United States had been vaccinated. Among the 59 patients who were U.S. residents, 13 were aged <12 months and too young to be vaccinated routinely, seven were children aged 12-15 months and had not yet received vaccination, 21 were children aged 16 months-19 years, including 14 (67%) who claimed exemptions because of religious or personal beliefs (Table). Among the 18 patients aged ≥20 years, 14 had unknown or undocumented vaccination status, two had claimed exemptions and acquired measles in Europe, one had evidence of immunity because of birth before 1957, and one had documentation of receiving 2 doses of MMR vaccine.

Of the five U.S. residents with measles who were vaccine eligible and had traveled abroad, all were unvaccinated. One was a child aged 15 months who was not vaccinated before travel, and two were adults who were unvaccinated because of personal belief exemptions. For two adults, the reason for not being vaccinated was unknown.

Reported by: SB Redd, PK Kutty, MD, AA Parker, MSN, MPH, CW LeBaron, MD, AE Barskey, MPH, JF Seward, MBBS, JS Rota, PA Rota, PhD, L Lowe, PhD, WJ Bellini, PhD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Editorial Note: Although ongoing measles transmission was declared eliminated in the United States in 2000 (1) and in the World Health Organization (WHO) Region of

the Americas in 2002 (2), approximately 20 million case of measles occur each year worldwide. The 2008 upsurg in measles cases serves as a reminder that measles is sti imported into the United States and can result in outbreak unless population immunity remains high through vacc nation. Among the 64 confirmed measles cases, prior vas cination could be documented for only one person.

Before introduction of measles vaccination in 1963 approximately 3 to 4 million persons had measles annual in the United States; approximately 400-500 died, 48,00 were hospitalized, and 1,000 developed chronic disabilit from measles encephalitis (1). Even after elimination endemic transmission in 2000, imported measles has con tinued to create a substantial U.S. public health burde of the 501 measles cases reported during 2000-2007, or in four patients was hospitalized, and one in 250 died ( Thus far in 2008, five U.S. residents and five visitors hav been documented as acquiring measles abroad. Of thes 10 persons, nine acquired measles in the WHO Europea Region. These importations likely are related to an increas in 2008 in measles activity in Europe. In Switzerlan approximately 2,250 measles cases have been reported sing November 2006. The Swiss measles outbreak started i Lucerne, where the measles vaccination coverage level i children is 78%, and spread across the country, predom

intly affecting children aged 5-15 years who were unvacnated because of parental opposition to vaccination.** In rael (which is included in the WHO European Region), - measles outbreak with approximately 1,000 cases is going (Ministry of Health, Israel, unpublished data, 008), and measles transmission is occurring in other uropean countries, predominantly among populations oposed to vaccination. This situation prompted travel dvisories to be issued in the United States and Europe.** ealth-care providers should advise patients who travel road of the importance of measles vaccination and should ›nsider the diagnosis of measles in persons with clinically ompatible illness who have traveled abroad recently or have ad contact with travelers.

The limited size of recent measles outbreaks in the United ates has resulted from highly effective measles and MMR accines, preexisting high vaccination coverage levels in reschool and school-aged children, and a rapid and effecve public health response. All children should receive doses of MMR vaccine, with the first dose recommended age 12-15 months and the second dose at age 4-6 years. nless they have other documented evidence of measles munity,§§ all adults should receive at least 1 dose. Two oses are recommended for international travelers aged

World Health Organization. Measles and rubella surveillance bulletin. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.euro. who.int/vaccine/publications/20080401_1.

U.S. travel advisories available at http://wwwn.cdc.gov/travel/content measles.aspx. European travel advisories available at http://ecdc.europa.eu/ health_topics/measles/080423_travel_advice.html.

Laboratory evidence of immunity, documentation of physician-diagnosed measles, or birth before 1957.

≥12 months, health-care personnel, and students at secondary and postsecondary educational facilities. Infants aged 6-11 months should receive 1 dose before travel abroad (3). During a measles outbreak, the vaccination response should be guided by the epidemiology of the outbreak and the outbreak setting and might include offering 1 dose of measles or MMR vaccine to infants aged 6-11 months, offering the second dose to preschool-aged children provided that 28 days have elapsed since the first dose, and recommending 1 dose to health-care workers born before 1957 unless they show other evidence of immunity.

