Communicable Diseases and
Immune Deficiency Syndrome. A person is considered to have AIDS
if, in addition to HIV infection, s/he has one or more of 29 opportunistic
infections or a CD4 cell count (a measure of cells important to
the immune system) of 200 or fewer per cubic centimeter of blood.
Antibiotic A medicine
that fights bacteria.
Antiviral A medicine
capable of destroying or weakening a virus.
Bacteria Tiny, one-celled
organisms present throughout the environment; some cause disease.
Communicable disease A
disease that can be transmitted from one person or animal to another.
Epidemic The occurrence
of disease within a geographic area or population that exceeds that
HIV Human immunodeficiency
virus, a retrovirus that causes the body's immune system to deteriorate.
process by which a person or animal becomes protected against a
disease; also called vaccination or inoculation.
Infectious disease A
disease caused by an infectious agent; many are communicable.
of the brain and spinal cord that can result in permanent brain
damage and death.
Opportunistic infection A
serious and unusual disease (e.g., rare type of cancer or pneumonia)
that is virtually absent among people with a healthy immune system.
Outbreak Sudden appearance
of a disease in a specific geographic area or population.
Pandemic An epidemic
occurring over a very large area.
Sexually transmitted disease
A disease caused by any one of more than 25 infectious
organisms transmitted primarily through sexual activity.
Tuberculosis (TB) disease An
illness in which TB bacteria multiply and attack any part of the
body but usually the lungs; TB is spread through the air.
Vaccine A product
that produces immunity to a specific disease.
Virus A tiny organism
that multiples within cells and causes disease; viruses are not
affected by antibiotics, the drugs used to kill bacteria.
[APRIL 1, 2002] The term public health
may refer to (1) the well-being of the population as it pertains
to health and disease or (2) the broad system of policies, resources,
practices, and programs intended to protect, maintain, and improve
the health of the population. Both focus on the health of the population
as a whole with an emphasis on preventing illness and attention
to the range of factors (physical, behavioral, social, economic)
that contribute to poor health in the population.
Evolution of the Public Health System
The public health system in the United States began
in the early to mid-1800s in response to epidemics of such infectious
diseases as cholera, diphtheria, smallpox, and typhoid. Local health
agencies were created to carry out activities (including quarantine,
isolation, and vaccination) to control communicable disease. In
the late 1800s, state governments created state health boards and
agencies, recognizing that environmental and communicable disease
threats are not confined by local boundaries.
Communicable Disease Reporting
Infectious diseases still are one of the most common
causes of suffering and death, and they impose a significant financial
burden on society. Some diseases have been controlledor eliminatedthrough
prevention, antibiotics, and vaccines. But new diseases constantly
appear, and some known diseases are reappearing in forms that resist
In Michigan, physicians, clinical laboratories, primary
and secondary schools, child-care centers, and camps are required
to report to the local health department the occurrence or suspected
occurrence of any disease, condition, or infection identified in
the Michigan Communicable Disease Rules. Reportable conditions include
AIDS and HIV infection, chlamydia, diphtheria, gonorrhea, hepatitis,
measles, meningococcal disease, meningitis, syphilis, and tuberculosis.
Michigan health care professionals and laboratories also may report
any condition, disease, or infection they believe may threaten public
health. The following data on selected communicable diseases in
Michigan are from the Michigan Department of Community Health (MDCH)
unless otherwise specified.
Many diseases that once were common now are controlled
by vaccine. Smallpox was eliminated worldwide in 1977 and vaccination
against it no longer is recommended. Poliomyelitis has been eliminated
in the western hemisphere, and measles in the United States is at
a record low; the organisms that cause these diseases have not disappeared,
however, and they will reemerge if vaccination rates drop.
