Morbidity and Mortality Weekly Report


May 23, 2003 / Vol. 52 / No. 20

Severe Acute Respiratory Syndrome Taiwan, 2003

On April 22, 2003, the Taiwan Department of Health (DOH) was notified of seven cases of severe acute respiratory syndrome (SARS) among health-care workers (HCWs) at a large municipal hospital in Taipei (hospital A). Subsequent cases at eight hospitals have been associated with exposures at hospital A. Previously, all reported cases had been associated with persons recently returning to Taiwan from SARS-affected regions. This report summarizes epidemiologic findings of the outbreak in Taiwan and describes the impact of health- care—associated transmission of SARS.

As of May 22, a total of 483 probable cases had been reported (Figure 1). All probable SARS patients were hospi- talized; 84 (17%) had been discharged, and 60 (12%) had died (Table). The median age of probable SARS patients was $3 years (range: 9 months—91 years); 341 (71%) cases were from Taipei City and Taipei County, the largest metropolitan region of the island. The first patient reported had onset of illness on February 25; the majority of cases occurred after April 21 and were associated with transmission in health-care


Initial Cases (March 14-April 21)

faiwan (2002 population: 23 million) has extensive busi- ness ties with Hong Kong and mainland China where SARS cases have been reported. The first case in Taiwan was identi- fied on March 14 in a traveler from Guangdong Province in China. During March 14—April 21, Taiwan reported 28 prob- able SARS cases; of these, four resulted from secondary trans- mission (one HCW and three family contacts). During this period, SARS was characterized by sporadic cases among busi ness travelers who were cared for primarily at large academic hospitals; secondary spread was limited to identified contacts. Initial actions by DOH included the formation of a SARS advisory committee, infection-control training, contact trac-

ing and quarantine, and airport and border surveillance.

Because of Taiwan's success with SARS control, in early April, the World Health Organization changed Taiwan's designa- tion from an “affected area” to an “area with limited local


Health-Care-Associated Transmission (April 22-—May 22) Since April 22, SARS cases in Taiwan have increased and

rs. Dur-

( Oo

have been associated primarily with health-care settin ing April 22—May 1, the number of probable cases in Taiwan more than tripled, from 28 to 89. The source of the outbreak was hospital A, where an unrecognized SARS index patient had multiple exposures with patients, visitors, and HCWs who were not protected adequately to prevent acquisition of SARS.

Hospital A. The index patient was a laundry worker aged 42 years with diabetes mellitus and peripheral vascular dis- ease who was employed at hospital A. On April 12, the worker had onset of fever and diarrhea and was evaluated in the emer- gency department (ED) on April 12, 14, and 15. The patient remained on duty and interacted frequently with patients, staff, and visitors. The patient had sleeping quarters in the hospital's basement and spent off-duty time socializing in the ED. On

\pril 16, because of worsening symptoms, the patient was


466 Update: Severe Acute Respiratory Syndrome United States, May 21, 2003

469 Elevated Mortality Associated With Armed Conflict Democratic Republic of Congo, 2002

471 Update: Global Measles Control and Mortality Reduc- tion Worldwide, 1991-2001 Update: Adverse Events Following Civilian Smallpox Vaccination United States, 2003


May 23, 2003

The MMWR »f publications is published by the Program Office, Centers for Disease Control Cp US. |

(SA 30333

Epidemiology Yeparrment of Health and

ind Preventio

Human Ser


Control and Prevention



' Centers for Utsease

litle]. MMWR 2003;52:| inclusive page

Centers for Disease Control and Prevention Julie L. Gerberding, M.D., M.P-H


} fe alt L, M.D., M.PH



Epidemiology Program Office

Stephen B. Thacker, M.D., M.S«¢

Office of Scientific and Health Communications

Division of Public Health Surveillance and Informatics

Notifiable Disease Morbidity and 122 Cities Mortality Data

Secondary Clusters.

