who met the returning family.
By February 22, consulate staff in China, staff at the medical facility,
administrators at orphanage A, and all adoption agencies involved received
information from CDC about measles exposure and prevention. Through the U.S.
Consulate in China, the Central China Adoption Agency (CCAA) and CDC
developed a collaborative strategy to control and prevent further spread of
measles. The strategy included nine steps: 1) retrospective notification of
families of adopted children from orphanage A who were interviewed at the
U.S. Consulate during January 30--February 12; 2) prospective notification
of families planning to travel to orphanage A advising them to delay travel
to China until further notice; 3) distribution of alerts to adoptive
families already in China; 4) notification of international adoption
agencies in China to advise prospective adoptive families to verify and
update the vaccination status of household members; 5) active screening for
febrile and rash illnesses among adopted children examined at the medical
facility in China; 6) isolation of children suspected to have measles and
restriction of their travel on commercial conveyances; 7) temporary
suspension of adoption proceedings at orphanage A until no new measles cases
were identified; 8) evaluation of children at orphanage A for measles; and
9) initiation of a vaccination campaign in orphanage A under the direction
of CCAA.
Contact investigations identified 14 U.S. measles cases (13 confirmed
serologically and one linked epidemiologically) among children who were
recently adopted from China and their family members and close contacts in
eight states, including 10 recently adopted children aged 9--12 months from
seven states (New York [three], Ohio [two], Illinois [one], Indiana [one],
Minnesota [one], Missouri [one], and Texas [one]), two U.S.-born adoptive
mothers (Indiana [aged 46 years] and Missouri [aged 39 years]), a U.S.-born
caretaker (Connecticut [aged 47 years]) who had lived for a week in the same
household as an adopted child with measles, and a sibling (Georgia [aged 28
months]) of a healthy adopted child from China. Thirteen U.S. measles cases
were imported; the case of the U.S.-born caretaker was an indigenous,
import-linked case.
All 14 cases of measles were identified during multistate investigations
during February--March 2001. Among the 13 imported cases in adopted children
and their family members, dates of onset of measles rash ranged from
February 15 to March 7, 2001. These dates suggest incubation periods
consistent with measles exposure in China, most likely at orphanage A but
possibly during the medical screening or travel. The one indigenous,
epidemiologically linked measles case was consistent with secondary
transmission of measles in the United States from an adopted child. During
the investigation, representatives of orphanage A retrospectively identified
cases of suspected measles that preceded the index patient's illness and
reported that newly arrived children at orphanage A had not been vaccinated
adequately against measles. After completion of a measles vaccine campaign
at orphanage A, no additional cases were reported, and the adoption of
children from the orphanage resumed on March 29, a total of 3 weeks after
the onset of the last known case of measles.
Reported by: A Reynolds, T Gong, U.S. Consulate; H Li, MD,
International Travelers Health Care Center, Guangzhou, China. K Hendricks,
MD, J Pelosi, MPH, Texas Dept of Health. S Lance-Parker, DVM, Georgia Div of
Public Health. W Staggs, MS, Indiana State Dept of Health. C Miller, MS,
Minnesota Dept of Health. G Storm, V Tomlinson, MPH, Missouri Dept of
Health. E Herlihy, MS, New York State Dept of Health. C Jennings, K Hunt,
Illinois Dept of Public Health. F Smith, MD, J Daniels, MD, Ohio Dept of
Health. Div of Global Migration and Quarantine, National Center for
Infectious Diseases; Div of Epidemiology and Surveillance, National
Immunization Program, CDC.
Editorial Note:
During 1997--2001, the annual number of reported measles cases in the
United States ranged from 86 to 138, with imported cases accounting for
26%--47% of the total (Table). The proportion of imported
cases of measles among internationally adopted children increased from 2% in
1997 to 20% in 2001; 10 of the 11 imported cases of measles among
internationally adopted children in 2001 were associated with this outbreak.
During fiscal year 2001, the U.S. Immigration and Naturalization Service
reported that 19,230 internationally adopted children, of whom 4,681 (24%)
were from China, were admitted to the United States.
Imported cases of measles continue to infect susceptible U.S. residents.
The current high level of immunity to measles in U.S. residents and the
coordinated efforts of numerous agencies in responding to imported cases has
limited indigenous spread. Three (23%) of 13 imported measles cases in this
investigation were in U.S. residents returning from abroad and constituted
6% of all imported cases for 2001, underscoring the need for U.S. residents
to verify their immunity against measles before international travel. The
criteria for immunity to measles are 1) having been born before 1957, 2) a
history of physician-diagnosed measles, 3) documentation of having received
2 doses of measles-containing vaccine, or 3) serologic evidence of measles
immunity. Travelers who are not immune should be vaccinated (1).
Since 1996, all persons seeking a U.S. immigrant visa are required to
show proof of having received at least the first vaccine of each series of
vaccinations recommended by the Advisory Committee on Immunization Practices
(ACIP), which includes measles (2). However, internationally adopted
children who are aged <10 years are exempted from the Immigration and
Nationality Act vaccination requirements with a signed statement from the
adopting parent(s) indicating that the child will receive vaccination within
30 days of entry into the United States. Parents of internationally adopted
children should be aware of the importance of confirming that they and their
family members are current in their vaccinations and that, soon after
arrival in the United States, their adopted children's vaccination status is
updated according to ACIP guidelines (1).
In addition, persons who will be in contact with internationally adopted
children during their first 3 weeks in the United States, especially
household members and caretakers, should be immune to measles or be
vaccinated before the adoption.
References
- CDC.
Measles, mumps, and rubella --- vaccine use and strategies for elimination
of measles, rubella, and congenital rubella syndrome and control of mumps:
recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 1998;47(No. RR-8).
- Illegal Immigration Reform and Immigrant Responsibility Act. Public
Law no. 10-208, 110 Stat 3009 (1996).
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