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Current Trends Measles on College Campuses -- United States, 1985
In the first 26 weeks of 1985, 334 (18.5%) of the 1,802 reported cases of measles in the United States occurred on 25 college campuses in 14 states and the District of Columbia. The proportion of reported measles cases on college campuses during this period is more than six times that in 1984, and approaches that of 1983, when it reached an all-time high of 19.8% (Table 1). Among states reporting measles cases on college campuses, the proportion varied by state from 0.5% to 100% (Table 2). A recent outbreak at Villanova University (suburban Philadelphia, Pennsylvania) illustrates the problem.
From March 22 through April 27, 1985, 21 measles cases occurred on the Villanova campus. Three additional cases occurred off campus--two in Pennsylvania and one in Maryland. All cases met the CDC clinical case definition of measles: generalized rash lasting 3 or more days, fever (37.8 C (101 F) or higher, if measured), and at least one of the following symptoms: cough, coryza, conjunctivitis. Eleven of the 24 cases were serologically confirmed.
Twenty of the 21 campus cases occurred among undergraduate students. Approximately 6,200 of the 11,000 students at the university are undergraduates; thus, the estimated attack rate among undergraduates was 3/1,000. The other case occurred in a 16-year-old male who worked part-time on campus as a foodhandler. Three patients were hospitalized, two with pneumonia.
The index case was a 19-year-old male who had rash onset on March 22 (Figure 1). The source of his infection is unknown. However, he had traveled to Fort Lauderdale, Florida, during spring break (March 2-10), where infected students from an outbreak at Boston University (BU) (1) were known to be present. The second generation of cases (April 3-6) consisted of seven students and the part-time campus employee. After second-generation measles patients had left campus during Easter vacation (April 2-9), three additional cases subsequently occurred in Maryland and in other areas in Pennsylvania.
To control the outbreak, surveillance was intensified, and vaccination clinics were held on campus. Expanded surveillance activities included a retrospective review of the infirmary's patient log, widespread publicity of the outbreak throughout the campus and in the student newspaper, communication with infection-control nurses at local hospitals, and contact with other colleges and universities in southeastern Pennsylvania. On April 15-17, voluntary vaccination clinics were held for students who could not recall a history of physician-diagnosed measles or measles vaccination after 1967 at 12 months of age or older. No information on measles vaccination status in student medical records was required by the university. More than 3,300 (53%) of the undergraduate students were immunized in these clinics with combined measles-rubella vaccine; only one case subsequently occurred. Reported by R Neville, PhD, J Stack, Villanova University, RD Gens, MD, GR Seastrom, H Julian, EJ Witte, VMD, State Epidemiologist, Pennsylvania State Dept of Health; Div of Immunization, Center for Prevention Svcs, CDC.
Editorial Note: The Villanova University outbreak is one of the larger college outbreaks reported in 1985. The largest occurred at Principia College, a Christian Science college in Illinois (1). One hundred twenty-eight cases were reported between January 15 and March 10, including 113 among students and 15 among other residents. Three deaths related to respiratory complications of measles occurred among students and residents at the college. BU was the site of another large outbreak, which began at the end of January and continued through the end of March (1). One hundred three students and two employees at BU were infected. Fifty-five persons were hospitalized for isolation and/or medical treatment, including one student who was admitted to the intensive-care unit with pneumonia. Thirteen persons developed otitis media.
The high mobility of college students, who may travel to countries where measles is endemic or epidemic, offers the potential for frequent introduction of measles virus onto college campuses. For example, an 18-year-old student who had traveled to Guatemala was the index case for an outbreak in 1983 involving 20 students at Louisiana State University (2). The index case for an outbreak involving 12 cases at Ohio State University in January and February 1985 was a student who had acquired measles while traveling to London and Sierra Leone. The index case for the BU outbreak was a student who had acquired measles while traveling in Venezuela (1).
Once measles virus is introduced onto a college campus, transmission among students may be sustained by several factors (3): (1) many students who grew up in the mid-1960s may have missed measles vaccination in the first years following the licensure of measles vaccine; (2) many students may not have been immunized before the adoption of comprehensive school laws now in effect in most states; (3) many students may have escaped natural measles infection because of decreasing transmission over the past 20 years; (4) some students may have been vaccinated with the killed measles virus vaccine without subsequent revaccination with live measles virus vaccine; and (5) many students may have been vaccinated with live measles virus vaccine before their first birthday, when measles vaccine is known to be less effective. These factors contribute to an estimated susceptibility level of 5%-15% among college-aged individuals in the United States (4,5). Since college students tend to congregate in large numbers, this susceptibility level may allow for substantial measles transmission.
Because of the likelihood for measles virus introduction onto college campuses and the increased chances for sustained transmission, effective measures to reduce the susceptibility levels of college students should be adopted and implemented as soon as possible. In May 1983, the American College Health Association adopted a Preadmission Immunization Policy, recommending that, by September 1985, colleges and universities require all students to present documentation of immunity to measles and other vaccine-preventable diseases as a prerequisite to matriculation or registration (6). The Immunization Practices Advisory Committee has likewise recommended since 1980 that college and university administrations strongly consider establishing such requirements (7).
Massachusetts, North Carolina, the District of Columbia, and Puerto Rico have adopted statutes requiring immunization of college students. In Rhode Island, the state health and education departments jointly promulgated a regulation, which took effect January 1, 1985, requiring documentation of immunity to measles and rubella for newly entering college students. In Mississippi, the Board of Trustees of State Institutions of Higher Learning adopted a requirement for proof of immunity to measles and rubella for students registering at 4-year state-supported institutions as of fall 1984. Elsewhere, individual universities and colleges have adopted their own internal immunization policies (8). One of the largest of these is the University of Michigan, which recently approved a requirement for documentation of immunity to measles and rubella for all incoming students, effective September 1985.
Despite this progress, the majority of colleges still lack immunization requirements. An early 1984 survey of 1,861 of the nation's 3,600 colleges showed that only 16% had requirements for measles and/or rubella immunity as a condition of attendance. No information is available on actual enforcement of these requirements where they exist.
Measles outbreaks on college campuses are costly, disruptive to college routine, and difficult to control. Control activities alone for outbreaks at Dartmouth College in 1984 and Indiana University in 1983, for example, cost more than $30,000 and $225,000, respectively (3). Data from the BU outbreak show that, on the average, measles patients missed 4-5 days of classes each; those hospitalized were in the infirmary for 2 days; and outpatients required 1-2 physician visits for their illness. To limit transmission, several BU-sponsored athletic events were cancelled or restricted to allow attendance only by BU students with proof of immunity.
Voluntary vaccination clinics usually result in low turnout. For example, those held during six college rubella outbreaks in 1983 and 1984 only reached 0.1%-12.3% of the college enrollment (9). While more than 50% of Villanova University undergraduates were vaccinated during the outbreak, many of those vaccinated may have already been immune and some susceptible students may not have been immunized. College immunization requirements for newly admitted students result in more accurate identification and more effective vaccination of susceptible individuals.
Some colleges are reluctant to adopt immunization requirements because: (1) they believe that their implementation would be an administrative burden, and/or (2) they fear that such policies would lead to a declining enrollment. However, the administrative burden and costs of enforcing college immunization requirements are much less
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