Vol. 52 / No. 20

MMWR 463

FIGURE 1. Number’ of probable cases of severe acute respiratory syndrome, by laboratory status' and date of illness onset

Taiwan, February 25—May 22, 2003

3 OV

Not tested

| | Negative 2 Confirmed


"N = 483 Laboratory testing was conducted using polymerase chain reaction






The decline in the number of recent cases is probably caused by reporting lags

break at hospital A. Preliminary data suggest that many of these clusters occurred when presymptomatic patients of patients with SARS symptoms attributed to other causes were discharged or transferred to other health-care facilities. SARS has now extended to multiple cities and regions of Taiwan, including several university and private hospitals (Figure Four of these hospitals, including a 2,300-bed facility in south ern Taiwan, have discontinued emergency and routine set vices. Sporadic community cases also have been reported in [aipei and southern Taiwan

In response, DOH has reorganized its outbreak response structure, appointed a SARS task force commander, and cre ated an emergency operations center. Efforts have focused on limiting nosocomial transmission by designating dedicated SARS hospitals throughout the island. Approximately 100 fever clinics also have been established to identify potential SARS patients and minimize risk for transmission in EDs.

Patie ll be led by tl atient care capacity will be expanded by the construction of

1,000 negative pressure isolation rooms; by the end of May, approximately 1,700 such rooms will be available. Campsites and military facilities have been identified to accommodate quarantined residents, and home quarantine will be enforced through web-based cameras. Screening for fever in all patients, HCWs, and visitors has been instituted at all health-care facilities. DOH also has developed an infection-control cur riculum to train infection-control teams on educating and monitoring HCWs. Standard operating procedures for the management and containment of nosocomial SARS clusters are being finalized.

Reported by: \/L Le WMD. Ct


464 MMWR

May 23, 2003

TABLE. Number’ and percentage of patients with probable severe acute respiratory oynareme (SARS), by selected char- acteristics Taiwan, 2003

Probable cases

Characteristics No. (%)

Age (yrs)

Clinical status

SARS-associated coronavirus laboratory findings

Editorial Note: Efforts to control SARS in Taiwan appeared

ipp! ul WeeKS a identification

Despite national eftorts

tO implement exte ntrol m res, unrecognized cases

ors ARS led tO

subsequent spread to other health ind community settings. These clus

ind mortality and

morbidlt |

| ] health-care facilities. In

| reighborhood

re affected

umong re about the epid

miology and transmi ) Multiple ractors prob

ibly contributed the rat ind wides] i transmission in |

hospital 4%

fever and diarrhea { del A Ss suspected and

ymptomatic with

infection-cont(rol |

SARS infec ' con-control cuideline

el lowever, in laiwa visitors include personal attendants

hired by families to Personal ittendants ire some pel I

sonal attendant ontributed to

disease spre id


1 1 ] Unrecognized cases o have been implicated in

recent outbreaks at heal acilities In Singapore 2).

FIGURE 2. Geographic distribution of probable cases of severe acute respiratory syndrome Taiwan, 2003*

Taipei Taoyuan city Taipei county \ county


Kaohsiung county

Several factors might contribute to difficulties in recognizing cases of SARS. Early symptoms of SARS are nonspecific and ire associated with other more common illnesses. Patients with SARS who are immunocompromised or who have chronic

conditions (e.g., diabetes mellitus or chronic renal insuffi

ciency) might not have fever when acutely ill or have symp

toms attributable to underlying disease, delaying SARS

R tests to detect SARS-( o\ are readily

diagnosis (2,3

available in Taiwan; however, these tests might not detect th virus early during illness, and a negative test result does not rule out SARS (4). Finally, some patients might not reveal useful contact information (e.g., exposure to an implicated health-care facility) for fear of being stigmatized by the local community or causing their friends and families to be quar antined

In Taiwan, exposures within health-care facilities have

accelerated SARS transmission. The public health investiga

o-rig-ienal: adj (o-'rij-an-"l) 1 : being the first instance or

source from which a copy, reproduction,

or translation can be made;

see also MMWR.

know what matters.

