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)