Cui Gang, director of the Ministry of Health's Vaccination
Management Department, received an e-mail from Lisa A. Lee, EPI
coordinator from the World
Health Organization representative in China on April 12, 2004.
Lee said that five US states had confirmed cases of measles in
children adopted in China and taken abroad. Investigators had
determined that nine of the 12 adopted children from two orphanages
in Hunan
Province had a measles-like rash illness, four of whom had been
serologically confirmed to have measles. Two other cases were
confirmed later.
Lee noted that the US was concerned about the cases because
measles is no longer endemic in the country.
China has 200 welfare centers involved in international
adoptions, most of which are located in Guangdong, Guangxi,
Jiangxi, Hunan, Hubei and Anhui provinces and Chongqing
Municipality.
The affected children in the April measles case had come from
two institutions: the Zhuzhou and Chenzhou Beihu District
orphanages. The adoptive parents and children spent 10 days
together and returned to their homes in five different US states on
the same day. The US Centers for
Disease Control and Prevention (CDC) determined that there had
been a measles outbreak in one of the orphanages and recommended
that adoption proceedings of children in that facility be suspended
temporarily.
The US saw a similar outbreak of measles among children adopted
in China in 2001, when 13 cases were confirmed serologically among
adopted children. Since then, measures have been taken by the
United States and China to control and prevent measles
transmission.
When the Hunan Provincial Health Department received the measles
bulletin from the Ministry of Health, it dispatched investigators
to the two orphanages involved.
The investigation confirmed the existence of 16 measles cases
from March 20 to April 3, 2004, at Zhuzhou Orphanage. A
10-month-old infant was confirmed as the first case. No new cases
had been reported since April 4. All 16 children were girls aged
seven to ten months, living in two rooms on the same floor of the
orphanage.
Investigators believe that the nine adopted children diagnosed
or suspected of having measles were infected while they were at
Zhuzhou Orphanage and became symptomatic after their arrival in the
US. Four were probably infectious while traveling from China to the
United States
According to the Hunan Provincial Disease Control and Prevention
Center, there were 812 confirmed measles cases in the province from
January to April 2004, a rise of 107.7 percent from the same period
in 2003.
Orphanages failed to vaccinate
Investigators determined that failure to vaccinate the children
was the cause of the measles outbreak at Zhuzhou Orphanage.
Zhang Hongxia, the facility's director, and Shi Xiangqun,
director of Chenzhou Orphanage, admitted that none of the 12
orphans had had measles vaccinations before traveling to the United
States.
Children are required by regulation to be vaccinated against
seven diseases: whooping cough, measles, diphtheria, polio,
tuberculosis, tetanus and hepatitis B. Social workers report that
children in orphanages are often weak and susceptible to diseases,
making inoculation extremely important.
Like other provinces in China, Hunan is required to cover the
cost of the vaccinations, but Zhang Hongxia and Shi Xiangxun both
admitted that lack of funds was not the reason for the failure to
inoculate the children. Chenzhou Orphanage, for example, receives
more than 2 million yuan (US$241,487) for daily expenses each
year.
Zhang Hongxia explained that they postponed the vaccine in the
first case of measles because of the illness. Then the nurse who
was responsible for vaccinations went on maternity leave without
going through a formal handing-over of the duty.
Shi Xiangqun explained that vaccinations should be given to
children in March, which was the period of SARS. They decided to
inoculate the children with gamma globulin for fear of fever caused
by the measles vaccination. "The gamma globulin is very expensive.
We spent 20 yuan (US$2.42) for each injection," Shi said.
Both directors asserted it was the first time they had failed to
inoculate orphans.
But the investigation revealed that the medical team at Chenzhou
Orphanage lacks work experience. They used iodine to clean the
vaccination sites after giving the measles injections, which
rendered the vaccine useless.
Wang Guoliang, vice director of Lusong Epidemic Prevention
Station in Zhuzhou City, said that the Zhuzhou Orphanage bought 700
doses of vaccine from the station. However, orphanage records make
few mentions of the vaccine at all.
No one takes responsibility
Welfare centers such as orphanages are under civil
administration. The local epidemic prevention department should
oversee vaccinations in these institutions. Shi said, "I have been
working here for two years. Nobody has come to help us with the
vaccinations. On April 20, I met some experts from Epidemic
Prevention Center for the first time when they were investigating
the measles outbreak."
The Chenzhou Orphanage is under the authority of the Beihu
District Epidemic Prevention Station. Since there is only one
orphanage in Chenzhou, the city's Disease Control and Prevention
Center should also be responsible for vaccinations in the
orphanage. However, each organization thought the other was taking
responsibility.
The final investigation report on the case also indicates that
none of the orphans had been vaccinated against tuberculosis.
Controls being implemented
Since the measles outbreak in Hunan Province, vaccinations have
been administered to the children who failed to receive them.
Zhou Yiping, an official from the provincial disease control and
prevention center, promised that orphans from the epidemic-stricken
area won't be sent abroad. At the same time, he reminded foster
parents to watch adopted children for 21 days before taking them
abroad.
On June 4, the US CDC issued an update on the incident, saying
that no new cases had been reported since April, and all the ill
persons had recovered without complications. The CDC recommended
that the temporary suspension of adoptions from Zhuzhou Orphanage
be ended and that standard adoption procedures be resumed.
The Ministry of Finance recently announced that the government
would cover costs of children's vaccinations, including both actual
injections and any treatment for side effects. The cost of this
program is estimated at 5 billion yuan (US$604 million) annually.
No implementation date for the program was provided.
(Dongfang Morning Post, translated by Wu Nanlan for
China.org.cn, June 25, 2004)