MMWR. Morbidity and Mortality Weekly Report 2003-05-23: Vol 52 Iss 20

CDC

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&

Morbidity and Mortality Weekly Report

Weekly

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

settings.

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

transmission.”

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

rs. Dur-

(
Oo

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
SARS.

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

INSIDE

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION

May 23, 2003

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

(SA 30333

Epidemiology
Yeparrment of Health and

ind Preventio

Human Ser

SUGGESTED CITATION

Control and Prevention

Article

numbers}.

'
Centers for Utsease

litle]. MMWR 2003;52:| inclusive page

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

M.D

} 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

3
OV

Not tested

| | Negative
2 Confirmed

Number

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

]

=

PETE, ALE!

~———-4---

oe

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

Ags

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

morbidlt
|

| ]
health-care facilities. In

|
reighborhood

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
I

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*

Taipei
Taoyuan city Taipei
county \ county

JU

Kaohsiung
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
antined

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

hospitals

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

467

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

States, 2003

14

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

Number

Mar

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.

References
World Health Organizatio
severe acute respirator

ww.who.int/csr/sarscount

2. CDC. Updated interim |
syndrome (SARS
casedefinition.htm

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

+. CDC. Interim definitions and criteria

Available at http://www.cdc.gov/ncidod/sars

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)
Sex
Female y (40) (49)
Male : (58) (50)
Unknown (2) (1)
Race
White 29 (45)
Black (2)
Asian 29 (45)
Other 2 (3)
Unknown (6)
Exposure
Travel! : (97)
Close contact (2)
Health-care worker (2)
Hospitalized >24 hrs**
Yes
No
Unknown
Required mechanical
ventilation
Yes
No
Unknown
SARS-associated
coronarivus laboratory
findings
Confirmed f

(O

Negative 20 (33)

Undetermined! 39 194 (67)

*N = 355
CDC. Updated interim U.S. case definition of severe acute respiratory
syndrome (SARS). Available at http://www.cdc.gov/ncidod/sars
casedefinition.htm

~ 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
compieted

til
Continuing
Education

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
conflicts.

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

AFRICA

Orientale
- {
Democratic\ Republic of Congo

Equateur

North
Kivu

South
Kivu

Bas Congo
Kasai
Occidentale Katanga
Kasai
Orientale

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

MMWR

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

west

Cause O
of security

| i
iw health zone

imMong

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

Location

No. interviewed No. births No. deaths CMR

Eastern
Katana
Kaliemie
Butembo
Kyondo
Pweto
Kisangan
Kalima
Ake tl

Mweso

Total
Western

Kimbanseke

Popokabaka

LUKUIa

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)

(35.0)

deaths per 1,000 population

CMkRs reported for all other

]
r tf mortality

umong the approximately 5 million inaccessible persons who

1

ed in the « ist as high a

ipprox!
!

+ 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

MMWR

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
system.

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

References

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

Si

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
}

ZU005

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
Ait

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 =

intri«

that coun

1 t 1

According to GBD ff the est late OOO

measles deaths in chi 2000, appr

Vol. 52 / No. 20

MMWR

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
ippropriate
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,
2002).

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.
References

United Nations ¢
\Y

World Declaratior

ldret n the 99)

tobe!

/
aoc

@ once.

atest

topic?

' +
reports

Online

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
I
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

May

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 .
Po

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

f
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

1
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\

associated
smallpox vaccination 2 »). Estimates

occurrence is thought to range from 2.4

lion vaccinees depending on age, vaccination

ic

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

hil

nation on April 26 showed only difficulties with concentra

j
;

|
ere OvDSCTVed

. bd
tion; no focal deficits O! encephalopathy W

Neurodiagnostic studies, including CSF examination and

Cl

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
ee

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

478

MMWR

May 23, 2003

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

data

DECREASE

A
INCREASE —

Ratio (Log Scale)*

Beyond Historical Limits

CURRENT

4 WEEKS

253
328
197

43

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

Cum.
2003

Cum.
2002

1

Hansen disease (leprosy)

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

Measles, total
Mumps
Plague
Poliomyelitis, paralytic
Psittacosis

Q fever
Rabies
Rubella
Rubella

numan

congenital

Streptococcal toxic-shock syndrome
Tetanus

Toxic-shock syndrome
Trichinosis

Tularemia

Yellow fever

Cum.
2003

Cum.
2002

32

se)

No
* 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(
states

on of HIV/AIDS Prev
2003
ynt
reported, four were indigenous and three we

were indigenous and one was

ention

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

MMWR

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

(20th Week)*

Reporting area

AIDS

Chlamydia’

Coccidiodomycosis

Cryptosporidiosis

Encephalitis/Meningitis
West Nile

Cum.
20035

|

Cum.

2002

Cum. Cum.
2003

2002

Cum. Cum.
2003 2002

Cum Cum
2003 2002

Cum Cum
2003 2002

UNITED STATES
NEW ENGLAND
Maine

N.H

vt

MA
vMaSS

E.N. CENTRAL
Ohi

Ind
Mict
Wis

W.N. CENTRAL
Minr

726

4

f

)

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

Cum.
2002 2003 2002 2003 2002 2002 2002

24 46 5 5,178 6.660 2.673 132,085
59. 3,048
2G

Vol. 52 / No. 20

MMWR

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

Hepatitis
(viral, acute), by type

Serotype B

Non-serotype B

Unknown serotype

A

Cum. Cum.

2003 2002

Cum. Cum.
2003 2002

2003

Cum. Cum.

Cum. Cum
2003 2002

Cum Cum
2003 2002

UNITED STATES
NEW ENGLAND
Maine

NH

Mass
R.|
Conn

MID. ATLANTIC

Upstate N.Y

66
51
4

4

2002

1A

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

4
4

Vol. 52 / No. 20

MMWR

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

(20th Week)*

Malaria

Meningococcal
disease

Pertussis

Rabies, animal

Rocky Mountain
spotted fever

Cum. Cum.
Reporting area 2003 2002

Cum. Cum.
2003 2002

2002

Cum. | Cum.

Cum. Cum.

Cum | Cum

UNITED STATES 301 394

NEW ENGLAND
Maine

N.H

vt

Mass

R.1

Conr

MID. ATLANTIC
Upstate N.Y.
NLY. City

N.J

Pa

E.N. CENTRAL
Yr

»)

Ind

W.N. CENTRAL

M nr

89 o

4

2003

389

2003 2002

161

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

Maine

Notn

* Incidence data f

Vol. 52 / No. 20

MMWR
(20th Week)*

Syphilis
Primary & secondary
Reporting area

Cum. Cum. Cum. Cum.
2003 2002 2003

NEW ENGLAND
Maine
N.H

NITED STATES

Congenital

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

69

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

it

MA

Varicella

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

Baltirr

) 50
429 5

Jac
Miami. F
Nort
Richmonc
Savannat

St. Peter:

CENTRAL

will be available

Vol. 52 / No. 20

May 23, 2003

he Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge
in electronic format and on a paid subscription basis for paper copy. To receive an electronic copy each week, send an e-mail message to Listserv@listserv.cdc.gov. The
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Printing Office, Washington, DC 20402; telephone 202-512-1800.

Data in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on
Friday; compiled data on a national basis are officially released to the public on the following Friday. Address inquiries about the MMWR Series, including material
to be considered for publication, to Editor, MMWR Series, Mailstop C-08, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333; telephone 888-232-3228.

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