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Update: Rashes Among Schoolchildren—27 States, October 4, 2001–June 3, 2002
Arch Dermatol. 2002;138:1391-1392.
SINCE OCTOBER 2001, a total of 27 states has reported investigations
of multiple groups of schoolchildren who have developed rashes. Rash illnesses
among schoolchildren in 14 states were reported in March1; since
the initial report, rashes have been reported in 13 additional states (Alabama,
Alaska, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts,
Minnesota, Missouri, New Hampshire, and New Jersey). Rashes also have been
reported among schoolchildren in Canada. The investigations have not identified
a common source for the reported cases of rashes among U.S. schoolchildren.
This report summarizes available data on these rashes and provides examples
for three states. CDC is continuing to monitor reports of rashes and is providing
technical assistance to state and local health departments investigating these
reports.
United States
Although rashes among schoolchildren are common, public concern has
been growing because of the number of simultaneous cases reported in schools
across the United States. During October 2001–May 2002, rashes among
groups of students were reported in approximately 110 U.S. elementary, middle,
and high schools. The number of students affected in each school ranged from
five to 274; the proportion of students affected ranged from <1% to 47%.
The sex distribution of cases varied among the schools, ranging from 33% to
100% female. Rashes varied by presentation, location on the body, and duration.
Most affected children were reported as having (1) a pruritic, sunburn-like
rash that appeared on the cheeks and arms, (2) a burning sensation on the
skin that might be associated with pruritis, or (3) a hive- or nettle-like
reaction that was observed moving from one part of the body to another. Rashes
tended to be self-limiting and ranged in duration from <1 hour to >1 month.
Because of the transient nature of the rashes, most children who were evaluated
were seen by school nurses; some children who had recurring or persistent
rashes were seen by dermatologists. Accompanying signs and symptoms such as
conjunctivitis, fever, vomiting, sore throat, or headaches were absent in
all but a few cases. The etiology of the rash illnesses remains unknown in
several states. Alaska, Illinois, Kentucky, Minnesota, Mississippi, and New
York have received reports of cases associated with parvovirus B19, and other
states have investigated small reports of rash illness that appear to be primarily
psychogenic in response to a child with a diagnosed rash or infection.
Case Reports
New York
On March 8, 2002, the New York State Department of Health (NYSDOH) sent
a notice to local health units and school superintendents across the state
to increase awareness and reporting of outbreaks of rash illness. At the time,
NYSDOH and a county health department were following an ongoing outbreak of
rash illness, which began in January and by April 2 involved 242 (7%) elementary-
and middle-school students in a school district with 3,371 children. No fevers
or other major signs and symptoms were reported to accompany the rashes, and
no rash illness was reported among employees in affected schools. To assess
the outbreak, school nurses selected a sample of affected students with active
rashes from five elementary schools and one middle school; 17 children with
rashes were interviewed on April 2 and evaluated by a team of health-care
providers by physical examination, serology for parvovirus B19, and viral
cultures of throat and stool specimens. Dates of rash onset for these 17 children
ranged from March 11 to April 1. Of the 17 children interviewed, 12 (71%)
were females. The ages of the students ranged from 5-13 years (mean: 9 years).
Five (29%) children reported having had symptoms (e.g., fatigue, stuffy nose,
and sore throat) that occurred within 4 days before rash onset. Of six (35%)
children who reported that another family member had a rash, four (67%) had
family members whose rashes occurred before the child's rash onset, and two
(33%) had family members whose onset followed the child's rash. Fifteen (88%)
children reported their rashes to be itchy; of these, nine (60%) children
reported no association with time of day or place. Three (18%) of the 17 children
that were interviewed reported having a low-grade fever (i.e., <100.3°F
[37.9°C]), nine (53%) children reported that the rashes were warm to the
touch, eight (47%) children associated the rashes with a burning sensation,
and 13 (77%) children reported that the rashes reappeared; information for
one child was not recorded. Five (29%) children had rashes that began on the
face and nine (53%) children rashes that began on the extremities or stomach
before spreading; two (12%) children had rashes that did not spread. On examination,
health-care providers described the rashes as maculopapular in 13 (77%) cases,
lacy and reticular in 14 (82%) cases, and morbilliform in six (35%) cases.
All 17 children submitted specimens for viral studies; 16 (94%) had negative
viral throat cultures, and one was positive for influenza A. Stool specimens
were submitted by nine children; all were negative on viral culture. Human
parvovirus B19 antibody assays were performed on 14 children; 13 (93%) were
positive for IgM antibodies, and 14 (100%) were positive for IgG antibodies.
