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Notes from the Field: Measles Among U.S.-Bound Refugees from Malaysia --- California, Maryland, North Carolina, and Wisconsin, August--September 2011

On August 26, 2011, California public health officials notified CDC of a suspected measles case in an unvaccinated male refugee aged 15 years from Burma (the index patient), who had lived in an urban area of Kuala Lumpur, Malaysia, which is experiencing ongoing measles outbreaks. Currently, approximately 92,000 such refugees are living in urban communities in Malaysia (1). Resettlement programs in the United States and other countries are ongoing. The health and vaccination status of urban refugees are largely unknown.

The index patient developed a fever on August 21 and a rash on August 22. He and his family (his mother and two siblings, aged 13 and 16 years) departed Malaysia on August 24 and arrived the same day in Los Angeles, California, where they stayed overnight. He was hospitalized for suspected measles on August 25. Serologic testing for immunoglobulin M confirmed the diagnosis of measles on August 30 (2). The sibling aged 16 years was unvaccinated and had onset of a febrile rash illness in Malaysia on August 18. Serologic testing performed on August 30 in Los Angeles indicated evidence of recent measles infection. However, the sibling was not infectious during the flight.

On September 1, Maryland public health officials notified CDC of laboratory-confirmed cases of measles in two unvaccinated refugee children (aged 7 months and 2 years) who were on the same flight as the index patient. A suspected case of measles in an unvaccinated refugee aged 14 years, who had traveled on the same flight, was reported by North Carolina public health officials on September 4 and confirmed on September 9. Whether these three patients were exposed to measles in Malaysia or during travel to the United States is unclear. On September 7, CDC was notified of another laboratory-confirmed case in an unvaccinated refugee child aged 23 months from Burma who traveled from Malaysia to Wisconsin through Los Angeles on August 24, but on a different flight than the index patient.

Thirty-one refugees who traveled from Malaysia on the same flight with the index patient on August 24 arrived in the following seven states: Maryland, North Carolina, New Hampshire, Oklahoma, Texas, Washington, and Wisconsin. State and local health departments and CDC were contacted and initiated contact investigations and response activities. As of September 12, contact investigations and heightened surveillance had revealed three additional laboratory-confirmed measles cases that were epidemiologically linked to the index patient: one case in a U.S. Customs and Border Protection Officer with unknown vaccination status who processed the index patient in the Los Angeles airport (reported by California public health officials on September 8), and two cases in nonrefugee, unvaccinated children (aged 12 months and 19 months) who were seated nine rows from the index patient during the flight (reported by California public health officials on September 9).

Rapid control efforts by state and local public health agencies have been a key factor in limiting the size of this outbreak and preventing the spread of measles in communities with increased numbers of unvaccinated persons. To prevent measles transmission and importation in this refugee population, refugee travel from Malaysia to the United States was temporarily suspended. CDC recommended that 1) U.S.-bound refugees in Malaysia without evidence of measles immunity (3) be vaccinated with measles, mumps, and rubella (MMR) vaccine and their travel be postponed for 21 days after vaccination; 2) refugees arriving in the United States receive their post-arrival health examinations as soon as feasible; 3) clinicians consider measles as a diagnosis in a refugee with a febrile rash illness and clinically compatible symptoms (i.e., cough, coryza, and/or conjunctivitis); 4) patients with suspected measles be isolated and appropriate specimens be obtained for measles confirmation and virus genotyping; and 5) cases be reported promptly to local health departments. To prevent measles in U.S. residents at home and abroad, CDC recommends that eligible persons without evidence of measles immunity (3) be vaccinated as recommended. Before international travel, infants aged 6--11 months should receive 1 MMR vaccine dose, and persons aged ≥12 months should receive 2 doses unless they have other evidence of measles immunity (3).

Reported by

Jennifer Zipprich, PhD, Kathleen Harriman, PhD, John Talarico, DO, California Dept of Public Health. Cindy Edwards, MHCA, Montgomery County Dept of Health and Human Svcs; David Blythe, MD, Dipti Shah, MPH, Maryland Dept of Health and Mental Hygiene. Jennifer Morillo, Sheree Smith, North Carolina Div of Public Health. Daniel Hopfensperger, Savitri Tsering, MSSW, Wisconsin Dept of Health Svcs. Greg Wallace, MD, Albert Barskey, MPH, Preeta Kutty, MD, Gregory Armstrong, MD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases; Karen Marienau, MD, Juliana Berliet, MPH, Keysha Ross, Christopher Schembri, MPH, Heather Burke, MA, MPH, Deborah Lee, MPH, Sharmila Shetty, MD, Michelle Weinberg, MD, Weigong Zhou, MD, PhD, Div of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases; Maria Said, MD, Eboni Taylor, PhD, EIS officers, CDC. Corresponding contributor: Eboni Taylor,, 404-639-4511.


International Organization for Migration. Assoc of Refugee Health Coordinators. Long Beach Dept of Health and Human Svcs; Immunization Program, Los Angeles County Dept of Public Health, California. Mark Hodge, MS, Montgomery County Dept of Health and Human Svcs, Maryland. Bur of Population, Refugees, and Migration, US Dept of State. Kim Crocker, Los Angeles Quarantine Station, Miguel Ocaña, MD, Washington, DC Quarantine Station, Clive Brown, MD, Div of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC.


  1. International Catholic Migration Commission. Combating gender-based violence (GBV) among urban refugees in Malaysia. Geneva, Switzerland: International Catholic Migration Commission; 2011. Available at Accessed September 16, 2011.
  2. CDC. Case definitions for infectious conditions under public health surveillance (measles). Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at Accessed September 16, 2011.
  3. 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).

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