On April 5th, a toddler recently adopted from China presented to a King County health care provider with a fever and a rash. There was a history of a prodrome, characterized by sore throat, cough, coryza, and conjuctivitis. Koplik's spots were present in the mouth and the child also had otitis media. The health care provider suspected measles and immediately notified Public Health-Seattle & King County (by calling 206-296-4774). Public Health arranged to have the specimen transported to the Washington State Public Health Laboratory the following morning for serologic measles testing. On the afternoon of April 6th, results of testing showed that the child was measles IgM positive, confirming an acute measles infection.

While lab results were pending, an investigation by Public Health revealed that this child and family were part of a group of eleven families, and twelve children adopted from orphanages, who spent approximately 10 days together in China before traveling to the US at the end of March 2004. Of the twelve children in the group, eight came to the Puget Sound area, and one each to Alaska, Florida, Maryland, and New York.

Interviews with the families of the other seven children who came to the Puget Sound area yielded reports of current, or resolved, recent febrile-rash illness in six of these children. Five of these six families had made a total of 14 visits to King County health care providers for their ill children since arriving in the US, seven of these visits were for rash illnesses. Unfortunately, measles had not been considered in the differential diagnosis of any of these children, and measles testing had not been ordered. All six of the ill children have subsequently been confirmed to have had measles.

Sites where persons may have been exposed to these children during their contagious period can be found on the Public Health-Seattle & King County Website at www.metrokc.gov/health. Because a measles outbreak cannot be declared over until two full incubation periods (42 days) have passed since rash onset in the last confirmed case, King County healthcare providers are requested to be vigilant for measles among all persons in the community with compatible symptoms.

Information on Measles Disease

Measles typically begins with a febrile prodrome lasting 2 to 4 days (range 1-7 days). Fever peaks at 103°-105° F, and is followed by the onset of cough, coryza and/or conjunctivitis. One to 2 days prior to the rash, and for 1 to 2 days after rash onset, Koplik's spots may appear as blue-white spots on the bright red background of the buccal mucosa. A maculopapular rash begins first at the hairline, spreading to the face and upper neck. The rash spreads downward on the body, eventually becoming a full body, generalized rash over the next three days. Other measles symptoms may include anorexia, diarrhea (especially in infants), and generalized lymphadenopathy.

The incubation period for measles is generally 7-18 days, but can be as short as 6 days and as long 21 days. The communicable period is approximately 5 days prior to rash onset, and 4 days after rash onset.

Why are International adoptees at risk for measles?

Though any person seeking an immigrant visa to the United States for permanent residency must show proof of having received recommended vaccines before immigration, internationally adopted children <11 years of age have been exempted from the overseas immunization requirements. Adoptive parents are required to sign a waiver indicating their intention to comply with the immunization requirements within 30 days after the infant or child's arrival in the United States. Nonetheless, this requirement would not have prevented any of the cases of measles in the current outbreak because the children were exposed prior to arrival in the United States.

As a result of this outbreak, on April 16, 2004, The Centers for Disease Control and Prevention (CDC) recommended a temporary suspension of adoption proceedings for children from the Zhuzhou Child Welfare Institute in the Hunan Province of China, which is currently experiencing an outbreak of measles.

Adoptive parents (and their families), who go overseas to pick up their child should obtain pre-travel advice, and should ensure that their own immunizations are up-to-date. In addition, health care providers should advise parents adopting children from countries where measles and other vaccine-preventable disease are endemic, to be vigilant for the development of such illnesses during the first 3 weeks after arrival in the US. They should also be advised to avoid extensive community exposures to new adoptees during this time when possible.

The CDC's Health Information for International Travel ("the yellow book") contains recommendations pertaining to international adoption, including pre-travel screening, overseas medical examinations, and follow-up medical examination after arriving in the US. It can be found online at: www.cdc.gov/travel/other/adoption.htm