466 MMWR

May 23, 2003

tion is ongoing, and the number of SARS cases associated with health-care settings will probably increase. The exten- sive outbreak in Taiwan underscores the need for HCW education that promotes the early recognition of SARS and the prompt implementation of appropriate infection control procedures. Che Sec educational efforts should be directed to HCWs in all facilities, including smaller and nonacademic


i City Bur of

enter for Disease

Update: Severe Acute Respiratory Syndrome United States, May 21, 2003

Cr es to work witl

1 state and local health depart

ments, the World Health Organization (WHQ), and other

partners tO investigate ¢ SO vere aculc¢ respiratory syn

drome (SARS SARS cases reported

worldwide and in the | ices and highlights recent

. ‘—* : . modifications definition that define

criteria for exclusion of previously reported SARS cases and

fo! reporting tra issociated cases of SARS

During November 1, 2002—May 21, 2003, a total of 7,956

SARS cases were p i

reported to WHO from 28 countries

including the United States; 666 deaths (cas«

! fatality propo!

tion: 8.4%) have been reported \ total of 355 SARS cases

identified in the United States have

been reported from 40

states with 290 (82 cases classified as suspect SARS and 65

18%) classified as probable SARS (more severe illnesses charac

terized by the presence of pneumonia or aculc respiratory dis

tress syndrome | Cure | ible ()ne probabk and nine suspect

Cases have een identified SINCE the last update )

Of the 65 probable SARS patients, 41 (63%) were hospi- talized, and two (3%) required mechanical ventilation. No SARS-related deaths have been reported in the United States. Of 65 probable cases, 63 (97%) were attributed to interna- tional travel to areas with documented or suspected commu- nity transmission of SARS within the 10 days before illness onset; the remaining two (3%) probable cases occurred in a health-care worker who provided care to a SARS patient and a household contact of a SARS patient. Among the 63 prob- able SARS cases attributed to travel, 33 (52%) patients reported travel to mainland China; 19 (30%) to Hong Kong Special Administrative Region, China; six (10%) to Singapore; two (3%) to Hanoi, Vietnam; nine (14%) to Toronto, Canada; and one (2%) to Taiwan. Of the probable SARS patients, five (8%) had visited more than one area with SARS during the 10 days before illness onset.

Laboratory testing to evaluate infection with the SARS- associated coronavirus (SARS-CoV) has been completed for 122 cases (26 probable and 96 suspect). Since the last update (3), the number of cases with laboratory-confirmed infection with SARS-CoV remains at six; all are probable SARS cases with no suspect SARS cases having laboratory evidence of infection with SARS-CoV. Negative findings (i.e., the absence of antibody to SARS-CoV in convalescent serum obtained -21 days after symptom onset) have been documented for 116 cases (96 suspect and 20 probable).

lhe number of new cases reported in the United States has been decreasing in recent wee ks. | he epidemiologic profile of reported cases remains unchanged with most cases associated with international travel and few instances of secondary spread to family members or other contacts. However, vigilance is critical to ensure rapid recognition and appropriate manage ment of persons with SARS

he low specificity of the surveillance case definition cap- tures many persons unlikely to have SARS. The CDC su veillance case definition has been revised to include interim criteria for excluding new oO! previously reported suspect Ol probable cases of SARS for whom an alternative diagnosis can fully explain the patient's illness (2). Factors that might be considered in assigning alternative diagnoses include the strength of the epidemiologic exposure criteria for SARS, the specificity of the diagnostic tests, and the compatibility of the clinical presentation and course of illness for the alternative diagnosis. The epidemiologic criteria for travel exposure also have been revised and now reflect updated information about the occurrence of community transmission in areas with SARS. Hanoi, Vietnam and Toronto, Canada are now considered reas with previous community transmission of SARS because

»30 days have elapsed since the onset of symptoms for the

Vol. 52 / No. 20 MMWR


FIGURE. Number’ of reported cases of severe acute respiratory syndrome, by classification and date of iliness onset United

States, 2003


@ Probable (n = 65) O Suspect (n = 290)



Month and day

last reported case (4). As a result, travel alerts for these cities were removed on May 15 and May 20, respectively. Persons reporting travel to these areas will meet the surveillance case definition if illness onset occurred within 10 days (i.e., one incubation period) after removal of the travel alert.

These revisions to the case definition are for surveillance

purposes only. Clinical judgment, rather than surveillance

criteria, should continue to guide the management of patients

and implementation of public health response measures when persons with an unknown respiratory illness are identified.

