In the period March-June 1981, 219 cases of measles were reported by the El Paso (Texas) City-County Health Department. All patients had a temperature of at least 101 F (38.3 C), a rash of at least 3 days' duration, and at least 1 of the following: cough, coryza, conjunctivitis, or Koplik's spots. Twelve cases were confirmed by a 4-fold rise in complement fixation (11) or hemagglutination inhibition (1) antibody titers between acute- and convalescent-phase serum specimens.

Rash onset occurred between April 11 and May 8 in 154 (70.3%) of the cases. Patients ranged in age from 3 months to 36 years. The largest number of cases, 81 (37.0%), occurred among 15-19 year olds followed by 67 among 0-4 year olds (Table 1). Of these 67 pre-school patients, only 9 (13.4%) attended day-care centers.

Of the 219 patients, 94 (42.9%) had histories of adequate measles vaccination*; 85 (38.8%) had no history of prior vaccination; and 37 (16.7%) had histories of inadequate vaccination. The vaccination status was unknown for 3 patients.

Five of the 9 El Paso County public school districts were involved in the outbreak. The highest attack rate, 2.3 cases/1,000 enrollees, occurred in the Ysleta Independent School District, where 63 of the 100 cases reported occurred in a single high school (Figure 2). On April 28, 776 (34.3%) of the 2,265 students at that high school were identified as being susceptible, and a special clinic was conducted at the school on the morning of April 29. Only 6 cases were reported after the clinic date, and no cases were reported 14 days or more (1 incubation period) after the measles vaccination clinic.

On April 29, the El Paso City-County Health Director formally declared an epidemic. All schoolchildren in the county were required to show proof of adequate measles vaccination or physician-verified measles illness. Over 120,000 school records were screened in public, private, and parochial schools. The majority of schools excluded students who were unvaccinated. Because of staff limitations, the health department elected to conduct vaccination clinics only at those public schools with at least 300 susceptible students. Special clinics were conducted at 14 of the county's 23 high schools, and, at the same time, regular clinic services and immunization services were maintained for the entire day in the public health clinics.

During the control program, 13,000 persons were vaccinated for measles by the El Paso City-County Health Department, an increase of 502% over the same period in 1980. In addition, the Texas Department of Health issued more than 7,000 doses of measles vaccine to private physicians, hospitals, and out-patient clinics in the El Paso area. Reported by BF Rosenblum, MD, MPH, EW Gorby, MD, E Orneles, S Balcorta, El Paso City-Couty Health Dept, JL Bradley, MD, Public Health Region III, RD Crider, Jr, C Mallory, CR Webb, Jr, MD, State Epidemiologist, Texas Dept of Health; Immunization Div, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Texas school immunization laws, rules, and regulations (as amended in 1978) provided for a graduated implementation of requirements for measles vaccination. For the school year 1980-1981, only students through the 7th grade (13 years of age) were required to show proof of measles protection. The lack of such regulations for middle and high school students probably explains the high attack rate in El Paso County in persons 15-19 years of age.

Based on experience in the El Paso outbreak, school regulations for the state of Texas were revised so that, effective September 1, 1981, a history of physician-verified measles or a history of adequate vaccination for measles would be required for all students to attend school, including high school. In May 1981, it was estimated that approximately 290,000 students in public junior and senior high schools would need measles vaccination as a result of the rule changes. From September 1 to November 30, 1981, a statewide record review of all junior and senior high school students was conducted, and from August 1 through November 30, 1981, 112,696 doses of measles vaccine were administered through public health clinics to students 10-19 years of age, an increase of 646% over the same period in 1980. It is now estimated that 98.3% of the 2,919,150 students currently enrolled in the 1,098 school districts in Texas from kindergarten through grade 12 are in compliance with the new state immunization requirements.

The cornerstone of the measles elimination effort is the achievement and maintenance of high immunization levels, and school requirements for all children from kindergarten through l2th grade are fundamental for success (1). Past studies have demonstrated that states with such regulations have the lowest incidence rates for measles (2-4) and that enforcement of these regulations with exclusion of non-compliant students correlates best with low measles incidence (3).

References

1. CDC. School immunization requirements for measles--United States, 1982. MMWR 1982;31:65-7.

2. CDC. Measles and school immunization requirements--United States, 1978. MMWR 1978;27:303-4.

3. Robbins KB, Brandling-Bennett AD, Hinman AR. Low measles incidence: association with enforcement of school immunization laws. Am J Public Health 1981;71:270-4.

4. CDC. School immunization requirements for measles--United States 1981. MMWR 1981;30:158-60. *Defined by the health department as vaccine administered after 12 months of age and after January 1968.

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