Skip Navigation LinksSkip Navigation Links
Centers for Disease Control and Prevention
Safer Healthier People
Blue White
Blue White
bottom curve
CDC Home Search Health Topics A-Z spacer spacer
Blue curve MMWR spacer

Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: Type 508 Accommodation and the title of the report in the subject line of e-mail.

Public Health Dispatch: Measles Epidemic --- Majuro Atoll, Republic of the Marshall Islands, July 13--September 13, 2003

During July 13--September 13, 2003, a total of 647 clinically diagnosed measles cases* were reported on Majuro Atoll in the Republic of the Marshall Islands (RMI); this is the first measles outbreak reported in RMI since 1988. An additional 74 suspected measles cases are under investigation. This report describes the clinically diagnosed measles cases and the public health response to stop the epidemic. Of the 647 cases, 15 (2%) are laboratory confirmed, either by serology, polymerase chain reaction, or viral culture. The age of patients ranged from 2 weeks to 43 years (median: 12 years); 479 (74%) patients were aged <20 years. The overall measles incidence on Majuro Atoll (estimated 2003 population: 25,097) is 26 cases per 1,000 population. The incidence is highest among infants aged <1 year (160 per 1,000 population), followed by children aged 1--4 years (40).

A total of 58 persons with measles have been hospitalized; three patients have died, including a malnourished child aged 15 months with diarrhea and pneumonia, a woman aged 27 years with pneumonia, and a woman aged 39 years whose immediate cause of death remains unknown. Postmortem examination was not available for any of these patients.

To stop measles transmission, the Ministry of Health in RMI recommended measles, mumps, and rubella vaccine (MMR) for all infants aged 6--11 months and all persons aged 1--40 years who did not have documented proof of measles immunity. Before the epidemic, estimated vaccine coverage with 1 dose of MMR was <75% for children aged 1--13 years, according to evaluations of computerized vaccination records and of children screened during the vaccination campaign. As of September 13, a total of 98% of persons aged 6 months--40 years had documentation of receipt of at least 1 dose of MMR. Campaign activities that delivered 16,913 doses included 1) vaccinating health-care and public health workers, 2) vaccinating children at nine vaccination posts across the atoll, 3) delaying the start of the school year until school children were vaccinated and requiring documentation of vaccination for school entry, and 4) conducting neighborhood and house-to-house vaccination in areas where adequate coverage was not reached.

To prevent spread from Majuro Atoll, vaccination campaigns were conducted in other atolls and islands in RMI. The Ministry of Health suspended travel of sea vessels and airlines from Majuro Atoll until vaccination campaigns had been completed in other atolls and islands, and required proof of MMR vaccination for all travelers leaving Majuro Atoll for other atolls or islands or for international destinations. A total of 17 measles cases have been reported from Ebeye Island in Kwajalein Atoll; 10 of these persons were exposed in Majuro Atoll. Two other atolls have reported six cases whose exposure was in Majuro Atoll. Measles surveillance has been enhanced in RMI, other Pacific islands, and in the United States. Spread to other areas in the Pacific and to the United States has been limited; five measles cases in Hawaii, three in Guam, one in Palau, and one in California are believed to be linked to this epidemic.

The source of importation of the measles virus to Majuro Atoll has not yet been determined, but the H1 genotype found in this outbreak is common in Asia, and the specific strain has been reported recently in measles cases from Japan and China (1,2). The Advisory Committee on Immunization Practices recommends that all international travelers be immune to measles because it is endemic or epidemic in many parts of the world, including developed countries (3,4). Persons aged <40 years who are traveling to RMI during the next 60 days should be aware that RMI requires documentation of measles immunity for all departing passengers on international flights. The documentation must fulfill the same age-specific requirements used in the vaccination campaign.

Reported by: J Langridrik, MPH, R Edwards, MPH, K Briand, MBBS, M Konelios, H Neamon, F Nathan, Ministry of Health. A Khalifah, Div of Applied Public Health Training, Epidemiology Program Office; H Nguyen, MPH, Epidemiology and Surveillance Div; Immunization Svcs Div, National Immunization Program; Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; M Marin, MD, R Nandy, MBBS, EIS officers, CDC.


This report is based on data contributed by P Asuo, MD, J Gancio, MD, H Emil, S Alfred, B Pharm, Majuro Hospital, Delap, Majuro Atoll, Republic of the Marshall Islands.


  1. Zhou J, Fujino M, Inou Y, et al. H1 genotype of measles virus was detected in outbreaks in Japan after 2000. J Med Virol 2003;70:642--8.
  2. Rota PA, Rota JS, Redd S, Papania M, Bellini WJ. Genetic analysis of measles viruses isolated in the United States 1989--2001: absence of an endemic genotype since 1994. J Infect Dis (in press).
  3. CDC. Health Information for International Travel, 2003--2004. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, 2003.
  4. CDC. Measles, mumps, and rubella--vaccine use and strategies for elimination of measles, rubella and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR--8).

* Defined as a case in a person with fever, a generalized maculopapular rash, and cough, coryza, or conjunctivitis.

Persons aged 12 months--18 years required documented history of 2 doses of MMR, with the first dose administered on or after the first birthday and the second dose at least 28 days after the first dose; otherwise, these persons received either their first or second dose as indicated. Persons aged >18 years required documented history of measles or 1 dose of MMR administered on or after the first birthday; otherwise, these persons received 1 dose of MMR.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

Disclaimer   All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to  

Page converted: 9/18/2003


Safer, Healthier People

Morbidity and Mortality Weekly Report
Centers for Disease Control and Prevention
1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A


Department of Health
and Human Services

This page last reviewed 9/18/2003