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Epidemiologic Notes and Reports Rubella Outbreak among Foreign- Exchange Students -- Tennessee

On August 3, 1981, the University of Tennessee at Martin reported that 7 Japanese exchange students had been hospitalized with a preliminary diagnosis of rubella. These students were part of a group of approximately 200 Japanese students and professors who had arrived in Tennessee on July 5, 1981, for the 10-week summer session. They all stayed in the same dormitory and attended classes that were separate from other summer-session meetings, but they mingled with students and the general public outside of class. The 200 Japanese visitors represented 7.4% of the 2,700 summer students then in attendance at this section of the university.

All 7 patients had a maculo-papular rash, low-grade fever (temperature of 102 F, 38.9 C), and either arthralgia or posterior auricular or occipital adenopathy. The initial patient had rash onset on July 11 (Figure 3), 6 days after leaving Japan; was hospitalized with a preliminary diagnosis of Rocky Mountain spotted fever; and was treated with chloramphenicol. The second patient had rash onset on July 25 and was hospitalized with a preliminary diagnosis of measles. Neither case was reported to the health department at the time of illness, and no serum specimens were available for rubella testing. Five tertiary cases occurred the first week of August; all these patients were kept in the university infirmary for at least 1 day each. By the end of the first week in August, all 7 cases were suspected to be rubella and were subsequently reported to the Tennessee Department of Public Health. The diagnosis was confirmed for 4 of the 5 tertiary cases on the basis of a greater than or equal to 4-fold rise in rubella hemagglutination inhibition titer between the acute- and convalescent-phase serum specimens.

An investigation on campus revealed that 21 Japanese students (10%) had previously received rubella vaccine. In contrast, a review of 200 health records chosen at random from records of the 2,500 American summer students in residence showed that 67% had documentation of having received rubella vaccine. On August 4, 188 Japanese students and faculty were vaccinated with combined measles and rubella (MR) vaccine. The MR vaccine was also offered to other summer students and staff. No other clinical cases of rubella occurred among the Japanese students, and there was no known spread to hospital employees or to other students on campus. Reported by IF Porter, MD, H Westmoreland, RN, University of Tennessee-Martin; P Duncan, RN, RH Hutcheson, Jr, MD, MPH, State Epidemiologist, Tennessee Dept of Public Health; Immunization Div, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: College-age adults form a large part of the population that remains susceptible to rubella in the United States (1). Like measles, rubella will probably be introduced periodically from foreign countries, often by college-age foreign-exchange students. The lack of disease spread in this instance is attributed to the separate dormitory and classes that the Japanese students attended, as well as to the higher rates of rubella vaccination among other summer students on that campus.

Universities should be encouraged to develop programs to ensure rubella vaccination at the time of entry for all students, staff, and faculty, including foreign-exchange and other visiting students and professors. Before vaccination, female students, staff, and faculty should be asked if there is any possibility that they are pregnant. Pregnant women should not be given rubella vaccine, and all other women should be informed of the risks of vaccination and advised not to become pregnant for 3 months after vaccination (2). Programs are most likely to be successful if proof of rubella immunity* is required.

In the example cited here, 3 generations of cases occurred before the diagnosis of rubella was considered. Since the incidence of rubella has declined to record low levels (3), clinicians and public health workers should be reminded to consider rubella in the differential diagnosis of rash illness and to collect appropriately timed blood specimens for serologic study. Only if rubella is diagnosed early in an outbreak can appropriate measures be instituted to control spread in the community and in institutions such as universities.


  1. Schiff GM, Linnemann CC, Jr, Shea L, Trimble S. Rubella surveillance and immunization among college women. Obstet Gynecol 1974;43:143-7.

  2. ACIP. Rubella prevention. MMWR 1981;30:37-42, 47.

  3. CDC. Rubella--United States, 1978-1981. MMWR 1981;30:513-5. *Documented history of rubella vaccination on or after the first birthday or presence of antibody to rubella. Clinical diagnosis of rubella should not be accepted as proof of immunity.

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