Measles at an International Gymnastics Competition -- Indiana, 1991

On September 7, 1991, the Indiana State Department of Health (ISDH) was notified of three suspected measles cases among athletes from New Zealand (NZ) participating in an international gymnastics competition September 6-15 in Indianapolis (Marion County). Among those potentially at risk for measles were approximately 700 athletes and 1200 coaches, trainers, and managers from 51 countries; an estimated 2500 volunteers and staff; international media, families, and employees; and approximately 60,000 spectators attending the competition. This report summarizes the epidemiologic investigation of these cases.

Sixteen NZ delegation members arrived August 29 and stayed on one floor of a hotel. Throughout the following week, they practiced in a curtain-divided area shared with three other teams and visited nearby shopping and eating establishments. On August 30, two 15-year-old female athletes (patients 1 and 2) developed cough, coryza, and conjunctivitis, followed by onset of rash on September 4. Patient 2's symptoms were mild and improved within 24 hours of onset of rash. A third athlete (patient 3), a 16-year-old female, developed symptoms on September 5 and rash on September 7. All three patients had measles IgM antibody in their acute serum specimens (greater than or equal to 1:40 by indirect fluorescent antibody (IFA) test). Complement-fixation testing of both the acute and convalescent specimens collected 7 weeks later demonstrated fourfold or greater rise in IgG measles antibody for patients 1 and 3 and a fourfold decline in measles IgG antibody for patient 2. The three patients had documented histories of live-virus measles vaccination in NZ at 11, 13, and 14 months of age and reported exposure to a person with physician-diagnosed measles at their NZ practice gymnasium approximately 2 weeks before onset of rash.

Following onset of rash, patients 1 and 3 were isolated in their hotel rooms for at least 4 days. Remaining NZ delegation members born after 1956 were isolated until serologic evidence of measles immunity could be determined; within 12 hours, all were demonstrated to be seropositive (measles IgG greater than or equal to 1:40 by IFA).

An investigation by the ISDH identified numerous groups with probable measles exposure. Because of the large-scale exposure, the seriousness of measles illness (1), the extreme infectiousness of the measles virus (1), and the difficulty in obtaining timely evidence of measles immunity from throughout the world, the ISDH recommended that all participants, volunteers, staff, and hotel employees born after 1956 receive live-virus measles vaccine (2).

During September 8-12, six vaccination clinics were held. The vaccine was administered using an automatic hypodermic injection apparatus. Among the 1300 persons vaccinated were 608 international delegates, 264 Indianapolis and 139 other Indiana residents, 152 out-of-state volunteers, and 137 hotel employees. More than 1100 (85%) persons were vaccinated within 72 hours after the opening ceremonies on September 6 when most widespread exposure occurred.

Three persons experienced adverse events following vaccination; all were local reactions at the injection site and resolved without serious consequences. Two of these three patients were treated with antibiotics and improved promptly; the third was thought to have had an allergic reaction and was treated with corticosteroids.

Surveillance for secondary cases included 1) twice-daily reports from delegations on whether any member had prodromal measles symptoms; 2) daily review of visits to the competition's medical station and observation of the venue for persons with measles symptoms; 3) letters to participants, volunteers, and staff advising them of the outbreak and control measures, signs and symptoms of measles, the need to seek health care, and the importance of notifying local public health officials if symptoms occurred; 4) daily telephone calls to all emergency rooms and urgent-care centers in Marion County during September 16-23; and 5) notification of states whose residents attended the competition. No additional cases associated with the outbreak have been reported.

Reported by: F Johnson, MD, RA Jones, Marion County Health Dept; MA Sprauer, MD, Acute Disease Div; JT McPherson, MS, Disease Control Laboratory Div; ML Fleissner, DrPH, State Epidemiologist, Indiana State Dept of Health. PA Stehr-Green, DrPH, New Zealand Communicable Disease Centre, Porirua, New Zealand. Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Measles outbreaks at sporting events are potentially serious because of the danger of transmission to susceptible persons in large groups gathered in a confined environment (3,4). The potential for measles spread at the gymnastics competition in Indiana was great because of extensive mingling of NZ athletes in the prodromal stage--the most infectious stage of measles--not only with international delegations but also with the local community and visitors from throughout the United States. During the last 6 months of 1991, 9239 measles cases were reported in NZ, although the actual number may have been three to four times higher (5). The outbreak in Indiana demonstrates the ease with which measles infection can be transmitted throughout the world.

The absence of secondary cases may have been due to 1) a relatively large number of immune contacts among attendees from other countries (from natural infection or previous vaccination), 2) self-selection for vaccination by those less likely to be immune, and 3) prompt case confirmation and aggressive vaccination of many contacts within 72 hours of most intense exposure (2). Quarantine or closing of events would not have been feasible and, because exposure had already occurred, may not have limited secondary spread. A major factor in the prompt response was the cooperation and coordination among the competition's officials, the Marion County Health Department, and the ISDH laboratory and immunization personnel. The availability of jet injectors and multidose vaccine vials also facilitated the timely response.

To assist in preventing outbreaks of vaccine-preventable diseases (VPDs) and facilitating control if an outbreak occurs, the following measures should be implemented by athletic governing bodies and local organizing officials of national and international athletic events: 1) all delegation members, staff, volunteers, and accompanying visitors should be appropriately vaccinated according to the recommendations of their respective nations before arrival; 2) delegation members, staff, and volunteers born after 1956 should be required to provide vaccination records or other documentation of immunity (such as serology or physician diagnosis) for measles and other VPDs; 3) vaccination records should be maintained in data bases that include birth date, home address (including country), and telephone number, and similar data collected on vaccination consent forms must be legible; 4) participants aged less than 18 years should have authority to designate an accompanying adult to authorize medical intervention; and 5) in the event of a VPD outbreak, local and state health departments should work quickly with organizing committees and governing bodies to establish plans for evaluation, treatment, exclusion, and prophylaxis and to ensure vaccination clinics are held promptly and conveniently.

References

1. Preblud SR, Katz SL. Measles vaccine. In: Plotkin SA, Mortimer EA, eds. Vaccine. Philadelphia: WB Saunders, 1988:182-222.

2. CDC. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989;38(no. S-9).

3. Davis RM, Whitman ED, Orenstein WA, Preblud SR, Markowitz LE, Hinman AR. A persistent outbreak of measles despite appropriate prevention and control measures. Am J Epidemiol 1987;126:438-49.

4. White J. Measles: a hazard of indoor sports. The Physician and Sportsmedicine 1991;19:21.

5. Galloway Y, Stehr-Green P. Measles in New Zealand, 1991. Communicable Disease New Zealand 1991;91:107-9.

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