\s state and local health departments review and reclassify cases using these new criteria, case counts might change but the result will more accurately reflect the occurrence of SARS in the United States.

Reported by: Star Investigative leam, CDC.

References World Health Organizatio severe acute respirator

2. CDC. Updated interim | syndrome (SARS casedefinition.htm

3. CDC. | pdate severe acute respi MMWR 2003;52;436-8

+. CDC. Interim definitions and criteria

Available at

MMWR May 23, 2003

TABLE. Number’ and percentage of reported severe acute respiratory syndrome (SARS) cases, by selected characteristics United States, 2003

Probable cases’ Suspect cases’ (n = 65) (n = 290)

"The important thing 15 Characteristic No. (%)§ No. _(%)*

Age (yrs)

. . 7 0-4 : (14) 44 (15) not to stop quest1zoning a - . = e 10-17 (6) ie) (3) 18-64 . (58) (69) ° . >65 L (19) : (7) Albert Einstein Unknown (2) (1) Sex Female y (40) (49) Male : (58) (50) Unknown (2) (1) Race White 29 (45) Black (2) Asian 29 (45) Other 2 (3) Unknown (6) Exposure Travel! : (97) Close contact (2) Health-care worker (2) Hospitalized >24 hrs** Yes No Unknown Required mechanical ventilation Yes No Unknown SARS-associated coronarivus laboratory findings Confirmed f


Negative 20 (33)

Undetermined! 39 194 (67)

*N = 355 CDC. Updated interim U.S. case definition of severe acute respiratory syndrome (SARS). Available at casedefinition.htm

~ Percentages might not total 100% because of rounding To mainiand China; Hong Kong Special Administrative Region, China Hanoi, Vietnam; Singapore; Toronto, Canada; or Taiwan

* As of May 21, no SARS-related deaths have been reported in the United

, States Collection and/or laboratory testing of specimens has not been compieted

til Continuing Education

Vol. 52 / No. 20

MMWR 469

Elevated Mortality Associated With Armed Conflict Democratic Republic of Congo, 2002

In August 1998, citing a need to control insecurity on their western borders, Rwanda and Uganda sent troops into the Democratic Republic of Congo (DRC) (estimated 2002 popu- lation: 51 million). Within 6 months, troops from seven neigh- boring countries were fighting in the DRC, with various Congolese groups supporting different invading armies (/). During 1998-2002, the majority of the fighting occurred in the DRC’s five eastern provinces (1996 population: 19.9 mil- lion). To assess the impact of the armed conflict on public health, the International Rescue Committee (IRC), with sup port from CDC, conducted a nationwide mortality survey to measure DRC’s nationwide crude mortality rate (CMR) and to compare CMRs in DRC’ five eastern provinces with CMRs in the five western provinces. This report summarizes the results of the survey, which indicate that the overall CMR in the DRC is the highest in the world, with the majority of deaths caused by preventable infectious diseases. The find- ings underscore the importance of the ongoing peace process, which appears to have contributed to a decrease in mortality rates in eastern DRC, and highlights the importance of col lecting population-based health data regularly during armed conflicts.

Conducted during September 14—November 13, 2002, the survey employed a three-stage cluster approach to measure CMRs. In the first stage, 20 health zones were selected sys- tematically proportional to the population: 10 in the war affected areas of the five eastern provinces (Katanga, Maniema, North Kivu, Orientale, and South Kivu) and 10 in the five western provinces (Bandundu, Bas Congo, Equateur, Kasai Occidentale, and Kasai Orientale) (Figure). Of approximately 14.3 million persons in the war-affected areas of the five east- ern provinces, 5 million (35%) could not be visited because of ongoing fighting, and the health zones in which these per- sons live were excluded from the site selection process. All health zones in the five western provinces were available for selection. In the second stage, 15 locations were selected in each targeted health zone, with the probability of selection proportional to population; the locations comprised the small- est known population units (i.e., specific avenues, clinic areas, or villages). In the final stage, a specific household was selected by using one of three methods: 1) counting all house holds in the selected population and selecting one at random; 2) dividing the selected population into roughly equal seg- ments, selecting one segment at random, counting the house- holds in that segment, and selecting one at random; or 3)

selecting a random point in space by using a map and a global

FIGURE. Health zones in which crude mortality rates were assessed International Rescue Committee Mortality Study, Democratic Republic of Congo, 2002


