From 1989 through 1991, in the United States, the incidence of reported measles increased sixfold to ninefold over the median annual incidence (1.3 per 100,000 population) reported from 1981 through 1988. In 1990, the peak of the resurgence, the incidence of measles among children aged less than 5 years was 15-fold higher than the median 1981-1988 incidence (4.8 per 100,000) (1). During 1991, approximately 9500 cases were reported (Figure 1), including 4662 cases among children aged less than 5 years (CDC, unpublished data). The measles epidemic is a consequence primarily of the failure to vaccinate preschool-aged children at appropriate ages (2); among children aged 16-59 months who developed measles during this resurgence, only 15% had received measles vaccine as recommended (CDC, unpublished data). This report compares the number of public clinic vaccinations* (i.e., all measles-containing vaccines (MCV) **, diphtheria-tetanus-pertussis vaccine (DTP), and oral polio vaccine (OPV)) for 1988 with that for 1989-1991 in response to the measles resurgence.

During 1989-1991, state health departments reported a provisional total of 55,467 measles cases that resulted in a minimum of 11,251 known hospitalizations, 44,127 hospital days, and 166 suspected measles-related deaths. The resurgence of measles prompted collaborative efforts among federal, state, and local government agencies and private physicians and other private-sector groups to improve overall vaccination coverage among preschool-aged children. Records of vaccine doses (MCV, DTP, and OPV) administered to preschool-aged children in public clinics are reported to CDC by age group by the 63 immunization projects in the United States and its territories for all publicly purchased vaccines. For this report, assessment of the response to the resurgence of measles was limited to vaccinations administered through the public sector (i.e., federally, state-, and locally funded clinics).

Doses of MCV, DTP, and OPV provided in public clinics in 1988 were compared with doses provided annually from 1989 through 1991 (Tables 1 and 2). Among children aged 12-23 months, *** the number of doses of MCV administered each year increased substantially after 1988. In 1991, the number of doses administered to children aged 1 year was 42% higher than in 1988. The estimated proportion of all children aged 12-23 months who received MCV through public clinics also increased, from 25% during 1988 to 33% during 1991. During 1989-1991, doses of MCV administered in public clinics increased (mean: 59%) in the 10 immunization projects with the largest measles outbreaks during these years; however, vaccination also increased (mean: 38%) in immunization project sites that did not have large measles outbreaks. In addition to increases in MCV vaccination, doses of DTP and OPV administered to children aged less than 12 months increased (DTP increased 26% and OPV, 22%). Overall, during 1989-1991, doses of MCV, DTP, and OPV administered to all preschool-aged children increased at a similar level.

Reported by: Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that since 1988, a steadily increasing number of doses of MCV, DTP and OPV have been administered to children at the appropriate age through public-sector vaccination programs. Moreover, these increases also occurred in areas other than those in which measles outbreaks occurred during 1989-1991.

Although the incidence of measles began to decrease during 1991, intense publicity efforts about the need for preschool vaccination continued, and the greatest number of doses of all three vaccines were administered that year (Figure 1). The reasons for the improved vaccination performance of the public sector reflect, in part, collaborative public- and private-sector efforts to 1) educate and motivate parents to ensure their children are vaccinated at recommended ages and 2) assure that providers both reduce barriers to vaccination and take advantage of all opportunities to vaccinate.

Some of the increase in vaccinations since the resurgence of measles also might reflect a shift in vaccine delivery from the private to public sector. A recent survey of physicians in Dallas suggested they were referring substantially more patients to public clinics where vaccines were available free or at nominal charge because these patients could not afford vaccination in the private sector (4). In particular, from 1982 through 1992, the price of vaccines to fully vaccinate a child increased approximately 10-fold in the private sector -- in part, because the Advisory Committee on Immunization Practices and the Committee on Infectious Diseases of the American Academy of Pediatrics now recommend 17-18 doses of different vaccines, compared with 10 doses in 1982 (5). Much of this increased cost must be borne by the parent since, as of 1990, only half of the traditional employer-based indemnity plans provided reimbursement for childhood vaccination (6).

During 1991, although approximately 400,000 more children were vaccinated against measles at the appropriate age than in 1988, only 33% of these 1-year-olds may have been vaccinated against measles at the recommended age in public clinics -- a percentage substantially lower than the estimated 50% of children traditionally served by the public sector. Major sustainable improvements in vaccination programs are still needed to meet the national health objective for the year 2000 to completely vaccinate 90% of children by their second birthday (objective 20.11) (7).

During the next several years, as children vaccinated during 1989-1991 enter school, vaccination records will become available for public health agencies to assess whether the increases in vaccine administered in the public sector were associated with overall increases in vaccination levels of preschool-aged children.

References

1. Gindler JS, Atkinson WL, Markowitz LE, Hutchin SS. The epidemiology of measles in the United States in 1989 and 1991. Pediatr Infect Dis J (in press).

2. National Vaccine Advisory Committee. The measles epidemic: the problems, barriers and recommendations. JAMA 1991;266:1547-52.

3. CDC. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989;38(no. S-9):7.

4. Schulte JM, Brown GR, Zetzman MR, et al. Changing immunization referral patterns among pediatricians and family practice physicians, Dallas County, Texas, 1988. Pediatrics 1991;87:204-7. 5.fOrenstein WA. Future directions. In: Proceedings of the 26th Immunization Conference. St. Louis: June 1-6, 1992 (in press). 6.Sullivan CB. Health insurance picture in 1990. Washington, DC: Health Insurance Association of America, 1991; HIAA publication no. 199ORB.

5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122-3; DHHS publication no. (PHS)91-50213.

• National data on vaccination coverage are not available to assess the overall impact of recent private- and public-sector vaccination efforts. However, response of the public sector (federally, state-, and locally funded clinics) could be evaluated because records of vaccine doses administered in public clinics to preschool-aged children are reported to CDC. ** Data includes doses administered of measles-mumps-rubella, measles-rubella, and measles vaccines. *** Measles vaccine is usually recommended for children aged 12-15 months depending on local policy (3).

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