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Morbidity and Mortality Weekly Report 


May 23, 2003 / Vol. 52 / No. 20 

Severe Acute Respiratory Syndrome — Taiwan, 2003 

On April 22, 2003, the Taiwan Department of Health 
(DOH) was notified of seven cases of severe acute respiratory 
syndrome (SARS) among health-care workers (HCWs) at a 
large municipal hospital in Taipei (hospital A). Subsequent 
cases at eight hospitals have been associated with exposures at 
hospital A. Previously, all reported cases had been associated 
with persons recently returning to Taiwan from SARS-affected 
regions. This report summarizes epidemiologic findings of 
the outbreak in Taiwan and describes the impact of health- 
care—associated transmission of SARS. 

As of May 22, a total of 483 probable cases had been 
reported (Figure 1). All probable SARS patients were hospi- 
talized; 84 (17%) had been discharged, and 60 (12%) had 
died (Table). The median age of probable SARS patients was 
$3 years (range: 9 months—91 years); 341 (71%) cases were 
from Taipei City and Taipei County, the largest metropolitan 
region of the island. The first patient reported had onset of 
illness on February 25; the majority of cases occurred after 
April 21 and were associated with transmission in health-care 


Initial Cases (March 14-April 21) 

faiwan (2002 population: 23 million) has extensive busi- 
ness ties with Hong Kong and mainland China where SARS 
cases have been reported. The first case in Taiwan was identi- 
fied on March 14 in a traveler from Guangdong Province in 
China. During March 14—April 21, Taiwan reported 28 prob- 
able SARS cases; of these, four resulted from secondary trans- 
mission (one HCW and three family contacts). During this 
period, SARS was characterized by sporadic cases among busi 
ness travelers who were cared for primarily at large academic 
hospitals; secondary spread was limited to identified contacts. 
Initial actions by DOH included the formation of a SARS 
advisory committee, infection-control training, contact trac- 

ing and quarantine, and airport and border surveillance. 

Because of Taiwan's success with SARS control, in early April, 
the World Health Organization changed Taiwan's designa- 
tion from an “affected area” to an “area with limited local 


Health-Care-Associated Transmission 
(April 22-—May 22) 
Since April 22, SARS cases in Taiwan have increased and 

rs. Dur- 


have been associated primarily with health-care settin 
ing April 22—May 1, the number of probable cases in Taiwan 
more than tripled, from 28 to 89. The source of the outbreak 
was hospital A, where an unrecognized SARS index patient 
had multiple exposures with patients, visitors, and HCWs 
who were not protected adequately to prevent acquisition of 

Hospital A. The index patient was a laundry worker aged 
42 years with diabetes mellitus and peripheral vascular dis- 
ease who was employed at hospital A. On April 12, the worker 
had onset of fever and diarrhea and was evaluated in the emer- 
gency department (ED) on April 12, 14, and 15. The patient 
remained on duty and interacted frequently with patients, staff, 
and visitors. The patient had sleeping quarters in the hospital's 
basement and spent off-duty time socializing in the ED. On 

\pril 16, because of worsening symptoms, the patient was 


466 Update: Severe Acute Respiratory Syndrome — United 
States, May 21, 2003 

469 Elevated Mortality Associated With Armed Conflict — 
Democratic Republic of Congo, 2002 

471 Update: Global Measles Control and Mortality Reduc- 
tion — Worldwide, 1991-2001 
Update: Adverse Events Following Civilian Smallpox 
Vaccination — United States, 2003 


May 23, 2003 

The MMWR »f publications is published by the 
Program Office, Centers for Disease Control 
Cp US. | 

(SA 30333 

Yeparrment of Health and 

ind Preventio 

Human Ser 


Control and Prevention 



Centers for Utsease 

litle]. MMWR 2003;52:| inclusive page 

Centers for Disease Control and Prevention 
Julie L. Gerberding, M.D., M.P-H 


} fe alt L, 
M.D., M.PH 

‘ ICE 


Epidemiology Program Office 

Stephen B. Thacker, M.D., M.S«¢ 

Office of Scientific and Health Communications 

Division of Public Health Surveillance 
and Informatics 

Notifiable Disease Morbidity and 122 Cities Mortality Data 

Secondary Clusters. 

Vol. 52 / No. 20 

MMWR 463 

FIGURE 1. Number’ of probable cases of severe acute respiratory syndrome, by laboratory status' and date of illness onset — 

Taiwan, February 25—May 22, 2003 


Not tested 

| | Negative 
2 Confirmed 


"N = 483 
Laboratory testing was conducted using polymerase chain reaction 






The decline in the number of recent cases is probably caused by reporting lags 

break at hospital A. Preliminary data suggest that many of 
these clusters occurred when presymptomatic patients of 
patients with SARS symptoms attributed to other causes were 
discharged or transferred to other health-care facilities. SARS 
has now extended to multiple cities and regions of Taiwan, 
including several university and private hospitals (Figure 
Four of these hospitals, including a 2,300-bed facility in south 
ern Taiwan, have discontinued emergency and routine set 
vices. Sporadic community cases also have been reported in 
[aipei and southern Taiwan 

In response, DOH has reorganized its outbreak response 
structure, appointed a SARS task force commander, and cre 
ated an emergency operations center. Efforts have focused on 
limiting nosocomial transmission by designating dedicated 
SARS hospitals throughout the island. Approximately 100 
fever clinics also have been established to identify potential 
SARS patients and minimize risk for transmission in EDs. 

Patie ll be led by tl 
atient care capacity will be expanded by the construction of 

1,000 negative pressure isolation rooms; by the end of May, 
approximately 1,700 such rooms will be available. Campsites 
and military facilities have been identified to accommodate 
quarantined residents, and home quarantine will be enforced 
through web-based cameras. Screening for fever in all patients, 
HCWs, and visitors has been instituted at all health-care 
facilities. DOH also has developed an infection-control cur 
riculum to train infection-control teams on educating and 
monitoring HCWs. Standard operating procedures for the 
management and containment of nosocomial SARS clusters 
are being finalized. 

