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Epidemiologic Notes and Reports Transmission of Measles Across State Lines -- Kentucky, New Hampshire, Tennessee, Virginia

A total of 25 cases of measles in 4 states have been linked to a single imported case. This illustrates the problem created by a highly contagious disease that can be spread rapidly without regard to geographic boundaries. States reporting measles associated with this outbreak in the period November 8, 1981-January 9, 1982, included: Virginia (18 cases), New Hampshire (3), Tennessee (3), and Kentucky (1) (Figure 2).

The index patient was a 15-year-old foreign-exchange student from El Salvador who had arrived in the United States on November 3, 1981, with her brother and 47 other Salvadoran students. The students were housed together in a dormitory in Washington, D.C., for 3 days. On November 6, they went to their temporary residences in 19 different states (Figure 3). The index patient went to Lee County, Virginia, and her brother went to Merrimack County, New Hampshire, where both were enrolled in public high schools. She developed a rash on November 8 in Virginia; her brother had rash onset on November 18 in New Hampshire. Both gave histories of having received measles vaccine in El Salvador at age 11-12 years.

Measles transmission in Lee County, Virginia (a rural, mountainous region in western Virginia, bordered by Kentucky and Tennessee), began with a high school classmate of the Salvadoran girl, who had rash onset on November 18. By January 9, a total of 17 cases that could be linked to the Salvadoran girl had occurred. One of the patients was a 20-year-old pregnant woman who had rash onset on January 5 following exposure to her 12-year-old brother. After delivering a healthy baby on January 6, the mother developed severe pneumonia that was followed by respiratory arrest. She was resuscitated and transferred to an intensive care unit in a larger hospital nearby in Tennessee. She recovered completely, and her baby remained well. Three additional measles cases occurred involving a 19-year-old woman and 2 pre-school children from Hancock and Sullivan counties, Tennessee. These cases were linked to the cases among school children in contiguous Lee County, Virginia. The woman developed high fever and dehydration, which necessitated her hospitalization. An additional case involved an elementary school student in Harlan County, Kentucky, who had rash onset on December 2, following exposure on a school bus in contiguous Lee County, Virginia.

Record reviews and mandatory school exclusions were instituted at 2 affected schools, and voluntary immunization programs were conducted at several other schools in Lee County, Virginia. A hospital in Sullivan County, Tennessee, excluded 21 employees who had direct contact with the 2 hospitalized patients and could not furnish evidence of immunity to measles.* A special immunization clinic was held in the hospital.

Measles transmission in Merrimack County, New Hampshire, was limited to 2 additional cases: a high school classmate of the Salvadoran boy, who had rash onset on December 1, and his 2-year-old cousin, who had rash onset on December 10. Susceptible contacts of these patients received immune globulin or measles vaccine. Record reviews at the local high school showed that 100% of the students had adequate evidence of immunity to measles.

Of the other 47 exchange students from El Salvador, 46 were contacted in their states of temporary residence and found to be well. One student had become ill and returned to El Salvador; further details of her illness were not available. Reported by D Simpson, RN, Harlan County Health Dept, R Mills, RN, J Skaggs, DVM, Acting State Epidemiologist, Kentucky State Dept for Human Resources; F Lakionatis, M Gilchrist, RN, Franklin School District, RM Schumacher, MD, Franklin, JM Horan, MD, State Epidemiologist, New Hampshire State Dept of Health and Welfare; C Varandan, MD, Lee County Community Hospital, M Ford, MD, G Vest, MD, Lonesome Pine Community Hospital, G Honeycutt, Jr, MD, Lee County Health Dept, Jonesville, R Hackler, M Gallaher, RN, H Nottebart, Jr, MD, E Smith, RN, GB Miller, Jr, MD, State Epidemiologist, Virginia State Dept of Health; C Chapman, MD, Sullivan County Health Dept, J Smiddy, MD, Holston Valley Community Hospital, Kingsport, MY Cooper, L Halston, PHN, RH Hutcheson, Jr, MD, State Epidemiologist, Tennessee State Dept of Public Health; Immunization Div, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This was a small but geographically widespread outbreak of measles resulting from a single imported case involving a foreign-exchange student with a history of vaccination abroad. The resulting investigations covered 19 different states and the District of Columbia. When measles transmission occurs across state lines, communication between the states is essential to contain the outbreak successfully.

Outbreaks resulting from importations of measles have been described previously (1-3), and imported measles cases are a continuing source of measles in the United States (4-5). In 1980 and 1981, the substantial decline in total measles cases led to a rise in the proportion of imported cases.

The illness experienced by the young mother illustrates that serious complications can result from measles in an adult population. Communities can protect themselves from importations of measles by achieving and maintaining high immunization levels. Investigations of imported measles cases should include a search for susceptible contacts at all points of the traveler's itinerary, as well as in the local community. Rapid containment of measles requires effective surveillance and aggressive outbreak-control measures, which include locating and investigating contacts who have crossed state lines.


  1. CDC. Multiple measles importations--New York. MMWR 1981;30:288-90.

  2. CDC. Measles--United States, first 39 weeks of 1980. MMWR 1980;39:501-2.

  3. Frank JA Jr, Hoffmann RE, Mann JM, Crowe JD, Hinman AR. Imported measles: a potential control problem. JAMA 1981;245:264-6.

  4. Amler RW, Bloch AB, Orenstein WA, Bart KJ, Turner PM Jr, Hinman AR. United States: measles importations from the Americas. Pan-American Health Organization. EPI newsletter 1981; III (6):5-6.

  5. CDC. Measles importations--United States. MMWR 1981;30:455-62. *Defined by CDC as a dated record showing administration of live measles vaccine on or after the first birthday or a history of physician-diagnosed measles illness.

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