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Issue Number 413            September 22, 2003


  1. CDC reports on decline in varicella incidence, 1990-2001
  2. CDC reports on measles epidemic in the Republic of the Marshall Islands, July 13-September 13, 2003
  3. Revised: IAC updates its Prototype of "Notification of Vaccination" Letter


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(1 of 3)
September 22, 2003

The Centers for Disease Control and Prevention (CDC) published "Decline in Annual Incidence of Varicella--Selected States, 1990-2001" in the September 19 issue of the "Morbidity and Mortality Weekly Report" (MMWR). Portions of the article are reprinted below.


[Article's opening paragraph]
Varicella (chickenpox) is a common, highly infectious, and vaccine-preventable disease. Before the introduction of the live attenuated varicella vaccine in 1995, approximately 4 million cases of varicella occurred annually in the United States, resulting in approximately 11,000 hospitalizations and 100 deaths. In 1996, the Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination of all children at age 12-18 months, catch-up vaccination of all susceptible children before age 13 years, and vaccination of susceptible persons with close contact to persons at high risk for serious complications. In 1999, ACIP updated these recommendations to include vaccination requirements for child care and school entry and for postexposure; ACIP also strengthened recommendations for vaccination of susceptible adults and indicated that varicella vaccine should be considered for outbreak control. Changes in the national annual reported incidence of varicella disease during 1972-1997 have been reported previously. This report summarizes trends in the annual reported incidence of varicella disease in selected states during 1990-2001. The findings underscore the continued need to improve varicella surveillance to monitor the impact of the varicella vaccination program and assess any changes in varicella transmission and disease. . . .

[A portion of the article's Editorial Note]
The findings in this report suggest that the steady decline in reported varicella incidence during 1999-2001 resulted from the increased use of varicella vaccine and not a decrease in reporting. These findings are consistent with data from three active surveillance sites at which individual cases are investigated (Antelope Valley, California; West Philadelphia, Pennsylvania; and Travis County, Texas). During 1995-2000, incidence of varicella for all age groups in these three sites declined substantially (range: 76%-87%), corresponding with the high average vaccination coverage of 80%.

The availability of a safe and effective varicella vaccine has reduced the impact of the disease substantially. High vaccination coverage levels among all age groups are necessary to ensure that persons do not reach adolescence or adulthood without having immunity to varicella. At the start of the 2002 school year, 33 states had implemented child care or school entry requirements for varicella (CDC, unpublished data, 2003), and five more states implemented such requirements in September 2003.

The existing national varicella surveillance system is not adequate to monitor the incidence of varicella disease or to assess the impact of the vaccination program. In 2001, disease incidence was reported by 22 states and the District of Columbia; however, only four states had adequate and consistent reporting for the study period. The Council of State and Territorial Epidemiologists has recommended that by 2005, states establish or enhance varicella surveillance programs that provide individual case reporting. . . .


To obtain the complete text of the article online, go to:

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To obtain a free electronic subscription to the "Morbidity and Mortality Weekly Report" (MMWR), visit CDC's MMWR website at: Select "Free Subscription" from the menu at the left of the screen. Once you have submitted the required information, weekly issues of the MMWR and all new ACIP statements (published as MMWR's "Recommendations and Reports") will arrive automatically by email.

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September 22, 2003

The Centers for Disease Control and Prevention (CDC) published "Measles Epidemic--Majuro Atoll, Republic of the Marshall Islands, July 13-September 13, 2003" in the September 19 issue of the "Morbidity and Mortality Weekly Report" (MMWR). The article is reprinted below in its entirety, excluding references.


During July 13-September 13, 2003, a total of 647 clinically diagnosed measles cases were reported on Majuro Atoll in the Republic of the Marshall Islands (RMI); this is the first measles outbreak reported in RMI since 1988. An additional 74 suspected measles cases are under investigation. This report describes the clinically diagnosed measles cases and the public health response to stop the epidemic. Of the 647 cases, 15 (2%) are laboratory confirmed, either by serology, polymerase chain reaction, or viral culture. The age of patients ranged from 2 weeks to 43 years (median: 12 years); 479 (74%) patients were aged less than 20 years. The overall measles incidence on Majuro Atoll (estimated 2003 population: 25,097) is 26 cases per 1,000 population. The incidence is highest among infants aged  less than 1 year (160 per 1,000 population), followed by children aged 1-4 years.