Reported by: \/L Le 
WMD. Ct 


464 MMWR 

May 23, 2003 

TABLE. Number’ and percentage of patients with probable 
severe acute respiratory oynareme (SARS), by selected char- 
acteristics — Taiwan, 2003 

Probable cases 

Characteristics No. (%) 

Age (yrs) 

Clinical status 

SARS-associated coronavirus 
laboratory findings 


Editorial Note: Efforts to control SARS in Taiwan appeared 

ipp! ul WeeKS a identification 

Despite national eftorts 

tO implement exte ntrol m res, unrecognized cases 

ors ARS led tO 

subsequent spread to 
other health ind community settings. These clus 

ind mortality and 


| ] 
health-care facilities. In 


re affected 

umong re about the epid 

miology and transmi ) Multiple ractors prob 

ibly contributed the rat ind wides] i transmission in 

hospital 4% 

fever and diarrhea { del A Ss suspected and 

ymptomatic with 

infection-cont(rol | 

SARS infec 
con-control cuideline 

el lowever, in laiwa visitors include personal attendants 

hired by families to Personal 
ittendants ire some pel 

sonal attendant ontributed to 

disease spre id 


1 1 ] 
Unrecognized cases o have been implicated in 

recent outbreaks at heal ‘ acilities In Singapore 2). 

FIGURE 2. Geographic distribution of probable cases of severe 
acute respiratory syndrome — Taiwan, 2003* 

Taoyuan city Taipei 
county \ county 



Several factors might contribute to difficulties in recognizing 
cases of SARS. Early symptoms of SARS are nonspecific and 
ire associated with other more common illnesses. Patients with 
SARS who are immunocompromised or who have chronic 

conditions (e.g., diabetes mellitus or chronic renal insuffi 

ciency) might not have fever when acutely ill or have symp 

toms attributable to underlying disease, delaying SARS 

P¢ R tests to detect SARS-( o\ are readily 

diagnosis (2,3 

available in Taiwan; however, these tests might not detect th 
virus early during illness, and a negative test result does not 
rule out SARS (4). Finally, some patients might not reveal 
useful contact information (e.g., exposure to an implicated 
health-care facility) for fear of being stigmatized by the local 
community or causing their friends and families to be quar 

In Taiwan, exposures within health-care facilities have 

accelerated SARS transmission. The public health investiga 

o-rig-ienal: adj 
(o-'rij-an-"l) 1 : being the first instance or 

source from which a copy, reproduction, 

or translation can be made; 

see also MMWR. 

know what matters. 

466 MMWR 

May 23, 2003 

tion is ongoing, and the number of SARS cases associated 
with health-care settings will probably increase. The exten- 
sive outbreak in Taiwan underscores the need for HCW 
education that promotes the early recognition of SARS and 
the prompt implementation of appropriate infection control 
procedures. Che Sec educational efforts should be directed to 
HCWs in all facilities, including smaller and nonacademic 


i City Bur of 

enter for Disease 

Update: Severe Acute Respiratory 
Syndrome — United States, 
May 21, 2003 

Cr es to work witl 

1 state and local health depart 

ments, the World Health Organization (WHQ), and other 

partners tO investigate ¢ SO vere aculc¢ respiratory syn 

drome (SARS SARS cases reported 

worldwide and in the | ices and highlights recent 

. ‘—* : . 
modifications definition that define 

criteria for exclusion of previously reported SARS cases and 

fo! reporting tra issociated cases of SARS 

During November 1, 2002—May 21, 2003, a total of 7,956 

SARS cases were p i 

reported to WHO from 28 countries 

including the United States; 666 deaths (cas« 

fatality propo! 

tion: 8.4%) have been reported \ total of 355 SARS cases 

identified in the United States have 

been reported from 40 

states with 290 (82 cases classified as suspect SARS and 65 

18%) classified as probable SARS (more severe illnesses charac 

terized by the presence of pneumonia or aculc respiratory dis 

tress syndrome | Cure | ible ()ne probabk and nine suspect 

Cases have een identified SINCE the last update ) 

Of the 65 probable SARS patients, 41 (63%) were hospi- 
talized, and two (3%) required mechanical ventilation. No 
SARS-related deaths have been reported in the United States. 
Of 65 probable cases, 63 (97%) were attributed to interna- 
tional travel to areas with documented or suspected commu- 
nity transmission of SARS within the 10 days before illness 
onset; the remaining two (3%) probable cases occurred in a 
health-care worker who provided care to a SARS patient and 
a household contact of a SARS patient. Among the 63 prob- 
able SARS cases attributed to travel, 33 (52%) patients 
reported travel to mainland China; 19 (30%) to Hong Kong 
Special Administrative Region, China; six (10%) to Singapore; 
two (3%) to Hanoi, Vietnam; nine (14%) to Toronto, Canada; 
and one (2%) to Taiwan. Of the probable SARS patients, five 
(8%) had visited more than one area with SARS during the 
10 days before illness onset. 

Laboratory testing to evaluate infection with the SARS- 
associated coronavirus (SARS-CoV) has been completed for 
122 cases (26 probable and 96 suspect). Since the last update 
(3), the number of cases with laboratory-confirmed infection 
with SARS-CoV remains at six; all are probable SARS cases 
with no suspect SARS cases having laboratory evidence of 
infection with SARS-CoV. Negative findings (i.e., the absence 
of antibody to SARS-CoV in convalescent serum obtained 
-21 days after symptom onset) have been documented for 
116 cases (96 suspect and 20 probable). 