Orientale - { Democratic\ Republic of Congo


North Kivu

South Kivu

Bas Congo Kasai Occidentale Katanga Kasai Orientale

positioning system unit if the population was spread over an entire clinic area with no further population breakdown Interviewers visited the selected households and explained the purpose of the survey to a person aged >14 years. A per- son consenting to an interview was asked about the age and sex of current household residents and the occurrence of any pregnancies, births, or deaths among current residents since January 2002. From households selected initially, interview ers \ isited the next 14 closest occupied households. If no per- son aged >14 years was home, or if members of a household refused to be interviewed, the household was skipped and the next was visited. Persons were included as household residents only if they had slept in that household on the preceding night. CMRs were calculated by using the following formula: CMR = (number of deaths / number of living residents minus half the number of births plus half the number of deaths) x 1,000 / the number of months in the recall period. Deaths were included if a decedent had slept in the inter- viewed household or lived with the interviewed family at the time of death during 2002. The recall period was January 1, 2002, through the median day of the specific health zone evalu- ation (median: 9.3 months; range: 8.5—10.3 months). The mortality rate for children aged <5 years (<SMR) was esti- mated by using the following formula: <SMR = (number of

deaths among children aged <5 years/number of children aged


May 23. 2003

ears who were alive at the time of the survey plus one half


] ] t deaths among those years during recall period) x

' '

1.000 / the number of months in the recall period [his equa m that both the total number of children born and

vears remained con

number of childret

Cy Was

xpressed as deaths pet r month. Previous

rindings indicate that

of 1.5 deaths per 1,000 population pet

Africa in the

month occurs in or areas of sub-Saharan

the time of the

isited in the east


Cause O of security

| i iw health zone


TABLE 1. Number of persons interviewed, numbers of births and deaths, and crude mortality rate (CMR)*, by location international Rescue Committee Mortality Survey, Democratic Republic of Congo, 2002


No. interviewed No. births No. deaths CMR

Eastern Katana Kaliemie Butembo Kyondo Pweto Kisangan Kalima Ake tl


Total Western




TABLE 2. Cause of reported deaths, by age, region, and illness International Rescue Committee Mortality Survey, Democratic Republic of Congo, 2002

East West Aged Aged Aged Aged <5 yrs >5 yrs <5 yrs >5 yrs Total (n= 198) (nm = 245) (n= 109) (n= 137) No (%)

68 33 208 (30.0) 42 (6.1)

31 (4.5)

25 (3.6)

28 (4.1)

25 (3.6)

21 (3.0)


deaths per 1,000 population

CMkRs reported for all other

] r tf mortality

umong the approximately 5 million inaccessible persons who


ed in the « ist as high a

ipprox! !

+ deaths pel 1,000 population [

( (


Editorial Note: The nationwide CMR estimate for the DR¢ of 2.2 deaths per 1,000 population per month presented

in this report is much greater than the 1.3 deaths per 1,000

Vol. 52 / No. 20


population per month reported in 1997, the year before the outbreak of war (4). As is usually the case in protracted wal settings, violence was not reported as the major cause of death (2). In both the war-aftected and the nonwar-affected areas surveyed, febrile illness and diarrhea associated with infec tious diseases were the most commonly reported causes of death. This might reflect deteriorating economic and health conditions combined with the disruption of the health-care system.

During January 1999—August 2001, three nongovernment organizations recorded substantially elevated CMRs through population-based sample surveys of specific health zones with populations ranging from 62,000 to 347,000 persons. Dut ing January—August 2001, Doctors Without Borders docu mented CMRs of 1.2—9.0 deaths per 1,000 population pet month in five health zones in five provinces ( 5). During 1999 2001, IRC conducted 11 surveys in seven health zones in the five eastern provinces. These surveys, with recall periods of

‘-17 months, documented CMRs of 2.7—12.1 deaths per 1,000 population per month (3). Through an extrapolation process, these two IRC surveys were used to estimate an avet age CMR of 5.4 deaths per 1,000 population per month in the five eastern provinces during August 1998—April 2001

