BOX 1–3 The Measles Epidemic, 1989–1991

Measles reached a record low in 1983 (1,497 cases), a 97 percent reduction from the more than 57,000 cases reported in 1977. The Carter Administration’s Measles Elimination Program had the goal of eradicating measles in the United States by 1982. However, measles was not eliminated, and this success was not sustained. In 1984 and 1985, outbreaks occurred among older children, including college-age youth who had entered school before the vaccine was in routine use. A new pattern emerged in 1986 when outbreaks occurred among preschool age children and were concentrated in inner city, low-income neighborhoods in 20 U.S. counties.

Sporadic outbreaks of disease became a measles epidemic between 1989 and 1991. During 1989 more than 18,000 cases and 41 deaths were reported, rising to an additional 25,000 cases and at least 60 deaths in 1990 (CDC, 1991). With a reservoir of unimmunized and underimmunized preschool-aged children, the disease spread rapidly through several cities, including Chicago, Houston, and Los Angeles, which accounted for one-third of all cases in 1989. CDC’s findings on selected cities (Chicago, Dallas, Los Angeles, Milwaukee, and New York) were used to develop a response to contain the epidemic, as well as new strategies to raise immunization rates. CDC found that half of the children who had had measles were not immunized, even though many of them had seen a health provider. Researchers dubbed these visits “missed opportunities” for immunization, and reducing missed opportunities became a priority. CDC also found that more than one in five of the unvaccinated children who contracted measles were also enrolled in Aid to Families with Dependent Children (AFDC), Medicaid, or the Supplemental Nutrition Program for Women, Infants, and Children (WIC). It became clear that underimmunized children could be identified through other publicly funded programs, and CDC developed demonstration projects to improve immunization levels among WIC clients.

While CDC conducted the laboratory and epidemiological studies of the measles epidemic, the federal response to the epidemic also was shaped by a new force in policy analysis, the National Vaccine Advisory Committee (NVAC). Created by Congress in 1986 as part of the National Vaccine Program, this body was designed to be an independent advisor to the Assistant Secretary for Health. By 1990, an active group of advisors had been appointed by the Bush Administration, and the measles epidemic led them to take unprecedented leadership (A Shot in the Arm for Vaccine Advocates, 1990). With the support of CDC and National Vaccine Program Office (NVPO) staff, NVAC prepared a measles white paper, which made key recommendations for responding to the measles epidemic (National Vaccine Advisory Committee, 1991).

Following release of the white paper, a federal Interagency Coordinating Committee was formed to outline an implementation plan involving eleven federal agencies. This committee met on a quarterly basis for 18 months, creating a “Public Health Service Action Plan to Improve Access to Immunization Services.” In testimony before the Senate Appropriations Committee in June 1991, Dr. William Roper, Director of CDC, stated that the measles “epidemic still affects predomi

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