lhe number of new cases reported in the United States has 
been decreasing in recent wee ks. | he epidemiologic profile of 
reported cases remains unchanged with most cases associated 
with international travel and few instances of secondary spread 
to family members or other contacts. However, vigilance is 
critical to ensure rapid recognition and appropriate manage 
ment of persons with SARS 

he low specificity of the surveillance case definition cap- 
tures many persons unlikely to have SARS. The CDC su 
veillance case definition has been revised to include interim 
criteria for excluding new oO! previously reported suspect Ol 
probable cases of SARS for whom an alternative diagnosis 
can fully explain the patient's illness (2). Factors that might 
be considered in assigning alternative diagnoses include the 
strength of the epidemiologic exposure criteria for SARS, the 
specificity of the diagnostic tests, and the compatibility of the 
clinical presentation and course of illness for the alternative 
diagnosis. The epidemiologic criteria for travel exposure also 
have been revised and now reflect updated information about 
the occurrence of community transmission in areas with SARS. 
Hanoi, Vietnam and Toronto, Canada are now considered 
reas with previous community transmission of SARS because 

»30 days have elapsed since the onset of symptoms for the 

Vol. 52 / No. 20 MMWR 


FIGURE. Number’ of reported cases of severe acute respiratory syndrome, by classification and date of iliness onset — United 

States, 2003 


@ Probable (n = 65) 
O Suspect (n = 290) 



Month and day 

last reported case (4). As a result, travel alerts for these cities 
were removed on May 15 and May 20, respectively. Persons 
reporting travel to these areas will meet the surveillance case 
definition if illness onset occurred within 10 days (i.e., one 
incubation period) after removal of the travel alert. 

These revisions to the case definition are for surveillance 

purposes only. Clinical judgment, rather than surveillance 

criteria, should continue to guide the management of patients 

and implementation of public health response measures when 
persons with an unknown respiratory illness are identified. 

\s state and local health departments review and reclassify 
cases using these new criteria, case counts might change but 
the result will more accurately reflect the occurrence of SARS 
in the United States. 

Reported by: Star 
Investigative leam, CDC. 

World Health Organizatio 
severe acute respirator 

2. CDC. Updated interim | 
syndrome (SARS 

3. CDC. | pdate severe acute respi 
MMWR 2003;52;436-8 

+. CDC. Interim definitions and criteria 

Available at 

MMWR May 23, 2003 

TABLE. Number’ and percentage of reported severe acute 
respiratory syndrome (SARS) cases, by selected 
characteristics — United States, 2003 

Probable cases’ Suspect cases’ 
(n = 65) (n = 290) 

"The important thing 15 Characteristic No. (%)§ No. _(%)* 

Age (yrs) 

. . 7 0-4 : (14) 44 (15) 
not to stop quest1zoning a - . = 
e 10-17 (6) ie) (3) 
18-64 . (58) (69) 
° . >65 L (19) : (7) 
Albert Einstein Unknown (2) (1) 
Female y (40) (49) 
Male : (58) (50) 
Unknown (2) (1) 
White 29 (45) 
Black (2) 
Asian 29 (45) 
Other 2 (3) 
Unknown (6) 
Travel! : (97) 
Close contact (2) 
Health-care worker (2) 
Hospitalized >24 hrs** 
Required mechanical 
coronarivus laboratory 
Confirmed f 


Negative 20 (33) 

Undetermined! 39 194 (67) 

*N = 355 
CDC. Updated interim U.S. case definition of severe acute respiratory 
syndrome (SARS). Available at 

~ Percentages might not total 100% because of rounding 
To mainiand China; Hong Kong Special Administrative Region, China 
Hanoi, Vietnam; Singapore; Toronto, Canada; or Taiwan 

* As of May 21, no SARS-related deaths have been reported in the United 

, States 
Collection and/or laboratory testing of specimens has not been 


Vol. 52 / No. 20 

MMWR 469 

Elevated Mortality Associated 
With Armed Conflict — Democratic 
Republic of Congo, 2002 

In August 1998, citing a need to control insecurity on their 
western borders, Rwanda and Uganda sent troops into the 
Democratic Republic of Congo (DRC) (estimated 2002 popu- 
lation: 51 million). Within 6 months, troops from seven neigh- 
boring countries were fighting in the DRC, with various 
Congolese groups supporting different invading armies (/). 
During 1998-2002, the majority of the fighting occurred in 
the DRC’s five eastern provinces (1996 population: 19.9 mil- 
lion). To assess the impact of the armed conflict on public 
health, the International Rescue Committee (IRC), with sup 
port from CDC, conducted a nationwide mortality survey to 
measure DRC’s nationwide crude mortality rate (CMR) and 
to compare CMRs in DRC’ five eastern provinces with CMRs 
in the five western provinces. This report summarizes the 
results of the survey, which indicate that the overall CMR in 
the DRC is the highest in the world, with the majority of 
deaths caused by preventable infectious diseases. The find- 
ings underscore the importance of the ongoing peace process, 
which appears to have contributed to a decrease in mortality 
rates in eastern DRC, and highlights the importance of col 
lecting population-based health data regularly during armed 

Conducted during September 14—November 13, 2002, the 
survey employed a three-stage cluster approach to measure 
CMRs. In the first stage, 20 health zones were selected sys- 
tematically proportional to the population: 10 in the war 
affected areas of the five eastern provinces (Katanga, Maniema, 
North Kivu, Orientale, and South Kivu) and 10 in the five 
western provinces (Bandundu, Bas Congo, Equateur, Kasai 
Occidentale, and Kasai Orientale) (Figure). Of approximately 
14.3 million persons in the war-affected areas of the five east- 
ern provinces, 5 million (35%) could not be visited because 
of ongoing fighting, and the health zones in which these per- 
sons live were excluded from the site selection process. All 
health zones in the five western provinces were available for 
selection. In the second stage, 15 locations were selected in 
each targeted health zone, with the probability of selection 
proportional to population; the locations comprised the small- 
est known population units (i.e., specific avenues, clinic 
areas, or villages). In the final stage, a specific household was 
selected by using one of three methods: 1) counting all house 
holds in the selected population and selecting one at random; 
2) dividing the selected population into roughly equal seg- 
ments, selecting one segment at random, counting the house- 
holds in that segment, and selecting one at random; or 3) 

selecting a random point in space by using a map and a global 

FIGURE. Health zones in which crude mortality rates were 
assessed — International Rescue Committee Mortality Study, 
Democratic Republic of Congo, 2002 