3). Medical Relief International (MERLIN) documented a CMR of 10.0 deaths per 1,000 population per month in the eastern health zone of Kalima in a 3-month period during 2000 (MERLIN, unpublished data, 2001

Although the method of selecting health zones was not ran dom in the two previous IRC surveys, by chance, two Eastern provinces (Kalima and Kalemie) were selected in both 2001 and 2002 and were evaluated during both years by using simi lar methods. The CMR in Kalima declined from 7.1 deaths per 1,000 population per month during January 2000—March 2001 to 3.0 during 2002. During the same period, the CMR in Kalemie declined from 10.8 deaths per 1,000 population per month to 4.2. The improved CMR reflects a decline of 96% in the rate of violent deaths, from 1.0 deaths per 1,000 population per month in 2000 to <0.1 in 2002. These find ings for the eastern provinces indicate a marked reduction in CMRs during 2002 compared with the preceding 3 years (3

he findings in this report are subject to at least four limi tations. First, avoiding areas with the worst security condi tions probably resulted in underestimating CMRs. Second data from past surveys conducted by IRC might not be com parable because different methods were used to select health zones. Third, because empty households experienced mor deaths than occupied households (6), CMRs probably were underestimated. Finally, no formal verbal autopsy procedure was followed, and no independent confirmation of the deaths

was sought.

Violence-related mortality in eastern DRC has when peace initiatives have been implemented accord signed in early 2001 curtailed hostilities substantialh and resulted in the withdrawal of most foreign troops du 2002. In addition, during 2000-2002 ipproximatel United Nations (UN) observers arrived in addition to increase in humanitarian assistance and aid workers Epidemiologists can provide timely and r presentative health data to assess the public health impact of armed conflict


After the first series of IRC surveys conducted in 2000, the

UN Security Council passed a resolution demanding the with

drawal of foreign troops he impact of the second round of IRC surveys conducted in 2001 on the current peace pro cess is unclear. Epidemiologic techniques involving creative flexible, and practical measurement techniques need to be developed further and employed on a regular basis to address the public health consequences of armed conflicts. Humani tarian efforts in DRC should focus on the war-affected east

] ern areas and on controlling infectious diseases


Update: Global Measles Control and Mortality Reduction Worldwide, 1991-2001

Despite international recognition of the high burden of dis ease associated with measles and the existence for 40 years of 1 safe, effective, and inexpensive vaccine, measles remains the leading cause of vaccine-preventable childhood mortality. In 1990, the World Summit for Children adopted a goal of vac cinating 90% of the world’s children against measles by 2000

In 2001, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) developed

the Global Measles Strategic Plan for 2001—2005 (2). Che

MMWR May 23, 2003

annual number of 153,000 (58%) occurred in the WHO African Region, and ith 1999 levels approximately 202,000 (26° in the South East Asian interruption of Region (4 Figure 1). Of the global measles deaths, >98% reas with occurred in the 75 countries with per capita gross domestic $1,000 (WHO, unpublished data, 2003

ultation in products of During 1991-2001, estimated worldwide measles vaccina


tion coverage ranged from 69% to 76%. However, world

(nhildren wide figures mask regional and national disparit cs During : I i

this period, estimated coverage for the WHO regions of the }


and the Western Pacific was 82° 94%;

minating Americas, Europe urden of estimated coverage for the Eastern Mediterranean Region was mil in the South East Asia Region was in 2000 m10n had the lowest estimated COV

Since 2000, WHO ar EF have recommended that, addition to achieving high coverage with the first dose of

] 11 | 1 1

litment 1s asies vaccine, all ¢ be offered a second opportunity ]

maximize both individual and popu

) opportu r mMeasies vaccination to 1

This ret ts a second opportunity

sles immunization for children who did not receive

cine from the routine program and for those who

did not develop immunity to measles after receiving 2001, a total of 156 (82!

iccine. During 199 | .

