acute and chronic disease patterns. CDC also monitors nationwide and international trends that have national implications.

In some cases, outbreaks can be sudden, with deadly effects (see Box 4–1). A single case of meningococcal meningitis, for example, can prompt emergency drills to identify the scores of people with whom the victim came in contact before falling ill so that each can be given immediate antibiotic therapy (Altman, 1999). To counter this threat, the Advisory Committee on Immunization Practices (ACIP) has urged the 520,000 college freshmen who live in dormitories to consider receiving the meningococcal vaccine, even though the vaccine is not expected to prevent more than a few dozen actual cases.

Disease prevention and control efforts are different from the treatment of disease itself. The latter generally falls within the domain of personal medical services and is covered by insurance; personal payments; managed care organizations; and public funding programs such as Medicaid, Medicare, and the State Children’s Health Insurance Program (SCHIP). Disease prevention and control, on the other hand, is an intrinsic role of public health agencies, which look beyond individual health to address the risk to whole populations. The major means of evaluating the impact of most vaccine-preventable disease programs is reports of the occurrence of these diseases (Orenstein and Bernier, 1990; Wharton

BOX 4–1 Alaskan Measles Outbreak in 1998

In late 1998 an outbreak of 33 confirmed measles cases (ages ranging from 2 to 28 years) occurred in Anchorage, Alaska, including 17 cases among a highly vaccinated high school population (CDC, 1999g). Analysis of the outbreak revealed that Alaskan schools did not require students entering kindergarten or first grade to have two doses of MMR until September 1996. Consequently, in the high school setting of 2,186 students, about half (1,057 students, or 49 percent) had received one dose of MMR, and the remaining half (1,112 students, or 51 percent) had received two or more doses (only 1 of the students had not received at least one dose of MMR before the outbreak). The Alaskan Department of Health and Social Services issued an emergency order requiring all Anchorage schoolchildren to have two doses of MMR by early January 1999. By mid-November 1998, 98.6 percent of the almost 50,000 Anchorage students were able to produce such documentation. Although no endemic measles virus is currently circulating in the United States (the outbreak was traced to importation by a 4-year-old child visiting from Japan), health officials have observed that outbreaks may continue to occur when imported cases are introduced into settings such as schools with incomplete second-dose MMR coverage.

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