- { 
Democratic\ Republic of Congo 




Bas Congo 
Occidentale Katanga 

positioning system unit if the population was spread over an 
entire clinic area with no further population breakdown 
Interviewers visited the selected households and explained 
the purpose of the survey to a person aged >14 years. A per- 
son consenting to an interview was asked about the age and 
sex of current household residents and the occurrence of any 
pregnancies, births, or deaths among current residents since 
January 2002. From households selected initially, interview 
ers \ isited the next 14 closest occupied households. If no per- 
son aged >14 years was home, or if members of a household 
refused to be interviewed, the household was skipped and the 
next was visited. Persons were included as household residents 
only if they had slept in that household on the preceding night. 
CMRs were calculated by using the following formula: 
CMR = (number of deaths / number of living residents 
minus half the number of births plus half the number of 
deaths) x 1,000 / the number of months in the recall period. 
Deaths were included if a decedent had slept in the inter- 
viewed household or lived with the interviewed family at the 
time of death during 2002. The recall period was January 1, 
2002, through the median day of the specific health zone evalu- 
ation (median: 9.3 months; range: 8.5—10.3 months). The 
mortality rate for children aged <5 years (<SMR) was esti- 
mated by using the following formula: <SMR = (number of 

deaths among children aged <5 years/number of children aged 


May 23. 2003 

ears who were alive at the time of the survey plus one half 


] ] 
t deaths among those years during recall period) x 

' ' 

1.000 / the number of months in the recall period [his equa 
m that both the total number of children born and 

vears remained con 

number of childret 

Cy Was 

xpressed as deaths pet r month. Previous 

rindings indicate that 

of 1.5 deaths per 1,000 
population pet 

Africa in the 

month occurs in or areas of sub-Saharan 

the time of the 

isited in the east 


Cause O 
of security 

| i 
iw health zone 


TABLE 1. Number of persons interviewed, numbers of births 
and deaths, and crude mortality rate (CMR)*, by location — 
international Rescue Committee Mortality Survey, Democratic 
Republic of Congo, 2002 


No. interviewed No. births No. deaths CMR 

Ake tl 






TABLE 2. Cause of reported deaths, by age, region, and illness — 
International Rescue Committee Mortality Survey, Democratic 
Republic of Congo, 2002 

East West 
Aged Aged Aged Aged 
<5 yrs >5 yrs <5 yrs >5 yrs Total 
(n= 198) (nm = 245) (n= 109) (n= 137) No (%) 

68 33 208 (30.0) 
42 (6.1) 

31 (4.5) 

25 (3.6) 

28 (4.1) 

25 (3.6) 

21 (3.0) 


deaths per 1,000 population 

CMkRs reported for all other 

r tf mortality 

umong the approximately 5 million inaccessible persons who 


ed in the « ist as high a 


+ deaths pel 1,000 population [ 



Editorial Note: The nationwide CMR estimate for the DR¢ 
of 2.2 deaths per 1,000 population per month presented 

in this report is much greater than the 1.3 deaths per 1,000 

Vol. 52 / No. 20 


population per month reported in 1997, the year before the 
outbreak of war (4). As is usually the case in protracted wal 
settings, violence was not reported as the major cause of death 
(2). In both the war-aftected and the nonwar-affected areas 
surveyed, febrile illness and diarrhea associated with infec 
tious diseases were the most commonly reported causes of 
death. This might reflect deteriorating economic and health 
conditions combined with the disruption of the health-care 

During January 1999—August 2001, three nongovernment 
organizations recorded substantially elevated CMRs through 
population-based sample surveys of specific health zones with 
populations ranging from 62,000 to 347,000 persons. Dut 
ing January—August 2001, Doctors Without Borders docu 
mented CMRs of 1.2—9.0 deaths per 1,000 population pet 
month in five health zones in five provinces ( 5). During 1999 
2001, IRC conducted 11 surveys in seven health zones in the 
five eastern provinces. These surveys, with recall periods of 

‘-17 months, documented CMRs of 2.7—12.1 deaths per 
1,000 population per month (3). Through an extrapolation 
process, these two IRC surveys were used to estimate an avet 
age CMR of 5.4 deaths per 1,000 population per month in 
the five eastern provinces during August 1998—April 2001 

3). Medical Relief International (MERLIN) documented a 
CMR of 10.0 deaths per 1,000 population per month in the 
eastern health zone of Kalima in a 3-month period during 
2000 (MERLIN, unpublished data, 2001 

Although the method of selecting health zones was not ran 
dom in the two previous IRC surveys, by chance, two Eastern 
provinces (Kalima and Kalemie) were selected in both 2001 
and 2002 and were evaluated during both years by using simi 
lar methods. The CMR in Kalima declined from 7.1 deaths 
per 1,000 population per month during January 2000—March 
2001 to 3.0 during 2002. During the same period, the CMR 
in Kalemie declined from 10.8 deaths per 1,000 population 
per month to 4.2. The improved CMR reflects a decline of 
96% in the rate of violent deaths, from 1.0 deaths per 1,000 
population per month in 2000 to <0.1 in 2002. These find 
ings for the eastern provinces indicate a marked reduction in 
CMRs during 2002 compared with the preceding 3 years (3 

he findings in this report are subject to at least four limi 
tations. First, avoiding areas with the worst security condi 
tions probably resulted in underestimating CMRs. Second 
data from past surveys conducted by IRC might not be com 
parable because different methods were used to select health 
zones. Third, because empty households experienced mor 
deaths than occupied households (6), CMRs probably were 
underestimated. Finally, no formal verbal autopsy procedure 
was followed, and no independent confirmation of the deaths 

was sought. 

