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Published Date: 2007-02-28 18:04:48
Subject: PRO/EDR> Measles, adult, adoption linked - USA ex China
Archive Number: 20070228.0715

MEASLES, ADULT, ADOPTION LINKED - USA EX CHINA
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Date: Fri 23 Feb 2007
From: ProMED-mail <promed@promedmail.org>
Source: MMWR Morb Mortal Wkly Rep 2007; 56(07): 144-6 [edited]
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5607a3.htm?s_cid=mm5607a3_e>

Measles among adults associated with adoption of children in China --
California, Missouri, and Washington, July-August 2006
-----------------------------------
On [15 Aug 2006], the Missouri Department of Health and Senior Services
(MoDHSS) was notified of a measles case in a Missouri resident who had
recently traveled to China. The patient had traveled with a group of 11
families seeking to adopt children from 3 orphanages in Guangdong Province.
Members of the group, which was sponsored by a Missouri-based adoption
agency, traveled separately but stayed at the same hotel in Guangdong
Province during 13-27 Jul [2006].
This report describes the multistate investigation that followed, which
identified 2 additional measles cases. None of the 3 patients recalled
contact during travel with anyone who appeared ill. All 3 patients
recovered fully, and no secondary cases were identified among family
members, other travelers, patients, or medical staff who might have been
exposed. Because of delays in diagnoses (the earliest case was identified 2
weeks after rash onset), no control measures (such as vaccination of
contacts or administration of immunoglobulin) were indicated. Communicable
diseases that are no longer endemic in the United States continue to occur
among travelers, often resulting in delayed recognition and delayed
notification of public health authorities. Because of the risk for spread
in the community of imported communicable diseases such as measles (1),
thorough investigation is needed to determine possible sources of infection
and the extent of disease spread in the community.
Case 1. On [13 Jul 2006], a woman from Missouri, aged 36 years, traveled
with her husband to Guangdong Province. She returned to the United States
on [28 Jul 2006] with her husband and their adopted child. On [30 Jul
2006], she had onset of fever. The next day, a rash appeared on her face
and trunk. On [2 Aug 2006], she sought medical care and was tested for
tickborne illnesses endemic in rural Missouri (such as Rocky Mountain
spotted fever and ehrlichiosis). On [9 Aug 2006], a measles immunoglobulin
M (IgM) antibody test was obtained, which was reported positive on [14 Aug
2006]. The patient had received 2 documented doses of measles-containing
vaccine (MCV) in her lifetime (1 dose at age 11 months and another at age
10 years). She and her husband had stayed at the same hotel as 10 other US
families while awaiting finalization of their adoptions. On [15 Aug 2006],
the CDC Division of Global Migration and Quarantine (DGMQ) was asked to
assist in contacting potentially exposed passengers on both a trans-Pacific
flight and a domestic flight, on which the patient had flown during her
return trip from China. On [18 Aug 2006], a list of trip participants was
obtained from the adoption agency. MoDHSS contacted each family by
telephone and identified 2 additional cases of rash illness (cases 2 and 3)
in persons from the adoption group.
DGMQ collaborated with MoDHSS to obtain the passenger manifests (that is,
lists of passengers and their seating assignments) and available
passenger-locator information (that is, personal contact information for
passengers) for potentially exposed passengers on the international and
domestic US flights on which the patient from Missouri had flown. Six
passengers seated near the patient on the international flight were
identified as potentially exposed; all 6 were contacted, and none reported
symptoms consistent with measles during one incubation period (7-21 days)
after the flight. The passenger manifest and passenger-locator information
for all passengers on the domestic US flight were obtained because no
seating was assigned for the flight.
Contact information was available for 101 of 118 passengers. DGMQ provided
that information to the state health departments in states where passengers
resided. The number of passengers who were contacted by the state health
departments is unknown. No measles cases associated with this flight were
reported to CDC.
Case 2. On [2 Aug 2006], a woman from California, aged 39 years, who had
been part of the same adoption trip, had onset of a maculopapular rash on
her face, chest, and back. She had returned from China on [28 Jul 2006] and
thus was not considered infectious* during her return travel to the United
States. She had no fever, coryza, cough, or conjunctivitis. MoDHSS learned
of this patient's symptoms while interviewing the patient from Missouri and
notified the California Department of Health on [16 Aug 2006]. A measles
IgM antibody titer was obtained and was positive. The patient reported
receiving at least 2 doses of MCV in her lifetime, for which no
documentation was available.