: widded | ' t ity rt countries provided 1second opportunity through suppleme | lr Ait

iry immMuNIZation actiVItic oO! through routine nie

vices (O Figure

Reported by:


OOO easle : 2000 mpared with FIGURE 1. Estimated number of measles deaths, by World Health Organization (WHO) region, 2000

: i 1on ; 3 @ ams =


that coun

1 t 1

According to GBD ff the est late OOO

measles deaths in chi 2000, appr

Vol. 52 / No. 20


FIGURE 2. Countries providing second opportunity* for measles immunization Worldwide, 1997-2001

Providing second opportunity (156 countries)

| Not providing second opportunity (35 countries)

*Country has implemented a 2-dose routine measles schedule and/or within the preceding 4 years has conducted a nationa 4 y

achieving >90% coverage of children aged <5 years

M Birmingham, J Bilous, B Hersh, Dept of Vaccines and Biologi World Health Oreanization, Geneva, Switzerland airns, P Strebe Global Immunization Div, National Immunization Program, CD( Editorial Note: Although substantial progress has been made in reducing measles deaths globally, in 2000, measles was estimated to be the fifth leading cause of mortality worldwide for children aged <5 years (4). Measles deaths occur dispro- portionately in Africa and South East Asia. In 2000, the Afri can Region of WHO, with 10% of the world’s population, accounted for 41% of estimated measles cases and 58% of measles deaths; the South East Asia region, with 25% of the world’s population and 28% of measles cases, accounted fot 26% of measles deaths (4). The burden of mortality in Africa reflects low routine vaccination coverage and high case-fatality ratios. In South East Asia, where vaccination coverage is slightly

below average worldwide lev els, the large population ampli

fies the number of cases and deaths resulting from ongoing

measles transmission.


Che overwhelming majority of measles deaths in 2000 occurred in countries eligible to receive financial support from the Global Alliance for Vaccines and Immunization’s Vaccine Fund (WHO, unpublished data, 2003). The majority of measles deaths occur among young children living in poor countries with inadequate vaccination services. Like human immunodeficiency virus, malaria, and tuberculosis, measles can be considered a disease of poverty. However, unlike these diseases, measles can be prevented through vaccination.

Support from the Vaccine Fund for strengthening vaccina tion services and raising routine vaccination coverage can help reduce the high burden of measles. However, in countries with historically inadequate vaccination services, routine vaccination alone is not sufficient to reduce measles deaths or to achieve measles control because the large numbers of older children who missed routine vaccination remain susceptible to measles. The Measles Mortality Reduction and Regional Elimination

Strategic Plan 2001-2005 outlines four main elements to

474 MMWR

May 23, 2003

reduce measles mortality: | achieving high 1.e., >YO%) vac cination coverage nationally and in each district with the first dose of measles vaccine administered through routine health

services to children who are aged 9 months or slightly older, ) offering a second opportunity for measles immunization o all children, 3) establishing eftective surveillance tor measles, ind 4) improving case management (3). Countries are encouraged tO review measles epidemiology, develop a 55 year plan for measles mortality reduction (8), identify reasons for low routine coverage, strengthen routine vaccination set Vices improve vaccination Safety and integrate measles Vaccl nation activiti with other public health activities as ippropriate Although well-conducted supplemental vaccination activi ties can increase population immunity substantially and measles cases and deaths, new birth cohorts rapidly idd susceptible persons to the population. Bolstering routine iccination services to ensu that the majority of infants receive measles vaccine and other vaccines is essential to sus- tain the impact of measles mortality reduction activities. In 2001, the Measles Partnership was formed to reduce .

measles deaths in Africa.

WHO, UNI the United Nations Foundation, the Ameri

Me mbers of this partnership include

can Red Cross, and CDC. During 2001-2002, this partner ship contributed $40 million for the vaccination of approxi mately 60 million children aged 9 months—14 years living in 13 African countries. Preliminary evidence suggests that these campaigns have had a substantial impact in reducing measles deaths (WHO African Regional Office, unpublished data, 2002).

Surveillance to assess burden of disease and guide vaccina- tion policy remains critical. Outbreak investigations should be used as an opportunity to learn about the changing epide miology of measles. These investigations can provide infor- mation about patterns of transmission, including case-fatality ratios and age distribution and vaccination status of cases. References

United Nations ¢ \Y

World Declaratior

ldret n the 99)


/ aoc

@ once.