Violence-related mortality in eastern DRC has 
when peace initiatives have been implemented 
accord signed in early 2001 curtailed hostilities substantialh 
and resulted in the withdrawal of most foreign troops du 
2002. In addition, during 2000-2002 ipproximatel 
United Nations (UN) observers arrived in addition to 
increase in humanitarian assistance and aid workers 
Epidemiologists can provide timely and r presentative health 
data to assess the public health impact of armed conflict 


After the first series of IRC surveys conducted in 2000, the 

UN Security Council passed a resolution demanding the with 

drawal of foreign troops he impact of the second round 
of IRC surveys conducted in 2001 on the current peace pro 
cess is unclear. Epidemiologic techniques involving creative 
flexible, and practical measurement techniques need to be 
developed further and employed on a regular basis to address 
the public health consequences of armed conflicts. Humani 
tarian efforts in DRC should focus on the war-affected east 

ern areas and on controlling infectious diseases 


Update: Global Measles Control 
and Mortality Reduction — 
Worldwide, 1991-2001 

Despite international recognition of the high burden of dis 
ease associated with measles and the existence for 40 years of 
1 safe, effective, and inexpensive vaccine, measles remains the 
leading cause of vaccine-preventable childhood mortality. In 
1990, the World Summit for Children adopted a goal of vac 
cinating 90% of the world’s children against measles by 2000 

In 2001, the World Health Organization (WHO) and 
the United Nations Children’s Fund (UNICEF) developed 

the Global Measles Strategic Plan for 2001—2005 (2). Che 

MMWR May 23, 2003 

annual number of 153,000 (58%) occurred in the WHO African Region, and 
ith 1999 levels approximately 202,000 (26° in the South East Asian 
interruption of Region (4 Figure 1). Of the global measles deaths, >98% 
reas with occurred in the 75 countries with per capita gross domestic 
$1,000 (WHO, unpublished data, 2003 

ultation in products of 
During 1991-2001, estimated worldwide measles vaccina 


tion coverage ranged from 69% to 76%. However, world 

(nhildren wide figures mask regional and national disparit cs During 
: I i 

this period, estimated coverage for the WHO regions of the 


and the Western Pacific was 82° 94%; 

minating Americas, Europe 1« 
urden of estimated coverage for the Eastern Mediterranean Region was 
mil in the South East Asia Region was 
in 2000 m10n had the lowest estimated COV 

Since 2000, WHO ar EF have recommended that, 
addition to achieving high coverage with the first dose of 

] 11 | 1 1 

litment 1s asies vaccine, all ¢ be offered a second opportunity 

maximize both individual and popu 

) opportu r mMeasies vaccination to 1 

This ret ts a second opportunity 

sles immunization for children who did not receive 

cine from the routine program and for those who 

did not develop immunity to measles after receiving 
2001, a total of 156 (82! 

iccine. During 199 
| . 

: widded | ' t ity rt 
countries provided 1second opportunity through suppleme 
| lr 

iry immMuNIZation actiVItic oO! through routine nie 

vices (O Figure 

Reported by: 


OOO easle : 
2000 mpared with FIGURE 1. Estimated number of measles deaths, by World 
Health Organization (WHO) region, 2000 

: i 
1on ; 
3 @ 
ams = 


that coun 

1 t 1 

According to GBD ff the est late OOO 

measles deaths in chi 2000, appr 

Vol. 52 / No. 20 


FIGURE 2. Countries providing second opportunity* for measles immunization — Worldwide, 1997-2001 

Providing second opportunity (156 countries) 

| Not providing second opportunity (35 countries) 

*Country has implemented a 2-dose routine measles schedule and/or within the preceding 4 years has conducted a nationa 
4 y 

achieving >90% coverage of children aged <5 years 

M Birmingham, J Bilous, B Hersh, Dept of Vaccines and Biologi 
World Health Oreanization, Geneva, Switzerland airns, P Strebe 
Global Immunization Div, National Immunization Program, CD( 
Editorial Note: Although substantial progress has been made 
in reducing measles deaths globally, in 2000, measles was 
estimated to be the fifth leading cause of mortality worldwide 
for children aged <5 years (4). Measles deaths occur dispro- 
portionately in Africa and South East Asia. In 2000, the Afri 
can Region of WHO, with 10% of the world’s population, 
accounted for 41% of estimated measles cases and 58% of 
measles deaths; the South East Asia region, with 25% of the 
world’s population and 28% of measles cases, accounted fot 
26% of measles deaths (4). The burden of mortality in Africa 
reflects low routine vaccination coverage and high case-fatality 
ratios. In South East Asia, where vaccination coverage is slightly 

below average worldwide lev els, the large population ampli 

fies the number of cases and deaths resulting from ongoing 

measles transmission. 


Che overwhelming majority of measles deaths in 2000 
occurred in countries eligible to receive financial support from 
the Global Alliance for Vaccines and Immunization’s Vaccine 
Fund (WHO, unpublished data, 2003). The majority of 
measles deaths occur among young children living in poor 
countries with inadequate vaccination services. Like human 
immunodeficiency virus, malaria, and tuberculosis, measles 
can be considered a disease of poverty. However, unlike these 
diseases, measles can be prevented through vaccination. 

Support from the Vaccine Fund for strengthening vaccina 
tion services and raising routine vaccination coverage can help 
reduce the high burden of measles. However, in countries with 
historically inadequate vaccination services, routine vaccination 
alone is not sufficient to reduce measles deaths or to achieve 
measles control because the large numbers of older children 
who missed routine vaccination remain susceptible to measles. 
The Measles Mortality Reduction and Regional Elimination 

Strategic Plan 2001-2005 outlines four main elements to 

474 MMWR 

May 23, 2003 

reduce measles mortality: | achieving high 1.e., >YO%) vac 
cination coverage nationally and in each district with the first 
dose of measles vaccine administered through routine health 

services to children who are aged 9 months or slightly older, 
) offering a second opportunity for measles immunization 
o all children, 3) establishing eftective surveillance tor measles, 
ind 4) improving case management (3). Countries are 
encouraged tO review measles epidemiology, develop a 55 
year plan for measles mortality reduction (8), identify reasons 
for low routine coverage, strengthen routine vaccination set 
Vices improve vaccination Safety and integrate measles Vaccl 
nation activiti with other public health activities as 
Although well-conducted supplemental vaccination activi 
ties can increase population immunity substantially and 
measles cases and deaths, new birth cohorts rapidly 
idd susceptible persons to the population. Bolstering routine 
iccination services to ensu that the majority of infants 
receive measles vaccine and other vaccines is essential to sus- 
tain the impact of measles mortality reduction activities. 
In 2001, the Measles Partnership was formed to reduce 

measles deaths in Africa. 