The federal Centers for Disease Control and Prevention
(CDC) Advisory Committee on Immunization Practices (ACIP) recommends
that all children born in the United States be vaccinated against
diphtheria, tetanus, pertussis, measles, mumps, poliomyelitis, rubella,
Haemophilus influenzae type b, hepatitis B, varicella (hereafter,
chickenpox), and pneumococcal disease. The 2001 National Immunization
Survey indicates that 70 percent of Michigan's two-year-olds were
fully immunizedthis is down from 77 percent in 2000. Recommended
immunizations for adults aged 65 years and older include a one-time
immunization against pneumococcal disease (including pneumonia),
a yearly flu shot, and a tetanus-diptheria vaccine every
In Michigan in 2001, there were only about 6,600 reported
cases of chickenpox and, for the first time, none of measles.
For reporting purposes, meningitis is grouped into
- Meningococcal disease includes meningococcal meningitis
(inflammation of the membranes surrounding the brain and spinal
cord) and meningococcemia (infection in the bloodstream).
- Bacterial meningitis pertains to types of bacterial
meningitis other than meningococcal disease.
- Viral meningitis is the most common form of meningitis,
but it is the least severe and usually resolves itself.
In Michigan from 1996 through 2001, the average number
of reported cases of meningococcal disease and other types of bacterial
meningitis were 67 and 203 cases, respectively. Reported cases in
the third category, viral meningitis, appear to increase in three-year
cycles: There were 1,561 cases in 1998 and 2,542 cases in 2001.
The bacteria and viruses that cause meningitis are
spread by direct contact with nose and throat secretions, usually
through kissing, coughing, sneezing, and sharing drinks, cigarettes,
and food. Children aged under four years and adolescents and young
adults aged 1524 are at higher risk than others for meningococcal
disease. A vaccine is available that can prevent some but not all
cases. In 1999 the ACIP recommended that (1) college freshman and
their parents be given information about meningococcal disease and
the benefits of vaccination, and (2) vaccinations be provided or
made easily available to freshmen who wish to reduce their risk
Early diagnosis and treatment of meningococcal disease
and other forms of bacterial meningitis are very important. Antibiotics
have decreased mortality rates from 60 percent in the 1930s to 1013
percent today, but people who recover may suffer permanent hearing
loss, kidney failure, or brain injury.
Tuberculosis (TB) is a communicable disease spread
through airborne respiratory secretions (droplets), usually from
a cough or sneeze. The bacteria may stay in the human body for many
years before causing active disease, and people who are infected
but not yet sick may take medicine so that they never develop it.
People who have the disease may be treated and cured, but if TB
patients do not take the medicine as prescribed, the bacteria may
become resistant to the medication. Sometimes the bacteria become
resistant to more than one drug (multi-drug resistant TB).
At higher risk than others are people aged over 65,
those with weakened immune systems (e.g., the homeless, alcoholics,
substance abusers, people with HIV/AIDS) and those born in countries
that have high TB prevalence.
Measures to prevent the spread of TB include limited
use of a vaccine in certain high-risk populations and testing/treating
people in regular contact with an infected person. Early detection
and treatment of infection reduces TB transmission to others.
National TB rates declined steadily from 1953 until
1985, when cases began to increase following a sharp cut in TB control
resources in the 1970s and the spread of HIV/AIDS in the 1980s.
Rates began to decline again after control activities were strengthened
in 1992. TB continues to grow globally, with 8 million new cases
a year; it causes 2 million deaths annually.
In Michigan the number of active TB cases has been
almost level since 1990; 331 cases were reported in 2001a
case rate of 3.3 per 100,000 population. Michigan's case rate for
TB consistently is lower than the national rate.
Sexually Transmitted Diseases
Sexually transmitted diseases (STDs) are common in
the United States. Women generally suffer more serious STD complications
than men, including pelvic inflammatory disease, ectopic pregnancy,
infertility, chronic pelvic pain, and cervical cancer from the human
papilloma virus. Blacks and Hispanics have higher rates of STD than
do whites. STD disproportionately affects adolescents and young
adults. In Michigan (2001 data),
- reported cases of chlamydia (30,499) are the highest
since reporting began, in 1993;
- reported cases of gonorrhea (17,121) have been
declining gradually; and
- reported cases of infectious syphilis (428) are
up, reflecting an outbreak in the Detroit area.
