Measles and Rubella Outbreak During Hajj, Security Forces, Makkah, 1996

In April 1997 (Dhul Qu'edah 1417 H), the Preventive Medicine Department (PMD) of the Makkah Health Directorate received a report of four cases of measles among police cadets from the Security Forces Hospital (SFH) in Makkah. PMD asked the Field Epidemiology Training Program team to investigate the extent and reasons for clustering of the cases.

We defined an outbreak associated case of measles as a febrile illness (>38.3 °C) with generalized maculopapular rash of three or more days duration, cough, coryza, or conjunctivitis occurring between 29 March and 9 April 1997 (20 Dhul Qu'edah to 2 Dhul Hija 1417 H).

We defined a case of rubella as mild fever, with a diffuse maculopapular rash and post auricular, occipital and posterior cervical lymphadenopathy with or without headache, malaise, mild coryza, and conjunctivitis occurring between 29 March and 9 April 1997 (20 Dhul Qu'edah to 2 Dhul Hija 1417 H).

From the SFH medical records five cases of measles and four cases of rubella were identified. The infection was serologically confirmed in all cases of rubella (IgM index of 1,000 or greater) and in one case of measles (IgM positive); the other four cases of measles were clinically diagnosed and showed Koplick's spots. The affected cases for both measles and rubella range from 20 to 31 years. Measles appeared first in one cadet, who had arrived from eastern province (EP) 2 days earlier. Rubella appeared first in one cadet stationed in the EP followed by three cadets stationed in the southern region (SR)(Figure 1). All cadets infected with rubella from SR had direct contact with the case from the EP. All cases of measles of measles and rubella were discharged with no complications.

For Hall, 500 cadets lived together in a large building 2400 sq. m. in Arafat. This area has 24 fans, numerous windows, and two main gates. The cadets sleep on bunk beds spaced half meter apart. Although cases with measles did not sleep in adjacent beds, they were in close contact at meal times and during training or leisure time. A total of 600 contact cadets were vaccinated against measles and rubella with MMR vaccine. Cadets, who were certain that they acquired natural measles or rubella infections were not vaccinated.

In 1995, a total of 41 cases of rubella occurred among security forces from Riyadh City that worked during Hajj, Following the appearance of two cases of rubella in two policemen about six weeks before Hajj season [1]. The public health surveillance in Madina, a Hajj associated area detected many cases of measles among policemen following the Hajj season of 1995.

Military barracks, colleges and universities are the most frequently reported setting of transmission of measles for persons 18 years of age or older.

In countries with long history of measles and rubella control through extensive vaccinations, serologic evidence of immunity, documentation of two doses with live vaccine after the first birthday, or measles vaccination documented by a physician are required for entrance into colleges [2]. The Edmoston-Zagreb strain, used in Saudi Arabia since 1992, has been reported in the literature to be more in Saudi Arabia vaccination of children with MMR at age of 18 month was made compulsory only in unogenic than the Schwartz vaccine, which was used in Saudi Arabia be-tween 1974 and 1992 [2]. In S1991. However vaccination coverage rates varies between urban and rural areas, and has barely exceeded 80%. Moreover, the MMR is 95% efficacious at best conditions (secondary vaccination failure).

Unlike natural infections, live attenuated vaccines do not confer lifelong immunity; and in absence of exposure to the wild viruses, immunity wanes over the years [2].

There are serosurveys that document the rate for measles susceptibility among the security forces recruits. Currently there is no well-defined policy for ascertaining the vaccination status of newly recruited security forces in Saudi Arabia. Although it could be cost-effective in some situations, serological screening is not routinely recommended [3]. In absence of such a comprehensive vaccination program, intensified surveillance of measles and rubella among security forces, would remain the only effective measure to control spread of measles and rubella during Hajj.