WHO, UNI the United Nations Foundation, the Ameri 

Me mbers of this partnership include 

can Red Cross, and CDC. During 2001-2002, this partner 
ship contributed $40 million for the vaccination of approxi 
mately 60 million children aged 9 months—14 years living in 
13 African countries. Preliminary evidence suggests that these 
campaigns have had a substantial impact in reducing measles 
deaths (WHO African Regional Office, unpublished data, 

Surveillance to assess burden of disease and guide vaccina- 
tion policy remains critical. Outbreak investigations should 
be used as an opportunity to learn about the changing epide 
miology of measles. These investigations can provide infor- 
mation about patterns of transmission, including case-fatality 
ratios and age distribution and vaccination status of cases. 

United Nations ¢ 

World Declaratior 

ldret n the 99) 



@ once. 



' + 


Vol. 52 / No. 20 

In this vaccination program, ( 1 the kood and Drug 

Disease 2000 Project: ain nethods a d Gene S 
Administration, and state health departments are conduct 
d: World Health Orgar tor 001; Glo , i I i sa 
det for Health Po [Disc mn Pay , \ surveill ince for vaccine-associated ad rs¢ nt imo! 
‘ ! U civilian vaccinees (/ As part of ¢ ccination | 
civilian vaccinees receive routin rollow-up ind reported 

a yo . i ———— f 1dverse events after vaccination rec follow-up as needed 
| Infect Dis 2003;187:S8-S14 The U.S. Department of Defense is conduct 
( Work h Or ( VHO { 
! H ror vaccine associated adverse event among Millltal i 
00 ( S \ ri : : 
O; i 007 ind providing follow up care to those persons with reported 
World Health Orean tio Stra es to du adverse events 
w Epidemiol Rec 2000;75:409-1( Adverse events that have been associated with smallpox 
y \ H () (;lob , . , , , 
: ‘ cination are Classified on the Dasis of evidence supporting tl 
OOF 00 P \ | Pp} 
100)? yR_G] reported diagnoses (_ases verified by virologic resting or in 
« | | liao t y | t | 
some instances D otmner Giagnostic testing ire Classified 
confirmed (Table 1). Cases are classified as probable if po 
sible alternative etiologies are investigated and excluded and 
ad | 
Update: Adverse Events Following SUPPpOrtTive information for the diagnosis is TOouNnd Patient 
_ . . . . 1 . 1 j 1 1 ‘ 
Civilian Smallpox Vaccination — ire Classified as suspected if they have clinical features com 
ats ; 
° patible with the diagnosis, but either further investigatior 
nite ares ' 
- . , , ' 
required or investigation of the case did not provide support 
) o y 2 9 I003. s | ‘ , was a 
During January 24—May 9, 2003, smallpox vaccine wa ing evidence for the diagnosis. All reports of events that 
is Yat ae ee — a 
€ » 36,2 ivilian hes al rub alth 
idministered to 36,217 civilian health-care and public healt! follow vaccination are accepted (i... events associated tem 
‘ , SS in ; ) iS ' , j , , 
workers in jurisdictions to prepare the United States for a porally); however, reported adverse events are not necessaril 
possible terrorist attack using smallpox virus. [his report associated causally with vaccination. and some or all of cl 
updates information On vaccine-associated adverse events events might be coincidental. | his report includes cas« 
o id o o } nro ; "i 
| among civilians vaccinated since the beginning of the pre reported as of Mav } that ithe! are unde! investigation OF 
gram and among contacts of vaccinees, received by CDC from have a reported tinal diagnosis. Because of ongoing discus 
} ‘ ver ? Oo " t rv c t 1 j 1 ; 
the Vaccine Adverse Event Reporting System (VAERS) as of sions of final case definitions. numbers and classifications of 


TABLE 1. Number of cases* of selected adverse events associated with smallpox vaccination among civilians, by type — United 
States, January 24—May 9, 2003 

No. new cases Total 
{ (May 3-9) (January 24—May 9) 
| Adverse events Suspected' Probable‘ Confirmed" Suspected Probable Confirmed 

Eczema vaccinatur < — — — 
Fetal vac la — _ — 
Generalized vaccinia 1 — 

inadvertent inoculation 

Ocular vaccinia ~ 
Pr gressive vaccinia ree a te 
Erythema multiforme major (Stevens-Johnson syndrome —_ —_ 
Myo/pericarditis ‘ = 7 . 

stvaccinial encephalitis or encephalomyelit 1 1 — 
Ls b y 

Pyogenic infection of vaccination site 

* Under investigation or completed as of May 9, 2003: numbers and classifications of adverse events will be updated regularly in MMWA as more 
nformation becomes available 
Events are classified as suspected if they have clinical features mpatidie with the diagr Ss but either further investigatior required or adaitiona 
investigation of the case did not provide supporting evidence for the diagnosis and did not identify an alternative diagnos 

i Events are classified as probabie if possibie uiternative etiologies are investigated and ipportive informatior round 
For the first six events listed, events are classified as confirmed if virologic tests are { tive. For the last four events, events are cClassitied a niirmed 
based on diagnostic testing (e.g., histopathology); confirmation of events thought to be immur ically mediated (i.e., erythema multiforme, myo/pericardaitis 
yr postvaccinial encephalitis or encephalomyelitis) does not establist 1uSalit 

* No cases reported 

476 MMWR 

May 23, 2003 

In collaboration with the Smallpox Vaccine Safety Work 
ing Group of the Advisory Committee on Immunization Prac 
tices, a Cas¢ detinition for myo pe ricarditis has bee n developed 
and will be described in a subsequent MMWR. Using this 
definition to categorize all reports received through May 9, 
1 total of 24 cases are consistent with the definition of 
myo/pericarditis; one of these was a new report received dur 
ing May 3-9 (Table | 

During May 3—9, no cases of eczema vaccinatum, erythema 
multiforme major, fetal vaccinia, or progressive vaccinia have 
been reported (Table 1). One case of suspected postvaccinial 
encephalomyelitis (PVE) was reported. 