A total of 58 persons with measles have been hospitalized; three patients have died, including a malnourished child aged 15 months with diarrhea and pneumonia, a woman aged 27 years with pneumonia, and a woman aged 39 years whose immediate cause of death remains unknown. Postmortem examination was not available for any of these patients.

To stop measles transmission, the Ministry of Health in RMI recommended measles, mumps, and rubella vaccine (MMR) for all infants aged 6-11 months and all persons aged 1-40 years who did not have documented proof of measles immunity. Before the epidemic, estimated vaccine coverage with 1 dose of MMR was less than 75% for children aged 1-13 years, according to evaluations of computerized vaccination records and of children screened during the vaccination campaign. As of September 13, a total of 98% of persons aged 6 months-40 years had documentation of receipt of at least 1 dose of MMR. Campaign activities that delivered 16,913 doses included 1) vaccinating health care and public health workers, 2) vaccinating children at nine vaccination posts across the atoll, 3) delaying the start of the school year until school children were vaccinated and requiring documentation of vaccination for school entry, and 4) conducting neighborhood and house-to-house vaccination in areas where adequate coverage was not reached.

To prevent spread from Majuro Atoll, vaccination campaigns were conducted in other atolls and islands in RMI. The Ministry of Health suspended travel of sea vessels and airlines from Majuro Atoll until vaccination campaigns had been completed in other atolls and islands, and required proof of MMR vaccination for all travelers leaving Majuro Atoll for other atolls or islands or for international destinations. A total of 17 measles cases have been reported from Ebeye Island in Kwajalein Atoll; 10 of these persons were exposed in Majuro Atoll. Two other atolls have reported six cases whose exposure was in Majuro Atoll. Measles surveillance has been enhanced in RMI, other Pacific islands, and in the United States. Spread to other areas in the Pacific and to the United States has been limited; five measles cases in Hawaii, three in Guam, one in Palau, and one in California are believed to be linked to this epidemic.

The source of importation of the measles virus to Majuro Atoll has not yet been determined, but the H1 genotype found in this outbreak is common in Asia, and the specific strain has been reported recently in measles cases from Japan and China. The Advisory Committee on Immunization Practices recommends that all international travelers be immune to measles because it is endemic or epidemic in many parts of the world, including developed countries. Persons aged less than 40 years who are traveling to RMI during the next 60 days should be aware that RMI requires documentation of measles immunity for all departing passengers on international flights. The documentation must fulfill the same age-specific requirements used in the vaccination campaign.


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To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to:

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(3 of 3)
September 22, 2003

The Immunization Action Coalition (IAC) recently revised its Prototype of "Notification of Vaccination" Letter. A clinic, private practice, or immunization clinic can use the letter to notify a health professional that they have vaccinated his or her patient. Users are encouraged to modify the prototype letter to suit their particular circumstances.

The prototype letter lists the vaccines often administered to children and adults. IAC has updated the letter to reflect the vaccines currently available.

To access a camera-ready (PDF) copy of the revised prototype letter, go to:

To access an HTML copy, go to:

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Editorial Information

  • Editor-in-Chief
    Kelly L. Moore, MD, MPH
  • Managing Editor
    John D. Grabenstein, RPh, PhD
  • Associate Editor
    Sharon G. Humiston, MD, MPH
  • Writer/Publication Coordinator
    Taryn Chapman, MS
    Courtnay Londo, MA
  • Style and Copy Editor
    Marian Deegan, JD
  • Web Edition Managers
    Arkady Shakhnovich
    Jermaine Royes
  • Contributing Writer
    Laurel H. Wood, MPA
  • Technical Reviewer
    Kayla Ohlde

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