Between April 9, and June 1, 1984, 37 cases of measles occurring over five generations were reported from the Hanover, New Hampshire, area to the New Hampshire Division of Public Health Services (DPHS) (Figures 1 and 2). Twenty-one cases were serologically confirmed.

Twenty-nine infections occurred among Dartmouth College students and their family contacts; one, in a bookstore employee; and one, in a resident of a nearby town. The six remaining cases occurred in four employees, one outpatient, and one neurosurgical inpatient at the Mary Hitchcock Memorial Hospital, a teaching facility of Dartmouth Medical School, the only hospital serving Hanover (population 9,376 (1983 census)). The ill hospital personnel included one nurse, one laboratory technician, and two house officers. Patients' ages ranged from 1 year to 43 years (median 21 years).

The overall attack rate among Dartmouth students was 0.7%, varying from a high of 3.2% among students at Dartmouth's Tuck School of Business Administration, the only graduate school involved, to a low of 0.6% in undergraduate students. Attack rates among nurses and physicians at the hospital were 0.3% and 0.7%, respectively, with an overall attack rate among hospital personnel of 0.2%.

The index patient, a 27-year-old male graduate student, had onset of rash April 3. The source of his infection was not known. He had traveled to Michigan, Massachusetts, New Jersey, and North Carolina for job interviews during the likely period of exposure. Indigenous measles had not been reported in New Hampshire during the previous 22 months. The second generation occurred from April 13 to April 16, when measles was diagnosed in the unimmunized 2H-year-old son of the index patient and in six additional graduate students. The third generation of measles (four cases) began April 20. One was the 14-month-old son of a noninfected graduate student and a playground contact of the son of the index patient. Two were graduate students; the fourth, an undergraduate student. The fourth generation, which began May 8, included 15 undergraduates; a 43-year-old individual from a nearby town; and four personnel, one outpatient, and one neurosurgical inpatient at the hospital. The fifth and last generation consisted of two undergraduate students and a medical center bookstore employee who became ill during the last week of May.

The Dartmouth College Student Health Services, assisted by DPHS, instituted outbreak-control measures following the report of the index patient on April 9. These measures included determining the immune status of students at the Tuck graduate school and vaccinating susceptible Tuck graduate students and susceptible family members and neighbors exposed to the index patient on a voluntary basis. On April 13, DPHS recommended that the entire student body (4,903 persons) be notified that measles had occurred on campus and that all student health immunization records be reviewed to identify susceptible individuals. Seventy student health aides assisted in surveillance and education. Steps were taken to identify and immunize susceptible athletes, to prohibit them from participating in off-campus events, and to advise teams from other colleges due to compete at Dartmouth that measles had occurred on campus.

An audit of the 4,903 student health records revealed that 2,923 (59.6%) did not have adequate documentation of measles immunity.* In most cases, dates of vaccination were lacking. Letters were sent to each of these possibly susceptible students explaining that they should be vaccinated unless they could provide documentation of immunity. The 375 employees of the college under 28 years of age received similar letters.

Vaccination clinics staffed by DPHS were opened on campus April 13 and maintained through April 27. The Student Health Services also established a walk-in vaccination clinic from April 16 throughout the course of the outbreak and operated other clinics at various congregation points on campus (Figure 1).

Because of these efforts, over 3,500 college employees, students, and their families were vaccinated. The Student Health Services and DPHS Immunization Program staff vaccinated or obtained proof of immunity for 2,528 (86.5%) of the 2,923 students identified as possibly susceptible. By the end of May, 4,508 (91.9%) of the 4,903 total students had documented proof of measles immunity in their health records.

All schools, day-care centers, colleges, and universities in New Hampshire were notified early in the outbreak of the possibility of indigenous measles, with a recommendation that the immune status of children, students, and employees in these facilities born after 1956 be reviewed. DPHS also informed other health-care providers, hospitals, and town health officers in the state, as well as public health officials in states bordering New Hampshire and in the Province of Quebec, Canada, that measles had occurred in the state.

This fall, Dartmouth College began routinely notifying new students who did not provide adequate documentation of measles immunity on enrollment health forms that the college strongly recommended vaccination. In addition, those students enrolled in the 1983-1984 academic year who still lacked documentation of measles immunity in June were recontacted on return to campus regarding their need for vaccination.

Although it is unclear how measles spread to the hospital, several routes of transmission are possible. A surgical house officer who developed measles shared an apartment with a noninfected Tuck graduate student. He continued to work after the onset of prodromal symptoms and was subsequently hospitalized for 6 days, during which he developed viral pneumonia and corneal ulcerations. The laboratory technician, believing himself immune because of age (27 years old), had drawn blood samples from individuals suspected of having measles at the Student Health Services clinic. The neurosurgical patient had onset of rash 11 days after admission. She was either exposed during her hospitalization or before admission, when she had been on campus and in the hospital for preadmission tests. Five of the 37 individuals who developed measles visited the hospital emergency room.

Because of the risks arising from nosocomial measles at the hospital, DPHS recommended that: (1) all professional staff, other employees, and hospitalized patients under 35 years of age either provide proof of immunity or be vaccinated, unless contraindicated; (2) all susceptible patients exposed to a known measles patient be vaccinated or given immune globulin, as medically indicated; and (3) susceptible persons in the community born after 1949 or vaccinated before 1968 be advised not to visit the hospital. The hospital conducted its own vaccination clinic starting April 13 (Figure 1). Eighty-six individuals voluntarily received vaccinations through May 17. On May 18, the day after the first hospital case was publicized, an additional 400 persons received vaccine. By June 1, the hospital had vaccinated 876 persons, most of whom were among the hospital's 2,200 personnel. Hospital policy now requires serologic testing of all new employees for evidence of immunity to measles and rubella and vaccination of those found to be seronegative. Reported by JH Turco, MD, DN MacKay, MD, R Smith, MD, B Conant-Sloane, PhD, NM Watkins, Dartmouth College, Dartmouth Medical School, Mary Hitchcock Memorial Hospital, Immunization and Epidemiology Programs, Bureau of Communicable Disease Control, E Schwartz, MD, State Epidemiologist, New Hampshire Div of Public Health Svcs; Div of Immunization, Center for Prevention Svcs, Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Since the measles elimination campaign began in 1978, indigenous measles has been eliminated from most of the United States. In 1983, a record low 1,497 measles cases were reported. From 1980-1983, however, an increasing proportion of measles cases have occurred on college campuses (Table 1).

Of the 1,497 measles cases reported in 1983, 570 (38.1%) were college or college-associated cases: 296 (19.8%) occurred on college campuses; 274 cases off campus were epidemiologically linked to those on campus (within two generations). Most of the college-associated cases (92.1%) were related to four campus outbreaks: Indiana University (IU)--385 cases (180 on campus, 205 spread); Miami University of Ohio--82 cases (20 on campus, 62 spread); University of Houston--32 cases (29 on campus, three spread); and Louisiana State University--26 cases (25 on campus, one spread) (1).

In the first 37 weeks of 1984, the number of reported measles cases on campuses has declined substantially, compared to the same period in 1983. Nevertheless, the college outbreak cited here is one of the larger reported campus outbreaks. Measles outbreaks on college campuses are of particular concern because measles is a more serious disease among adults than among schoolchildren (2).

Measles transmission among college students may be sustained by several factors (3): (1) many children growing up in the mid-1960s may have missed measles vaccination in the first years following the licensure of measles vaccine; (2) many students may not have been

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