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Comparative Measles Incidence among Exposed Military and Nonmilitary Persons in Anchorage, Alaska

Military Medicine, Jul 2004 by Glover, Danny J, DeMain, Jeffrey, Herbold, John R, Schneider, Paula J, Bunning, Michel

An outbreak of measles that occurred in Anchorage, Alaska, in 1998 resulted in 33 diagnosed cases: 26 were laboratory confirmed and 7 were clinically confirmed. Twenty-nine (88%) of 33 cases occurred in individuals who had not been immunized with at least two measles-mumps-rubella (MMR) vaccinations; 25 (76%) of 33 occurred in school-age children, 0 to 19 years of age. This study identifies the difference in the incidence of measles between the civilian school-age population, who was not completely immunized (two MMR vaccinations given at least 30 days apart), and the military dependent population who had been completely immunized. All cases occurred among civilians, and most (25 of 33 confirmed cases) were associated with school attendance. The authors conclude that a two-dose regimen of MMR vaccine is required to adequately protect individuals against measles.

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Introduction

Anchorage, Alaska, experienced the largest measles outbreak in the United States from September through November 1998. From January 1 through September 18, 1998, only 50 cases of measles had been reported to the U.S. Centers for Disease Control and Prevention (CDC) for the entire United States.1 Reported cases from the Anchorage outbreak totaled 33, which included 26 laboratory confirmed and 7 clinically confirmed cases. Nine other reported cases were considered probable, but were not confirmed. The disease was introduced into the Anchorage metropolitan area in mid-August by a 4-year-old Japanese tourist. This case was confirmed by laboratory testing.2 During the period from September through November 1998, the illness spread; 29 (88%) of 33 confirmed cases occurred in persons who had received only one measles-mumps-rubella (MMR) vaccination before exposure, one case occurred in an individual with two MMR vaccinations before exposure, and three cases had unknown vaccination histories. Twenty-five (76%) of 33 cases were observed in school-age children and were associated with exposure at school.

This report looks at the distribution of measles in the Anchorage, Alaska, outbreak and the incidence rates observed in those with and without access to military health care. No cases of measles were diagnosed in the military population, which was defined as active duty, retirees, and dependents of active duty and retirees. We conclude that the prevention of measles was associated with complete immunization (at least two injections administered at least 30 days apart) before exposure. To accurately compare similar populations, this study is limited to the school-age and younger civilian and military dependent populations.

Background

Measles is a highly contagious viral disease caused by rubeola virus (a member of the genus Morbiilwirus of the family Paramyxovindae). The disease is characterized by fever, cough, conjunctival injection, coryza, an erythematous maculopapular rash, and a pathopneumonic lesion on the buccal mucosa (koplik spot). Complications include pneumonia, laryngotracheobronchitis, diarrhea, and acute encephalitis with resultant neurological sequelae. Fatality occurs in 1 to 2 of 1,000 cases as a result of pulmonary or neurological complication. Young children, nonimmunized individuals, and individuals who have a compromised immune system are at highest risk.3

This vaccine-preventable disease has been controlled in the United States since 1968 by widespread childhood immunizations, which are usually administered as a MMR vaccine. Protective immunity can be attained in children by administering two injections of the vaccine, with the first dose recommended at 12 to 15 months of age and the second dose at 4 to 6 years of age. Immunity in older persons is attained by two shots at least 30 days apart. This vaccination schedule is known to prevent illness from measles and has also proven effective in stopping outbreaks of measles if administered to a susceptible population.

Populations Defined

The susceptible population in the Anchorage, Alaska, outbreak was defined as persons who had not received a complete immunization (i.e., had not received at least two vaccinations) before the outbreak. Before 1996, Alaska did not require a second MMR for entry into primary school; many school-age children in Anchorage had not completed a two-shot series. Persons who lacked documentation of complete immunization were predominately individuals who received their health care from nonmilitary delivery systems. Civil service employees do not have access to the military health care delivery system unless they are military retirees. Most individuals who had access to the military health care delivery system had documentation of complete immunization in their records. Complete immunization or infection of susceptible persons occurred within 3 months, the duration of the outbreak.

The most susceptible population in Anchorage and the surrounding area was school-age and younger persons. The population of Anchorage in the 0- to 19-year age group is reported to be 84,025, according to the 19XX census data.4 The military community in the Anchorage area consists of members of the Air Force, Army, Marines, Navy, and Coast Guard. The number of military dependents of active duty and retired personnel between the ages of O and 19 years is reported to be 10,658 (Table I).

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Comparative Measles Incidence among Exposed Military and Nonmilitary Persons in Anchorage, Alaska

Military Medicine, Jul 2004 by Glover, Danny J, DeMain, Jeffrey, Herbold, John R, Schneider, Paula J, Bunning, Michel

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