Measles -- Duval County, Florida, 1991-1992

An outbreak of measles occurred in northeastern Florida (Bradford, Clay, Duval, Nassau, Putnam, and St. Johns counties) in 1991 and early 1992. A total of 193 confirmed cases of measles were reported to the Florida Department of Health and Rehabilitative Services (FDHRS). This report summarizes an investigation of the outbreak in Duval County (1990 population: 676,556), which reported 146 (76%) of the cases.

The outbreak in Duval County began in April 1991 and peaked in October 1991. The last case was reported in January 1992 (Figure 1). Seventy-five (51%) cases were reported from three inner-city zip code areas in Jacksonville. The overall incidence of measles in Duval County was 22 cases per 100,000 population. The age-specific incidence was highest for children aged less than 5 years (205 cases per 100,000). Of the 146 reported measles cases, 111 (76%) occurred among children aged less than 5 years, including 42 (29%) among children aged less than 12 months. Transmission between mother and infant was documented in 12 cases (six mother-infant pairs). School-aged children (aged 5-19 years) and adults aged greater than or equal to 20 years accounted for 15% and 9% of cases, respectively.

Ninety-seven (66%) reported cases occurred among non-Hispanic blacks for a race-specific incidence of 58 per 100,000 population. The race-specific incidence for non-Hispanic whites was nine per 100,000. One case was reported in a Hispanic child. The highest age- and race-specific incidence was for non-Hispanic black children aged less than 5 years (462 per 100,000), more than six times higher than the incidence for non-Hispanic white children aged less than 5 years (75 per 100,000).

Overall, 27 (18%) case-patients were appropriately vaccinated; 119 (82%) were unvaccinated. Among children aged 16 months-4 years, 19% were appropriately vaccinated. In contrast, 77% of school-aged children were appropriately vaccinated. Of all reported cases, 47% occurred among children younger than the routine age for vaccination (i.e., 16 months).

Seventy-five (51%) case-patients were reported to have one or more complications of measles, including 69 (47%) with otitis media and 12 (8%) with pneumonia. Thirty-four (23%) required hospitalization for a total of 274 hospital days (median: 4 days; range 1-195 days). Seventy-nine percent of those hospitalized were aged less than 2 years. A 26-year-old who developed pneumonia was hospitalized for 195 days and required mechanical ventilation for 129 days.

Medical settings, particularly pediatric emergency rooms (ERs), and a pediatric ward were important sources of exposure during this outbreak. These settings were identified as the likely source of infection for 17 (12%) persons. In one case, a patient presented to an ER with a temperature of 105 F (40.6 C), generalized rash, cough, coryza, and conjunctivitis and was released with a diagnosis of viral exanthem. This patient was the source of infection for 13 other persons, including four relatives, one of whom was later hospitalized with severe measles-related complications. Two persons who acquired measles in medical settings were health-care workers aged 37 and 38 years.

Outbreak-control measures included reducing the age for measles vaccination to 6 months; targeting measles vaccination programs to high-incidence residential areas; educating the community on the importance of vaccination through schools and the media; ensuring availability of vaccination on demand at Duval County public health clinics; and encouraging measles vaccination of children seen in the emergency department of the public hospital.

Reported by: ANK Cope, MS, PF Frank, J Montgomery, MPH, J Ripka, V Nguyen, MD, A Vroon, MD, Duval County Public Health Unit; M Rathore, MD, Univ of Florida Health Sciences Center, Gainesville; R Scavetto, H Janowski, MPH, Florida Dept of Health and Rehabilitative Svcs. Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The measles outbreak in Duval County is similar to others reported among preschool-aged children in 1989-1991, which have typically involved unvaccinated black and Hispanic children living in inner-city areas (1-4). This outbreak emphasizes that measles transmission can be sustained for periods of several months, even in a relatively small urban area. Measles vaccination coverage levels among preschool-aged children in Duval County are not known. However, a 1991 retrospective school-enterer survey indicated that only 71% of Florida children were vaccinated against measles by their second birthday (H. Janowski, FDHRS, personal communication, 1992); coverage levels are likely to be lower in inner-city areas. Only increasing age-appropriate vaccination coverage will prevent outbreaks among preschool-aged children.

The Duval County outbreak also illustrates the importance of medical settings as a source of infection. Measles transmission in pediatric ERs can play a prominent role in propagating measles outbreaks (5). Assurance of measles immunity among health-care workers and consideration of measles vaccination programs during outbreaks can help decrease the risk of measles transmission in these settings (6,7). Administration of measles vaccine in ERs can provide postexposure prophylaxis and may increase overall vaccination levels in the community.

References

1. CDC. Update: Measles outbreak -- Chicago, 1989. MMWR 1990;39:317- 9,325-6.

2. CDC. Measles outbreak -- New York City, 1990-1991. MMWR 1991;40:305-

4. CDC. Measles -- United States, 1990. MMWR 1991;40:369-72.

5. Atkinson WL, Hadler SC, Redd SB, Orenstein WA. Measles surveillance -- United States, 1991. In: CDC surveillance summaries (November 20). MMWR 1992;41(no. SS-6):1-12.

6. Farizo KM, Stehr-Green PA, Simpson DM, Markowitz LE. Pediatric emergency room visits: a risk factor for acquiring measles. Pediatrics 1991;87:74-9.

7. CDC. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989;38(no. S-9).

8. Atkinson WL, Markowitz LE, Adams NC, Seastrom GR. Transmission of measles in medical settings -- United States, 1985-1989. Am J Med 1991;91(suppl 3B):320S-324S.

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