\ man aged 38 years with a history of heavy tobacco use 
had acute respiratory distress and hypoxia on April 18, a total 
of 10 days after primary smallpox vaccination. He had a diag 
nosis of acute epiglottitis and was hospitalized and treated 
with intravenous corticosteroids, bronchodilators, antibiot 
ics, and intermittent lorazepam for agitation. He improved 
ind was discharged on April 25 on an oral steroid taper and 
bupropion to aid in smoking cessation 

On April 26, he had acute behavioral changes characterized 
by intense agitation, emotional lability, and confusion, and 
was readmitted. On examination, the patient was afebrile and 
oriented with no focal neurologic deficits, but with moderate 
difficulty with concentration. Computerized tomography 
CT) of the head showed several punctate areas of deep white 
matter hypodensity. Magnetic resonance imaging (MRI) of 
the brain with and without gadolinium displayed multiple 
nonenhancing punctate areas of increased signal in the deep 
subcortical white matter seen mainly on fluid attenuation 
inversion recovery (FLAIR) sequences, a nonspecific finding 

potentially consistent with a history of heavy smokin 

go, severe 

hypertension, or amphetamine use. Laboratory studies showed 
an elevated creatine phosphokinase (CPK) of 3,000 u/L (nor- 
mal: <175 u/L), and a urine toxicology screen was positive 
for marijuana and benzodiazepines; other studies were not 
mal. Cerebrospinal fluid (CSF) protein, glucose, cell counts, 
and markers of acute demyelination (oligoclonal banding, IgG 
indices) were normal; CSF polymerase chain reaction for her 

pes simplex virus and vaccinia virus were negative. An elec- 

troencephalogram (EEG) showed changes consistent with 

benzodiazepine effect. The patient's behavioral changes 

improved, CPK levels decreased to 278, and he was discharged 
on April 29 with a diagnosis of steroid-induced psychosis. 

On May 3, the patient suffered an uprovoked generalized 

tonic-clonic seizure. An MRI was unchanged from the previ- 
ous scan. However, post-infectious demyelination was con 
sidered because of the patient's smallpox vaccination history. 
He was placed on phenytoin, steroids were increased, and 

he was discharged the following day with a diagnosis ot 

post-infectious encephalomyelitis. As of May 8, the patient 
remained mildly confused and emotionally labile. 

During May 3-9, one other serious adverse event was 
reported for hospitalization and antibiotic administration, and 

23 other nonserious events were reported (Table 2). Among 

the 488 vaccinees with reported other nonserious adverse 
events during January 24—May 9, the most common signs 

88), headache 
74) (Table 2). All of 

these commonly reported events are consistent with mild 

and symptoms were fever (n 92), rash (n 
(n = 82), pain (n = 78), and fatigue (n 
expected reactions following receipt cf smallpox vaccine. Some 
vaccinees reported multiple signs and symptoms. 

During this reporting period, no vaccinia immune globu- 
lin was released for civilian vaccinees. No cases of vaccine 
transmission from civilian vaccinees to their contacts have 
been reported during the vaccination program (Table 3). A 
total of 10 cases of transmission from military personnel to 
civilian contacts have been reported. Surveillance for adverse 
events during the civilian and military smallpox vaccination 
programs is ongoing; regular surveillance reports will be pub- 

lished in MMWR. 

TABLE 2. Number of cases* of other adverse events reported 

after smallpox vaccination among civilians, by severity — 

United States, January 24—May 9, 2003 

No. new Total 
cases (January 24—- 

(May 3-9) May 9) 

Other serious adverse events! 13 59 

Other nonserious adverse events‘ 23 488 

Adverse events 

“Under investigation or completed as of May 9, 2003; numbers and 
classifications of adverse events will be updated regularly in MMWR as 
, more information becomes available 
Events that result in hospitalization, permanent disability, life-threatening 
illness, or death. These events are temporally associated with vaccination 
but are not necessarily causally associated with vaccination 

~ (ncludes one case of hospitalization for antibiotic administration 
Include expected self-limited responses to smallpox vaccination (e.g 
fatigue, headache, pruritis, local reaction at vaccination site, regional 
lymphadenopathy, lymphangitis, fever, myalgia and chills, and nausea) 
additional events are temporally associated with smallpox vaccination 
but are not necessarily causally associated with vaccination 

TABLE 3. Vaccinia immune globulin release and vaccinia 
transmission to contacts — United States, January 24- 
May 9, 2003 

No. new Total 
cases (January 24—- 
Events (May 3-9) May 9) 
Vaccinia immune globulin release 0 1 
Vaccinia transmission to contacts* 
Health-care settings 0 0 
Other settings 0 0 

“No cases of transmission from civilian vaccinees have been reported 
Ten cases of transmission from military personnel to civilian contacts 
have been reported and are included in Table 1 (eight inadvertent 
inoculation, and two ocular vaccinia) 