Patients with measles frequently seek medical care, and emergency departments are common sites of measles transmission (4). To prevent transmission of measles in healthcare settings, patients should be asked to wear a surgical mask (if tolerated) for source containment, airborne infection-control precautions (5) should be followed stringently, and patients should be placed in a negative airpressure room as soon as possible. If a negative air-pressure room is not available, the patient should be placed in a room with the door closed. Measles cases should be investigated, patients isolated promptly, and specimens obtained for laboratory confirmation and viral genoptying. Case contacts without documented evidence of measles immunity should be vaccinated, offered immune globulin, or asked to quarantine themselves at home from the fifth day after their first exposure to the twenty-first day after their last exposure. Contacts with measles-compatible symptoms should be managed in a manner that will prevent further spread (3,5).

Health-care personnel place themselves and their patients at risk if they are not protected against measles. In accordance with current recommendations, health-care personnel should have documented evidence of measles immunity readily available at their work location (3). If this documentation is not available when measles is introduced, major costs and disruptions to health-care operations can result from the need to exclude potentially infected staff members and rapidly ensure immunity for others (6). Many of the measles cases in children in 2008 have occurred among children whose parents claimed exemption from vaccination because of religious or personal beliefs and in infants too young to be vaccinated. Forty-eight states currently allow religious exemptions to school vaccination requirements, and 21 states allow exemptions based on personal beliefs.*** During 2002 and 2003, nonmedical exemption rates were higher in states that easily granted exemptions than states with medium or difficult exemption processes (7); in such states, the process of claiming a nonmedical exemption might require less effort than fulfilling vaccination requirements (8).

unvac

Although national vaccination levels are high,+++ cinated children tend to be clustered geographically or socially, increasing their risk for outbreaks (6,9). An upward trend in the mean proportion of school children who were not vaccinated because of personal belief exemptions was observed from 1991 to 2004 (7). Increases in the proportion of persons declining vaccination for themselves or their children might lead to large-scale outbreaks in the United States, such as those that have occurred in other countries (e.g., United Kingdom and Netherlands) (10). Ongoing measles virus transmission has been eliminated in the United States, but the risk for imported disease and outbreaks remains. High vaccination coverage in the United States has limited the spread of imported measles in 2008. Nevertheless, the measles outbreaks in 2008 illustrate the risk created by importation of disease into clusters of persons with low vaccination rates, both for the unvaccinated and those who come into contact with them.

"Documented receipt of 2 doses of live measles virus vaccine, laboratory evidence of immunity, documentation of physician-diagnosed measles, or birth before

1957.

*** Institute for Vaccine Safety. Vaccine exemptions. Baltimore, MD: Johns Hopkins Bloomberg School Public Health; 2007. Available at http://www.vaccine safety.edu/cc-exem.htm.

*** CDC. Statistics and surveillance: immunization coverage in the U.S. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm.

References

1. Orenstein WA, Papania MJ, Wharton ME. Measles elimination in United States. J Infect Dis 2004;189(Suppl 1):S1–3.

2. De Quadros CA, Andrus JK, Danovaro-Holliday MC, CastileSolórzano C. Feasibility of global measles eradication after intern tion of transmission in the Americas. Expert Rev Vaccines 2008;7:355-62 .

3. CDC. Measles, mumps, and rubella-vaccine use and strategies f elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee Immunization Practices (ACIP). MMWR 1998;47(No. RR-8). 4. Farizo KM, Stehr-Green PA, Simpson DM, Markowitz LE. Pediatr emergency room visits: a risk factor for acquiring measles. Pediatr 1991;87:74-9.

5. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infec tion Control Practices Advisory Committee. 2007 guideline for iscla tion precautions: preventing transmission of infectious agents in heart care settings. Am J Infect Control 2007;35(Suppl 2):S65–164. 6. Parker AA, Staggs W, Dayan GH, et al. Implications of a 2005 meas outbreak in Indiana for sustained elimination of measles in the United States. N Engl J Med 2006;355:447-55.

7. Omer SB, Pan WK, Halsey NA, et al. Nonmedical exemptions school immunization requirements: secular trends and association a state policies with pertussis incidence. JAMA 2006;296:1757-63. 8. Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarus EJ. Processes for obtaining nonmedical exemptions to state immer zation laws. Am J Public Health 2001;91:645–8.