' + reports


Vol. 52 / No. 20

In this vaccination program, ( 1 the kood and Drug

Disease 2000 Project: ain nethods a d Gene S Administration, and state health departments are conduct d: World Health Orgar tor 001; Glo , i I i sa det for Health Po [Disc mn Pay , \ surveill ince for vaccine-associated ad rs¢ nt imo! ! U civilian vaccinees (/ As part of ¢ ccination | civilian vaccinees receive routin rollow-up ind reported

a yo . i ———— f 1dverse events after vaccination rec follow-up as needed | Infect Dis 2003;187:S8-S14 The U.S. Department of Defense is conduct ( Work h Or ( VHO { ! H ror vaccine associated adverse event among Millltal i 00 ( S \ ri : : O; i 007 ind providing follow up care to those persons with reported World Health Orean tio Stra es to du adverse events w Epidemiol Rec 2000;75:409-1( Adverse events that have been associated with smallpox y \ H () (;lob , . , , , : cination are Classified on the Dasis of evidence supporting tl OOF 00 P \ | Pp} 100)? yR_G] reported diagnoses (_ases verified by virologic resting or in « | | liao t y | t | some instances D otmner Giagnostic testing ire Classified confirmed (Table 1). Cases are classified as probable if po sible alternative etiologies are investigated and excluded and ad | Update: Adverse Events Following SUPPpOrtTive information for the diagnosis is TOouNnd Patient _ . . . . 1 . 1 j 1 1 Civilian Smallpox Vaccination ire Classified as suspected if they have clinical features com ats ; ° patible with the diagnosis, but either further investigatior nite ares ' - . , , ' required or investigation of the case did not provide support ) o y 2 9 I003. s | , was a During January 24—May 9, 2003, smallpox vaccine wa ing evidence for the diagnosis. All reports of events that is Yat ae ee a » 36,2 ivilian hes al rub alth idministered to 36,217 civilian health-care and public healt! follow vaccination are accepted (i... events associated tem , SS in ; ) iS ' , j , , workers in jurisdictions to prepare the United States for a porally); however, reported adverse events are not necessaril possible terrorist attack using smallpox virus. [his report associated causally with vaccination. and some or all of cl updates information On vaccine-associated adverse events events might be coincidental. | his report includes cas« o id o o } nro ; "i | among civilians vaccinated since the beginning of the pre reported as of Mav } that ithe! are unde! investigation OF I gram and among contacts of vaccinees, received by CDC from have a reported tinal diagnosis. Because of ongoing discus } ver ? Oo " t rv c t 1 j 1 ; the Vaccine Adverse Event Reporting System (VAERS) as of sions of final case definitions. numbers and classifications of


TABLE 1. Number of cases* of selected adverse events associated with smallpox vaccination among civilians, by type United States, January 24—May 9, 2003

No. new cases Total { (May 3-9) (January 24—May 9) | Adverse events Suspected' Probable‘ Confirmed" Suspected Probable Confirmed

Eczema vaccinatur < Fetal vac la _ Generalized vaccinia 1

inadvertent inoculation

Ocular vaccinia ~ Pr gressive vaccinia ree a te Erythema multiforme major (Stevens-Johnson syndrome —_ —_ Myo/pericarditis = 7 . Po

stvaccinial encephalitis or encephalomyelit 1 1 Ls b y

Pyogenic infection of vaccination site

* Under investigation or completed as of May 9, 2003: numbers and classifications of adverse events will be updated regularly in MMWA as more nformation becomes available Events are classified as suspected if they have clinical features mpatidie with the diagr Ss but either further investigatior required or adaitiona investigation of the case did not provide supporting evidence for the diagnosis and did not identify an alternative diagnos

i Events are classified as probabie if possibie uiternative etiologies are investigated and ipportive informatior round For the first six events listed, events are classified as confirmed if virologic tests are { tive. For the last four events, events are cClassitied a niirmed based on diagnostic testing (e.g., histopathology); confirmation of events thought to be immur ically mediated (i.e., erythema multiforme, myo/pericardaitis yr postvaccinial encephalitis or encephalomyelitis) does not establist 1uSalit