Vol. 52 / No. 20 

Reported by: Sal/pon 

Editorial Note: PVE is a rare adverse e\ 

smallpox vaccination 2 »). Estimates 

occurrence is thought to range from 2.4 

lion vaccinees depending on age, vaccination 


veillance methods (2—4); approximately 15° 
cases are fatal, and approximately 25% of survivors develoy 
substantial neurologic sequelae (2). Although the exact 

pathogenesis is unknown, it is likely that both 

nM a direct, vac 

cinia-associated acute viral encephalomyelitis and an autoin 

1 Al iil 

mune-mediated inflammatory reaction resulting in 

postvaccination demyelination (acute disseminated encepha 

lomyelitis [ADEM}]) occur (6). Patients with PVE show signs References 

of encephalitis (alteration of mental status and focal neuro CDi 

logic deficits), myelitis (upper- and lower-motor neuron dys 

function, sensory level and bowel and bladder dysfunction 

or both. Rarely, vaccinia virus might be detected in CSI 

Several features of this case are not typical of PVE. Exam 


nation on April 26 showed only difficulties with concentra 


ere OvDSCTVed 

. bd 
tion; no focal deficits O! encephalopathy W 

Neurodiagnostic studies, including CSF examination and 


EEG, were normal. Consideration of PVE followed seizure 


MRI findings before and after the seizure might in 
demyelination consistent with ADEM, but might also be con 

sistent with the patient's heavy smoking history, although 

unusual in a person aged <50 years Although neither MRI 

displayed the multifocal enhancing white matter lesions 

ciated typically with ADEM, it is unknown whether 


treatment with high-dose steroids might impact 

ings of ADEM. Other potential etiologies for dé 
of a seizure in this patient include bupropion us¢ 
tigation of this case is ongoing. 

This case highlights the difficulty 

: , ; , 
he diagnosis is exclusionary. lemporal 



May 23, 2003 

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals May 17, 2003, with historical 




Ratio (Log Scale)* 

Beyond Historical Limits 





TABLE |. Summary of provisional cases of selected notifiable diseases, United States, cumulative, week ending May 17, 2003 (20th Week)* 




Hansen disease (leprosy) 

Hantavirus pulmonary syndrome 
Hemolytic uremic syndrome, postdiarrheal 
HIV infection, pediatric 

Measles, total 
Poliomyelitis, paralytic 

Q fever 



Streptococcal toxic-shock syndrome 

Toxic-shock syndrome 


Yellow fever 





* incidence 
Not n ll} 
Updated monthly from reports to the Divi 
(NCHSTP). Last update April 27 
Of nine cases reported, eic 
* Of seven cases 

reported cases 
data f 

tifiable ir 

r reporting years 2002 and 20( 

on of HIV/AIDS Prev 
reported, four were indigenous and three we 

were indigenous and one was 


isional and Cumulative (year-to-date) 

Surveillance and Epidemiology, National Center 

imported from another country 
> imported from another country 

for HIV 

STD, and TB Prevention 

Vol. 52 / No. 20 


TABLE Il. Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 

(20th Week)* 

Reporting area 





West Nile 





Cum. Cum. 


Cum. Cum. 
2003 2002 

Cum Cum 
2003 2002 

Cum Cum 
2003 2002 












480 MMWR May 23, 2003 

TABLE Il. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 
(20th Week)* 

Escherichia coli, Enterohemorrhagic (EHEC) 
Shiga toxin positive, Shiga toxin positive, 
0157:H7 serogroup non-0157 not serogrouped Giardiasis Gonorrhea 

Cum. Cum. Cum Cum. Cum. Cum. ; Cum. Cum. 
Reporting area 2003 

2002 2003 2002 2003 2002 2002 2002 

24 46 5 5,178 6.660 2.673 132,085 
59. 3,048 

Vol. 52 / No. 20 


TABLE Il. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 

(20th Week)’ 

Reporting area 

Haemophilus influenzae, invasive 

All ages 
All serotypes 

Age <5 years 

(viral, acute), by type 

Serotype B 

Non-serotype B 

Unknown serotype 


Cum. Cum. 

2003 2002 

Cum. Cum. 
2003 2002 


Cum. Cum. 

Cum. Cum 
2003 2002 

Cum Cum 
2003 2002 





Upstate N.Y 





482 MMWR May 23, 2003 

TABLE Il. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 
(20th Week)* 

Hepatitis (viral, acute), by type 

B Cc Legionellosis Listeriosis Lyme disease 

Cum | Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. 
Reporting area 2003 | 2002 2003 2002 2003 2002 2003 2002 2003 2002 

NITED STATE y ¢ 1,174 8 329 279 155 163 1,856 2,514 

1€ 160 


Vol. 52 / No. 20 


TABLE Ii. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 

(20th Week)* 




Rabies, animal 

Rocky Mountain 
spotted fever 

Cum. Cum. 
Reporting area 2003 2002 

Cum. Cum. 
2003 2002 


Cum. | Cum. 

Cum. Cum. 

Cum | Cum 








Upstate N.Y. 
NLY. City 







M nr 

89 o 




2003 2002 


2003 2002 

484 MMWR May 23, 2003 

TABLE Il. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 
(20th Week)* 

Streptococcus pneumoniae, invasive 
Streptococcal disease, Drug resistant, 
Saimonellosis Shigellosis invasive, group A all ages Age <5 years 
Cum. Cum. Cum. Cum Cum. Cum. Cum. Cum. Cum. Cum. 

Reporting area 2003 2002 2003 2002 2003 2003 2002 2003 

NITED STATES ) 32 1 O56 7 5 512 2 : 1.041 95 163 
NEW ENGLANI 1 ; ; ; c 



* Incidence data f 

Vol. 52 / No. 20 

(20th Week)* 

Primary & secondary 
Reporting area 

Cum. Cum. Cum. Cum. 
2003 2002 2003 




TABLE Il. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 17, 2003, and May 18, 2002 


Tuberculosis Typhoid fever (Chickenpox) 
Cum. Cum. Cum Cum Cum 
2002 2003 2002 2003 2002 2003 




486 MMWR May 23, 2003 

TABLE Ili. Deaths in 122 U.S. cities,“ week ending May 17, 2003 (20th Week) 
All causes, by age (years) All causes, by age (years) 

All P&l' All 
Reporting Area Ages >65 45-64 | 25-44] 1-24] <1 | Total Reporting Area Ages >65 45-64 | 25-44 

A AIT 4 4 4 

YEW ENGLAND 52 34 3 39 3 { Be S. ATLANTIC 1.722 
, 3 14 € f Atlanta. G 70) 30 212 


) 50 
429 5 

Miami. F 

St. Peter: 


will be available 

Vol. 52 / No. 20 

May 23, 2003 

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