9. Smith PJ, Chu SY, Barker LE. Children who have received no vaccine who are they and where do they live? Pediatrics 2004;114:187-95. 10. CDC. Measles outbreak-Netherlands, April 1999–January 200 MMWR 2000;49:299–303.

Notice to Readers

Arthritis Awareness Month May 2008 May is Arthritis Awareness Month, an observance intended to focus attention on the substantial and growing proble of arthritis in the United States. Arthritis, the most com mon cause of disability in the United States, affects one i five adults and nearly 300,000 children (1-3). By the yea 2030, approximately 67 million U.S. adults will be affecte by arthritis (4), compared with an estimated 46 million during 2003-2005 (3).

The emphasis of this year's observance is on encouragin persons with arthritis to stay physically active. The U.S. Sur geon General has stated that regular physical activity is nec essary for everyone to maintain normal muscle strength, join structure, and joint function (5). Moderate physical activit is recommended for all children and adults with arthritis and walking might be one of the most accessible ways t become physically active. Walking is low impact, can be don almost anywhere and anytime, and requires only a good pa of shoes. For persons with arthritis, walking might be counter intuitive when joints hurt; however, it is a safe, effective, and

nderused intervention that helps reduce joint pain, rengthen joints, and improve joint function. The CDC Arthritis Program helps fund state arthritis ograms designed to increase the quality of life among rsons affected by arthritis by implementing recommenitions in the National Arthritis Action Plan: A Public Health rategy (6). The program also promotes progress toward hieving the arthritis-related objectives in Healthy People 10 (7). Information about physical activity and self-manement education programs for adults with arthritis is ailable from CDC at http://www.cdc.gov/arthritis/ tervention/index.htm. Additional information about rthritis Awareness Month activities is available from the rthritis Foundation online (http://www.arthritis.org) or telephone (800-568-4045).

eferences

CDC. Prevalence of disabilities and associated health conditions among adults-United States, 1999. MMWR 2001;50:120-5.

CDC. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2003-2005. MMWR 2006;55: 1089-92.

Sacks JJ, Helmick CG, Luo YH, Ilowite NT, Bowyer S. Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001-2004. Arthritis Rheum 2007;57:1439–45.

Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum 2006;54:226–9. CDC. Physical activity and health: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 1999. Available at http://www.cdc.gov/nccdphp/sgr/sgr.htm. Arthritis Foundation, Association of State and Territorial Health Officials, CDC. National arthritis action plan: a public health strategy. Atlanta, GA: Arthritis Foundation; 1999. Available at http://www.cdc. gov/nccdphp/pdf/naap.pdf.

US Department of Health and Human Services. Healthy people 2010 midcourse review. Washington, DC: US Department of Health and Human Services; 2006. Available at http://www.healthypeople.gov/data/ midcourse.

Notice to Readers

Annual Conference on Assessment Initiative August 18-20, 2008

The Annual Conference on Assessment Initiative, sponsored by CDC, will be held August 18-20, 2008, in Atlanta, Georgia. This meeting will focus on sharing information on innovative systems and methods that improve the way data are used for public health programs, services, and policies at the local and state levels. Sessions will address data dissemination, health assessment research, applied data analysis, presentation techniques, and community healthassessment processes and outcomes.

Participants will include staff members from local and state health departments, federal agencies, and community organizations interested in the collection, analysis, and dissemination of data for community health assessments. Conference attendees can register online at http://www.ppleventreg.com/ events/hhs/index.php?id=19; the deadline for online registration is August 4, and no registration fee is charged. The deadline for making reservations with the Sheraton Atlanta Hotel is July 14 (at the conference website or by telephone, 800-833-8624 or 404-659-6500).

Abstracts for the poster session are due by July 18 and should be e-mailed to Nelson Adekoya at nba7@cdc.gov. Abstracts should be a maximum of 250 words and clearly state the purpose of the poster. Topics of interest include approaches to assessment, impact and outcome of community health assessment, systems and approaches used for data dissemination, community partnerships, and statistical methods used in assessment. A maximum of 40 abstracts will be accepted, and applicants will be notified of acceptance by August 1. Additional information regarding the Assessment Initiative is available at http://www.cdc. gov/ncphi/od/ai.