Interstate Transmission of Measles in a Gypsy Population -- Washington, Idaho, Montana, California

A measles outbreak among 44 persons, with rash onsets ranging from September 4, through November 14, 1983, was reported from Washington, Idaho, Montana, and California (Figure 5). The source was a measles outbreak in Chicago, Illinois. Seven (16%) patients were hospitalized during the outbreak (Table 2), three of whom were hospitalized with dehydration, two with severe vomiting and diarrhea, one with otitis media, and one with bronchitis. No deaths were reported. Of the 44 patients, 27 (61%) were children of people who call themselves Gypsies.

The outbreak began with a 2-year-old Gypsy boy who lived in a neighborhood in Chicago where an outbreak of measles occurred. He had onset of rash on September 4 in Billings, Montana, where he infected a 13-year-old Gypsy boy who subsequently had rash onset September 19 while attending a wedding in Spokane, Washington. The wedding, which was held in a banquet room at a race track, was attended by approximately 375 people from Gypsy communities in Idaho, Montana, Oregon, and Washington. Approximately 75 of the attendees were children. Of these, 17 were infected by the 13-year-old boy, for an attack rate of 23%. None of the 17 children had adequate evidence of immunity to measles.* The resulting outbreak involved persons living in four states.

Washington: Twenty-eight cases were reported in four spread generations of infection. All 13 cases in the first two generations occurred among the Gypsy population. Three additional generations occurred, involving other persons in their communities. Transmission probably occurred at the race track, in patients' homes, and in school.

Twenty-one (75%) of the 28 patients lacked adequate evidence of immunity to measles. Of these, 15 were Gypsies, four were children of chiropractors who refused permission for vaccination, and two were either too young or too old to attend school, and therefore, were not affected by the school immunization law. The four children of chiropractors had been allowed to attend school on the basis of personal exemptions. In addition, three patients were infected in medical settings--an 8-year-old child, who was infected by another patient while visiting a private physician, and a 32-year-old ward clerk and a 27-year-old emergency-room nurse who were infected when exposed to four children with measles. The nurse was probably infectious while she attended a national conference for approximately 800 emergency-room nurses in Anaheim, California. Following this incident, immunization program staff contacted these nurses in their 46 states of residence, but no additional cases were identified.

Idaho: Nine cases occurred among unimmunized individuals. Four of the patients attended the wedding in Spokane with the 13-year-old Gypsy boy. In addition, a 38-year-old man who did not attend the wedding was probably infected by the same boy. No additional cases occurred after October 10.

Montana: Three patients were infected by the 13-year-old boy at the wedding. No additional cases were reported after October 7.

California: A 2H-year-old unvaccinated child from a migrant family in Santa Clara had rash onset November 12. She was infected by her 18-month-old sister, who acquired measles in Washington from children of one of the affected Gypsy families. Reported by LG Dales, MD, J Chin, MD, State Epidemiologist, California Dept of Health Svcs; D Adams, District III Health Dept, Canyon County, G Hurst, District V Health Dept, Twin Falls County, J Jelke, District VI Health Dept, Bannock County, B Arnell, District VII Health Dept, Bonneville County, F Dixon, MD, CD Brokopp, DrPH, State Epidemiologist, Idaho Dept of Health and Welfare; Immunization Program, KT Reddi, MD, Chicago Dept of Health, BJ Francis, MD, State Epidemiologist, Illinois Dept of Public Health; BL Desonia, SC Linder, JK Gedrose, State Epidemiologist, Montana Dept of Health and Environmental Sciences; MQ Luther, MD, BA Feyh, MS, S Thompson, Spokane County Health District, BJ Baker, DA Johnson, VJ Ross, RH Leahy, MD, Chief, Office of Preventive Health Svcs, JM Kobayashi, MD, State Epidemiologist, Washington State Dept of Social and Health Svcs; Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This outbreak primarily involved a highly mobile group of Gypsies and demonstrates that clusters of susceptibles can sustain measles transmission. Similar interstate measles outbreaks in other highly mobile groups have been reported in recent months (1,2). Outbreaks have also been reported among children where parents oppose immunization on religious or philosophical grounds (3). The failure of measles to spread extensively in the community in each outbreak suggests that immunization levels in the general population are high.

It is believed that approximately 500,000 Gypsies currently reside in the United States (4). Even though most Gypsies do not object to immunization, none of the Gypsy patients in this outbreak had been vaccinated against measles. Folk medicine is often preferred over established medical practices; Gypsies generally avoid established medical care except when very ill (5,6). Moreover, many Gypsy children do not attend school, and therefore, are not affected by school immunization laws.

Since such populations are difficult to reach in vaccination programs and since measles is continually imported into the United States in low numbers, the potential exists for occasional small outbreaks, as reported here. Communities can best protect themselves by ensuring that high immunization levels are achieved and maintained. The kind and quality of surveillance and epidemiologic follow-up demonstrated by this outbreak were made possible by rapid, effective communication between the 46 states involved in the active surveillance and tracing of contacts of patients. Highly motivated and responsive staff again played a significant role in the delineation and containment of this outbreak and the maintenance of high immunization levels.

References

1. CDC. Measles among members of a drum and bugle corps--Arkansas, California, Kansas. MMWR 1983;32:561-2, 567.

2. CDC. Transmission of measles across state lines--Kentucky, New Hampshire, Tennessee, Virginia. MMWR 1982;31:123-6.

3. CDC. Measles among children with religious exemptions to vaccination--Massachusetts, Ohio. MMWR 1981;30:550, 555-6.

4. Wetzel RC, Dean JM, Rogers MC. The art of pediatrics: Gypsies and acute medical intervention. Pediatrics 1983;72:731-5.

5. Mandell F. Gypsies: culture and child care. Pediatrics 1974;54:603-7.

6. Anderson G, Tighe B. Gypsy culture and health care. Am J Nurs 1973;73:282-5.

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