Case 3. On [29 Jul 2006], a woman from Washington, aged 38 years, was
evaluated in the emergency department of a military hospital for fever
(102.9 deg. F [39.4 deg. C]) and a maculopapular rash on her chest and
face. She described headache, facial swelling, cough, nasal congestion,
nausea, and diarrhea that began [27 Jul 2006] while en route from China to
Seattle. Her symptoms initially were attributed to amoxicillin she was
taking for sinusitis diagnosed before her travel, and the drug was
discontinued. On [31 Jul 2006], approximately 48 hours after discontinuing
the antibiotic, she returned to the hospital with continued fever and rash
that had progressed to her trunk and arms. She was hospitalized for 4 days
to evaluate her symptoms and elevated levels of hepatic transaminases.
Viral hepatitis studies were negative. The patient improved and was
discharged. On [21 Aug 2006], MoDHSS notified the Washington State
Department of Health (WSDH) that the woman had traveled with the adoption
group. Serum obtained on [22 Aug 2006] by the local health department was
reactive for measles IgM antibody. The patient had received one documented
MCV dose at age one year.
WSDH and CDC were unable to identify contacts of the patient from
Washington on the international flight because a manifest from the carrier
could not be obtained. For the interstate flight, the delay in receiving
notification of the patient's illness meant that the airline was unable to
provide the manifest for the indicated flight in a timely manner.
Therefore, a manifest was not requested by WSDH.
[byline: C Woodfill, P Franklin, F Khan, et al]
MMWR editorial note
-------------------
During 2001-2005, import-associated measles cases (that is, imported,
import-linked, or imported virus cases)** accounted for the majority of
cases reported in the US (1,3,4). Imported measles cases among adoptees
from China have been reported previously (4,5). This report documents
imported measles cases during July-August 2006, among adopting parents from
the US who were exposed to measles while visiting China.
China is the leading country of origin for foreign-born children adopted in
the US (6). During 1998-2005, annual US adoptions of children from China
increased by 88 per cent, from 4206 to 7906 (6). A national measles
outbreak in China increased reported measles cases there from 70 549 in
2004 to 124 219 in 2005 (7). In Guangdong Province, 11 146 measles cases
were reported during January-June 2006, a 30 per cent increase compared
with the same period in 2005 (8). This situation in China presented an
increased risk for measles exposure to travelers and potential importation
into the United States. China has set a measles-elimination goal for 2012,
and the country is conducting activities to achieve this goal (such as
conducting an international field review [November 2006] and convening the
1st National Technical Advisory meeting on measles elimination [December
2006]).
According to the Advisory Committee on Immunization Practices (ACIP),
persons born during 1957 or later without 1) adequate documentation of
immunity by previous vaccination with 2 doses of MCV, 2) laboratory
evidence of immunity, or 3) physician-diagnosed measles should be
vaccinated with the measles, mumps, and rubella (MMR) vaccine before travel
abroad (9). The US Department of State requires that internationally
adopted children aged [greater than] 10 years receive the following
vaccines before entry into the US: measles, mumps, and rubella; polio;
tetanus and diphtheria toxoids; pertussis; _Haemophilus influenzae_ type B;
hepatitis B; varicella; and pneumococcal. For those aged [less than] 10
years, the adopting parents must sign an affidavit promising to provide
these vaccinations within 30 days of entry to the US. The education that
most adoptive parents receive regarding their own medical preparations
before travel can vary substantially. In this instance, the adoption agency
provided the ACIP recommendations to the clients and repeatedly advised
their clients about the importance of being properly vaccinated; however,
no standard mechanisms were in place to ensure that these recommendations
were followed before travel abroad. In the US and internationally, several
organizations (such as the American Academy of Pediatrics Section on
Adoption and Foster Care and the Joint Council for International Children's
Services) are working to improve immunization and education standards
regarding international adoptions. Health-care providers should continue to
promote appropriate pretravel vaccination for their patients.
Investigation of all 3 cases was substantially delayed because of delays in
diagnosis and delays in notifying jurisdictions where exposed travelers
resided. Because measles is rare in the US (as a result of high
immunization levels), it is often unrecognized by clinicians who might not
consider measles in a differential diagnosis. Health-care providers should
routinely gather information regarding the patient's travel history and
maintain a high level of suspicion for measles in patients with rash,
fever, and recent travel to areas of known measles endemicity. Although a
single dose of measles vaccine administered in the 2nd year of life induces
immunity in 95 per cent of vaccinees (10), cases can occur even among
vaccinated persons. More common than vaccine failure is incomplete
documentation or inaccurate recall of vaccination status. In the cases
described in this report, the patient from Missouri had 2 MCV doses
documented, the patient from Washington had 1 MCV dose documented, and the
patient from California had no MCV doses documented.
