Measles -- New Jersey

An ongoing measles outbreak in New Jersey that began in November 1985 is the largest U.S. measles outbreak since 1983.

Information is available on the 334 cases reported between November 15, 1985, and March 13, 1986 (Figure 1). Seventeen (5.1%) cases have been serologically confirmed. Residents of Jersey City accounted for 269 (80.5%) cases; cases have also occurred among residents of 14 other municipalities surrounding Jersey City. The index patient was a 2H- year-old Hispanic child who developed a rash on November 15, 1985. The source of his infection is unknown. Of the total 334 patients, 38% had Hispanic surnames. Of the 322 patients with known age, 197 (61.2%) were preschool-aged children (under 5 years of age). Of these 197, 100 (50.8%) were under 16 months of age (too young for routine measles vaccination), and 97 (49.2%) were 16 months-4 years of age. In Jersey City, attack rates were 13.0/1,000 for infants under 1 year of age, 8.8/ 1,000 for 1- to 4-year-olds, and between 1.0/1,000 and 2.3/1,000 for persons in the 5- to 19-year age groups. Complications occurred among 45 (13.5%) of these 334 patients. Thirty-two (9.6%) had pneumonia;

four (1.2%) had otitis media; six (1.8%) had diarrhea; one (0.3%) had encephalitis; and two (0.6%) had other complications. Seventy (21.0%) were hospitalized. There were no measles-associated fatalities.

Transmission occurred in a variety of settings, including hospital inpatient units and emergency rooms, outpatient diagnostic settings, physicians' offices, medical clinics, schools, day-care centers, and homes. Preventability status was known in 316 cases*; 109 (34.5%) were preventable by CDC criteria (1). Of these, 86 (78.9%) occurred among preschoolers (16 months-4 years), and 23 (21.1%) occurred among school-aged children. Of the 207 nonpreventable cases, 100 (48.3%) were among children under 16 months of age, including 59 under 12 months of age, and 41 12-15 months of age. One hundred one (48.8%) were school-aged children with histories of appropriate vaccination (vaccination at 12 months of age or older), and six (2.9%) were born before 1957 (too old for routine vaccination). Outbreak-control activities included intensified surveillance; mass publicity through newspapers, radio, and television; audits of school and day-care center records; and additional free vaccination clinics at various locations throughout Jersey City. On January 22, 1986, the recommended age for measles vaccination in Jersey City during the outbreak was lowered to 12 months. Nine additional vaccination clinics were held. However, only 156 of approximately 1,000 children 12-15 months of age in Jersey City presented for vaccination. On March 12, because of the continuing high attack rate among children under 12 months of age, the recommended age for measles vaccination during the outbreak was lowered to 6 months,

with revaccination at 15 months of age. Reported by W Lezynski, Jersey City Div of Health, R Altman, MD, L Dimasi, J Dawalt, J Hansson-Skaling,

F Krichling, R Ashley, Communicable Diseases Operations Program Br; B Spurr, Communicable Disease Field Program, W Parkin, DVM, State Epidemiologist, New Jersey State Dept of Health; Div of Field Services, Epidemiology Program Office, Div of Immunization, Center for Prevention Svcs, CDC. Editorial Note: This outbreak is occurring primarily in Jersey City, a city with a population of approximately 223,500, of which 27% is black non-Hispanic and 18% is Hispanic. There is also a large undocumented alien population in the city. This outbreak is different from most recent U.S. outbreaks in that a large proportion of cases has occurred among preschool-aged children. Most recent outbreaks have occurred in junior or senior high schools or universities (2-4). Immunization levels in preschool-aged Jersey City children are known to be low. Although current information is not available, a retrospective survey conducted in 1981 indicated that only 56% of Jersey City children had been vaccinated by 2 years of age (5). Nationwide, immunization levels for preschool-aged children are lower than those for school-aged students (which are greater than 95%), since most preschoolers are not enrolled in institutions (e.g., day-care centers) that uniformly require immunization for entry. However, immunization levels for 2-year-olds in Jersey City are lower than those in suburban areas of New Jersey (81%) (5) as well as the national average (66%-84%) (6). Thus, it appears that the size and extent of this outbreak reflect a large pool of susceptibles in the preschool- aged population. These susceptible preschoolers have probably contributed to the spread of measles to children under 16 months of age.

In most parts of the United States, children in this age group have a low probability of exposure to measles. Therefore, the Immunization Practices Advisory Committee currently recommends that children be vaccinated against measles at 15 months of age. Although multiple modes of transmission have been identified in this outbreak, a large proportion of transmission has occurred in medical settings. Some medical-setting transmission occurred when young children were taken to physicians during the prodrome of their illnesses (when they are infectious, but without rash). However, transmission was also the result of inadequate isolation of children with rash illnesses (7).

Outbreak-control efforts have been frustrated by the lack of public response to vaccination efforts by the New Jersey State Department of Health. While lowering the age of vaccination to as low as 6 months of age is an important control measure (8), if infants and children are not vaccinated, this will have little impact on the outbreak. The Jersey City outbreak has recently spread to Patterson, a neighboring city, where preschool-aged children have predominantly been affected.

There may be similar low immunization levels among preschoolers in other urban areas of New Jersey and elsewhere in the United States, creating a potential for similar outbreaks to occur. Increased efforts should be directed at increasing immunization levels in this hard-to- reach age group. References 1. CDC. Classification of measles cases and categorization of measles elimination programs. MMWR 1983;31: 707-11. 2. CDC. Multiple measles outbreaks on college campuses--Ohio,

Massachusetts, Illinois. MMWR 1985;34:129-30. 3. CDC. Measles on a college campus--Ohio. MMWR 1985;34:89-90. 4. CDC. Measles outbreak among vaccinated high school students--Illinois. MMWR 1984;33:349- 51. 5. New Jersey State Department of Health. Unpublished data. 6.

Eddins DL, Sirotkin, BI, Holmgreen P, Russell S. Assessment and

validation of immunization status in the U.S. Dallas, Texas: 20th immunization conference proceedings, 1985:51-61. 7. Davis RM, Orenstein WA, Frank JA, et al. Transmission of measles in medical settings. JAMA 1986;255:1295-8. 8. ACIP. Measles prevention. MMWR 1982;31:217-24, 229-31. *Cases among preschool-aged children 16 months- 4 years of age for whom there were no data on vaccination status were assumed to be preventable.

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