The results of this investigation support the conclusion that the outbreak
was due to parvovirus B19, which causes erythema infectiosum (i.e., fifth
disease).
Georgia
During January, the Georgia Division of Public Health received a report
that 12 students from an elementary school had developed pruritic rashes in
a single day; 10 children were in the same class. Dermatologists who examined
all 12 children diagnosed the rashes as contact dermatitis. The rashes resolved
by the next day, and no additional cases occurred. The school cleaned the
classroom on the day the rashes occurred, including vacuuming the carpet,
washing table tops, and wet dusting all surfaces. The school nurse determined
that the pruritic rashes were the only sign or symptom; one child had a history
of a preceding illness (a cold the previous week). The onset of rash illnesses
began after one child developed a pruritic eczematic rash on one arm. After
several minutes, a second child complained that her arm was itching; within
the hour, eight children seated at the same table also were scratching their
arms and complaining about rashes. A child from another classroom reported
a pruritic rash after sitting with the other children at lunch; another child,
also from another class, reported a rash after seeing the index child in the
school clinic. Although environmental or allergic exposure cannot be ruled
out, the school nurse's description suggests that all the rashes (with the
exception of the index case) were caused by scratching secondary to observing,
encountering, or interacting with the child with the eczematic rash.
Missouri
During February 5–March 19, a total of 33 (21%) students with
rash illness was reported in a rural elementary school with 161 students;
12 (36%) of the 33 affected students sought medical care. The illnesses were
mild and lasted a median of 4 days (range: 6 hours–14 days). Of the
71 children in kindergarten through fourth grade, 25 (35%) were affected.
Most affected students had rashes limited to the hands and forearms, but five
(15%) children had rashes that were generalized or involved the face; five
(15%) children had pruritic rashes. Dates of rash onset were February 19 for
six cases and February 28 for 12 cases; these 18 cases accounted for 55% of
cases among students. However, single cases continued to be reported as late
as March 19. Of the 33 cases reported, 23 (70%) occurred among girls. Two
siblings developed rashes 4 days apart; no other rashes among family members
were reported to the school nurse. Contact dermatitis was the most likely
explanation for most cases, possibly from frequent use of hand cleaners and
alcohol-based sanitizers or from surfaces cleaned with ammonia-based products.
Other possible etiologies offered by clinicians for these rashes included
scabies, dry skin, and parvovirus B19 infection; however, none of these diagnoses
was confirmed.
Public Health Response
Despite public perceptions that all rash cases are inter-related, even
in a single school, children's rashes can result from a variety of etiologies,
including medications, dry or sensitive skin, eczema, allergies, viral infections,
and psychogenic or environmental factors. Investigations have identified cases
for some of the rashes reported. In other cases, the etiology remains unknown.
CDC is continuing to monitor reports of groups of schoolchildren with
rashes and is providing technical assistance to state and local health departments
investigating these reports. In addition, CDC is receiving public inquiries
from adults (with or without exposure to children) who suspect they might
have a related rash. These public inquiries are forwarded to state or local
health departments for follow-up.
CDC Editorial Note:
Rashes reported in schools have affected school policies and practices.
Normal school operations were disrupted when students were moved or evacuated
from their classrooms, and the costs of conducting environmental assessments
have added a financial burden. In the absence of an identifiable etiology
for the rashes, many school administrators and board members had to consider
whether short-term school closures were warranted and to decide if children
with rashes should be excluded from school or if children without rashes should
be permitted to stay home from school.
Schools that identify groups of students and/or staff with rashes should
report cases to their state or local health department to determine what kind
of investigation should be conducted to ensure that no identifiable hazards
exist within the school setting. To assist with these efforts, CDC has developed
and distributed to health departments a document with suggested approaches
for investigating reports of rashes among groups of schoolchildren. In particular,
efforts should be made to (1) collect uniform information from affected persons
so cases of rashes reportedly associated with school settings can be differentiated
from rashes occurring from other causes; (2) monitor reported cases to ensure
that the rashes have resolved; (3) determine whether similar rashes are occurring
among household members who have not been exposed to the school setting; and
(4) confirm that no other associated signs and symptoms are occurring or developing
subsequent to the rashes.
When accompanied by other signs and symptoms, rashes can be an important
indicator of serious health conditions; however, few schoolchildren with rashes
had any accompanying signs and symptoms. The level of parental concern and
media attention elicited by reports of rashes among schoolchildren underscores
the need for continuing investigation.
MMWR. 2002;51:524-527.
2 references omitted
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