Measles Outbreaks on University Campuses--Indiana, Ohio, Texas

Indiana, Ohio: A total of 174 students with clinically diagnosed* and/or laboratory confirmed measles were reported at Indiana University (IU)--Bloomington (approximate enrollment 31,000). Rash onset occurred from February 1 to April 2, 1983 (Figure 1). The outbreak was explosive, with at least 89 second generation cases. No source was identified. The students, who ranged in age from 17 to 31 years, were residents of 17 states, New York City, and Kenya (Figure 2). Attack rates among Indiana residents were not significantly different from those among nonresidents. An additional 17 clinical measles cases from other reporting areas were epidemiologically linked to the IU outbreak, including a cluster of 13 cases among students attending Miami University, Oxford, Ohio.

The risk of measles was greater among students living on campus than off campus (p 0.00001): 11.1 cases per 1,000 students living in fraternity or sorority houses on campus; 9.3/1,000 in campus dormitories; and 2.2/1,000 in off-campus housing. Of the 174 cases at IU, 124 (71.3%) occurred among freshmen and sophomores. However, neither age nor grade level was a significant risk factor when corrected for types of local housing.

Intensive voluntary control efforts by state, county, and university health officials began on February 15. By March 6, an estimated 13,000 doses of measles-rubella (MR) vaccine were administered to students, faculty, staff, and guests on the IU campus**. Because of the continuing outbreak (168 cases as of March 6) and the high proportion of students who remained unvaccinated, on March 7, the State Health Commissioner announced a plan to require documentation of immunity for IU students returning to campus after spring recess (March 11-21) without documentation of immunity.*** As a result of this announcement, approximately 8,000 additional doses were given by March 21. An estimated 7,000 students who were born before 1957 were not required to show written proof of immunity because they were more likely to have had natural exposure to measles. More than 3,100 students showed written proof of immunity on returning from spring break. By April 15, 2,000 students, 6.4% of the total enrollment, lacked documentation of immunity.

Texas: An outbreak of 32 measles cases, including 29 cases among university students, was reported at the University of Houston (UH) campus, Houston, Texas. Rash onset occurred from February 2 to March 28, 1983. Initial transmission occurred in campus dormitories where 2,603 (10.0%) of the estimated 26,000 enrolled students reside. Of the 32 cases, 20 (62.5%) occurred in Dormitory A and two cases were reported from Dormitory B. The remaining cases occurred among off-campus students (seven) and community residents (three).

To control the outbreak, the City Health Officer designated the university as an epidemic area and ordered immunization of all dormitory residents. From February 21 to March 3, vaccination clinics were conducted in all five dormitories. Proof of measles vaccination was provided by 17.2% (448) of the entire dormitory population (2,603); 2,151 (82.6%) students were vaccinated. The four remaining students were evicted on March 7. All UH students were required to provide proof of immunity or be barred from participation in any official university function outside the city. An additional 4,686 students were vaccinated in voluntary clinics on campus. Reported by D Lotz, R Hongen, MD, Student Health Service, Indiana University, TW Sharp, MD, Monroe County Health Dept, Bloomington, RG Blankenbaker, MD, G Chastain, CL Barrett, MD, State Epidemiologist, Indiana State Board of Health; E Freund, Jr, University of Cincinnati School of Medicine, TJ Halpin, MD, State Epidemiologist, Ohio State Dept of Health; C Buu, MD, M Key, MD, Houston City Dept of Public Health, J Bopp, B Brownstein, B Gurd, R Hicks, G Osborn, PhD, BJ Smith, MD, C Wallace, JR Whitehurst, MD, University of Houston, CE Alexander, MD, CR Webb, MD, State Epidemiologist, Texas State Dept of Health; Div of Immunization, Center for Prevention Services, CDC.

Editorial Note

Editorial Note: College students accounted for 52.6% (241/458) of U.S. measles cases reported in the first 13 weeks of 1983. Although measles has previously been reported from colleges and universitites, the IU outbreak is the largest in recent times. The susceptibility level of this group is difficult to assess since very few colleges require immunization records. Nevertheless, the fact that attack rates in the IU outbreak were similar for students regardless of state of residence suggests that susceptibility to measles is not unique to Indiana colleges. Estimates of susceptibility among college students range from 1% to 20%, with most estimates at 5%-15% (1).

Measles outbreaks on campuses are disruptive and costly. Moreover, measles infection has a higher risk of complications when it occurs in the college age group; at IU, 16 of 174 students with measles required stays at the student health center for observation. Because no routine program exists to require that students prove immunity to measles before college entry, it was necessary to vaccinate more than 20,000 students who had no record of vaccination. Assuming at least 80% of the IU students were immune, a high proportion of the students were vaccinated unnecessarily. If records had been available before the outbreak, the number of days lost from classes and the number of unnecessary vaccine doses administered might have been substantially reduced.

The IU outbreak demonstrates that voluntary vaccination programs generally meet with only limited success. Based on these experiences, future college outbreaks should be met with immediate requirements that all students be vaccinated or show proof of immunity.

Although formal economic analysis of this outbreak has not yet been completed, known direct costs of the outbreak control activities exceeded $225,000. It is more cost-effective to prevent measles outbreaks than to attempt to control them. Colleges should consider establishing immunization requirements as a condition of registration to be confident that students born after 1956 are immune to measles.

Reference

1. CDC. Measles in universities--Indiana, 1983. MMWR 1983;32(8):113-4.

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