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Multistate Investigation of Measles Among Adoptees from China --- April 9, 2004

On April 9, this report was posted as an MMWR Dispatch on the MMWR website (

On April 6, 2004, Public Health --- Seattle and King County, Washington, reported a laboratory-confirmed case of measles in a recently adopted child from China. Public health authorities in Washington state notified CDC, which collaborated with health officials in other states to locate other recently adopted children from China and contact their adoptive families. This report summarizes the preliminary results of an ongoing multistate investigation that has so far identified four confirmed and five suspected cases of measles among adoptees from China, underscoring the need for health-care providers to remain vigilant for measles and other vaccine-preventable communicable diseases in children adopted from international regions.

The investigation determined that a group of 11 families traveled to China in March to adopt children. The group, and their 12 adopted children, remained together for approximately 10 days during the adoption process before departing for the United States on March 26. The 12 children were adopted from two orphanages in Hunan Province. They traveled to five U.S. states. Eight traveled to Washington, and one each traveled to Alaska, Florida, Maryland, and New York.

As of April 9, investigators had determined that nine of the 12 adopted children had measles-like rash illness, including four (three in Washington and one in Maryland) who were serologically confirmed to have measles. The nine serologically confirmed or suspected cases were in patients aged 12--18 months; they had rash onset during March 22--April 6. The three children who did not develop measles-like rash illness traveled to Washington (a child aged 7 years), Alaska (a child aged 13 months), and Florida (a child aged 13 months). To date, all 12 children have been or are being evaluated for laboratory evidence of measles or are under observation by public health authorities. Vaccination status or history of measles illness is not known for any of the 12 children. State and local health departments are continuing to investigate, seeking potential cases, identifying and evaluating potential contacts, and providing prophylaxis when indicated, as recommended by the Advisory Committee on Immunization Practices (1).

Three of the children with suspected measles were likely infectious* while traveling from China to the United States on March 26 on the following airline flights: United Airlines flight 862 from Hong Kong to San Francisco, Cathay Pacific flight CX872 from Hong Kong to San Francisco, United Airlines flight 476 from San Francisco to Seattle, and United Airlines flight 794 from San Francisco to Seattle. Because most persons in the United States are immune to measles, U.S. airline passengers usually are at low risk. However, persons traveling on the four flights who have fever or rash on or before April 16 should be evaluated for measles by a health-care provider. Investigators have determined that the other six children with rash illness were not likely to have been infectious with measles during the time they traveled from China to their ultimate destinations in the United States.

Reported by: Alaska Dept of Health and Social Svcs. Florida Dept of Health. Maryland Dept of Health and Mental Hygiene. New York State Dept of Health. Public Health --- Seattle and King County; Snohomish Health District; Washington State Department of Health. Epidemiology and Surveillance Div, National Immunization Program; Div of Global Migration and Quarantine, National Center for Infectious Diseases, CDC.

Editorial Note:

Measles, a highly infectious viral illness that can cause pneumonia, diarrhea, encephalitis, and death, continues to be imported into the United States (2). Although measles is no longer endemic in the United States (3), as this investigation highlights, maintaining high levels of vaccination coverage and strong surveillance in the United States is critical.

During 2001, an outbreak among children adopted internationally resulted in 14 U.S. measles cases, 10 among adopted children and four among caregivers and siblings aged 28 months--47 years (4). Health-care providers should have a high index of suspicion for measles in persons with febrile rash illness from families who recently adopted children from abroad and among persons who have had close contact with children who were adopted recently from abroad. Suspected cases should be reported to the local health department.

In the latest outbreak, all confirmed and suspected cases of measles have been in children aged >12 months, for whom vaccination with measles-containing vaccine is recommended in both the United States (1) and China (5). Vaccination of internationally adopted children is not required before their immigration into the United States, but should occur within 30 days of entry (6). Although this measure should ensure that internationally adopted children receive recommended vaccines expeditiously, it cannot prevent importation of vaccine-preventable infectious diseases. Efforts to ensure that adoptees are administered safe and age-appropriate vaccines in their country of origin in accordance with recommendations of the World Health Organization or the country of origin could help prevent this type of importation in the future.


  1. 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).
  2. CDC. Brief report: imported measles case associated with nonmedical vaccine exemption---Iowa, March 2004. MMWR 2004;53:244--6.
  3. Measles---United States, 1999. MMWR 2000;49:557--60.
  4. Measles outbreak among internationally adopted children arriving in the United States, February---March 2001. MMWR 2002;51;1115--6.
  5. Lixia W, Guang Z, Lee LA, et al. Progress in accelerated measles control in the People's Republic of China, 1991--2000. J Infect Dis 2003;187(Suppl 1):S252--7.
  6. Illegal Immigration Reform and Immigrant Responsibility Act of 1996. Public Law 10-208; 110 Stat 3009.

* The infectious period for measles is from 4 days before to 4 days after onset of rash.

The incubation period for measles from the time of exposure to onset of rash is 7--21 days.

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