DGMQ is authorized*** to conduct investigations involving international
flights arriving in the US and can assist state health departments with
investigations involving interstate flights. In the case of interstate
flights, DGMQ may request passenger manifests and passenger-locator
information to assist the state in which the plane lands. Once notified of
an exposure, DGMQ contacts the airline to obtain the passenger manifest and
passenger-locating information of contacts. A software application
developed by DGMQ, eManifest, is used to securely import, sort, and assign
passenger-locator information to jurisdictions. These data are transmitted
securely to state and territorial health agencies via the Epidemic
Information Exchange (Epi-X) forum. Staff from the 18 CDC quarantine
stations follow up with public health agencies to ensure the information
has been received. DGMQ continues to work with airlines to develop
mechanisms for the timely provision of passenger-locator information to CDC
and with federal and state partners to improve the process of distributing
this information.
Acknowledgment
The findings in this report are based, in part, on contributions by C
Queen, Harrison County Health Dept, Missouri; and S Hadler, Z Shuyan, and Y
Takashima, WHO Representative Office, China.
References:
1. CDC. Measles-United States, 2005. MMWR 2006; 55: 1348-51. [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5550a2.htm>]
2. Council of State and Territorial Epidemiologists. Revision of measles,
rubella, and congenital rubella syndrome case classifications as part of
elimination goals in the United States. Position statement 06-ID-16.
[available at <http://www.cste.org/ps/2006pdfs/psfinal2006/06-id-16final.pdf>]
3. CDC. Measles-United States, 2004. MMWR 2005; 54: 1229-31. [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5448a1.htm>]
4. CDC. Epidemiology of measles-United States, 2001-2003. MMWR 2004; 53:
713-6. [available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5331a3.htm>]
5. CDC. Multistate investigation of measles among adoptees from China-April
9, 2004. MMWR 2004; 53: 309-10. [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5314a5.htm>]
6. US State Department. Immigrant visas issued to orphans coming to the US.
[available at <http://travel.state.gov/family/adoption/stats/stats_451.html>]
7. World Health Organization. WHO Vaccine Preventable Diseases Monitoring
System 2006 global summary. [available at
<http://www.who.int/vaccines/globalsummary/immunization/countryprofileselect.cfm>]
8. Chinese Center for Disease Control and Prevention. Measles data analysis
Jan-Aug 2006. China EPI Bulletin 2006; 5: 5-6.
9. 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(RR-8). [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm>]
10. King GE, Markowitz LE, Patriarca PA, Dales LG. Clinical effectiveness
of measles vaccine during the 1990 measles epidemic. Pediatr Inf Dis J
1991; 10: 883-7.
* The infectious period for measles generally is considered to be from 4
days before the onset of rash to 4 days after the onset of rash. The
California patient completed travel 5 days before the onset of rash.
** Imported measles includes cases in which exposure and infection occurred
outside the United States; import-linked measles includes indigenously
acquired measles that is epidemiologically linked to an imported case;
imported virus measles includes indigenous cases that are caused by a known
imported measles genotype but do not have an epidemiologic link to an
imported case (1,2).
*** Additional information available at
<http://www.cdc.gov/ncidod/dq/factsheetlegal.htm>
--
ProMED-mail
<promed@promedmail.org>
[In the 2004 incident, measles cases were 1st identified in the adoptees
after arriving in the USA. In that case, the children came from an
orphanage in Hunan province China, and onset of fever and rash began after
arrival in the USA. As those children were felt to be in the early
infectious stage of their illness during travel to the USA, contact tracing
of fellow travellers was conducted. In another incident in 2001 there were
13 cases of measles among adoptees and their adoptive family members, also
coming from an orphanage in another unnamed part of China (information on
this outbreak can be found at: CDC. Measles outbreak among internationally
adopted children arriving in the United States, February-March 2001. MMWR
2002; 51(49): 1115-6, available at:
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5149a3.htm>).
In the above incident, the cases were among the adoptee families,
suggesting that the exposure was most likely during the visit to the
orphanage where there may have been clinically infectious cases at the time
of the visit. The MMWR's editorial comment on the need for adoptive
families to check their own immunization status prior to leaving for
overseas is very important.
ProMED-mail apologizes for the delay in posting this article. - Mod.MPP]

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