Several biological, social, and behavioral factors
contribute to the rapid spread of STDs, including
- the presence of only mild or no symptoms, resulting
in failure to seek treatment and unknowing transmission to others;
- the stigma associated with STDs and the general
reluctance of Americans to discuss sexual behavior;
- the poverty and marginalization of people in high-risk
behavior groups (e.g., sex workers, adolescents, prisoners, migrant
workers), which reduce their access to health care services; and
- alcohol and drug abuse, which may involve the exchange
of sex for drugs, anonymous sex partners, decreased motivation
and ability to use protection, and lack of interest in medical
Early STD detection and treatment is essential, and
behavior-change counseling is important to prevent recurrence and
spreading it to others.
Hepatitis A, B, and C are the most common types of
hepatitis, a viral liver disease. Vaccines are available to prevent
hepatitis A and B but not C.
- Disease caused by the hepatitis A virus (HAV) can
make people very sick but usually resolves within six months.
- Disease caused by the hepatitis B virus (HBV) is
more serious and can cause lifelong infection, cirrhosis of the
liver, liver cancer, liver failure, and death. It is spread from
person to person through blood or other body fluids and also may
be spread from an infected pregnant woman to her fetus. (It is
very important that pregnant women be tested for HBV so that if
necessary, a baby may be immunized at birth.)
- Disease caused by the hepatitis C virus (HCV) is
as serious as that caused by HBV. Hepatitis C usually is transmitted
through large or repeated exposures to bloodfor example,
through needle sharing among drug users. Consistent data are lacking
regarding the extent to which sexual activity contributes to HCV
transmission. Hepatitis C was discovered in 1989 and is called
the silent epidemic because it has received little
public attention. The number of documented cases is but a fraction
of the total number of individuals believed to be infected. As
many as 4 million Americans and 200,000 Michiganians may be infected,
and the majority of them are unaware of it and the risks it poses
to their health. Not only is it important to identify HCV-infected
persons so that they may be treated, but, from a public health
standpoint, it is critical to counsel them on ways to prevent
The 2001 hepatitis data for Michigan are as follows:
HAV, 327 cases; HBV, 618 (up from the average of 457/year in the
previous five years), and HCV, 4,451 (up dramatically from 339 in
Since reporting on Acquired Immune Deficiency Syndrome
(AIDS) began, in 1981, almost half a million Americans and nearly
22 million people worldwide have died of the disease. In the United
States, the number of new infections continues at about 40,000 a
year, and the estimated number of people living with HIV/AIDS has
increased to between 800,000 and 900,000. Racial and ethnic minority
groups are disproportionately affected by HIV/AIDS and now comprise
the majority of new human immunodeficiency virus (HIV) infections,
people living with AIDS, and AIDS deaths nationally and in Michigan.
An estimated half of all new infections nationally are among people
aged under 25.
HIV is communicable (capable of being transmitted)
and chronic (of long duration or slow progression). It is
spread through exchange of body fluids (blood, semen, vaginal secretions,
and breast milk), most commonly by sexual contact (vaginal, anal,
or oral) and sharing dirty needles during intravenous drug use.
Babies born to untreated HIV-positive women may be infected (perinatal
transmission), but the incidence is greatly reduced when pregnant
women adhere to specific therapies. Transmission from HIV-positive
blood transfusions is virtually nonexistent in the United States
today due to blood screening.
As of January 1, 2002, just under 10,500 people were
reported to be living with HIV/AIDS in Michigan, but the
estimated number is 15,500. The number of new HIV-infection
diagnoses is about 825 a year, down from about 1,100 cases annually
in 199597. Perinatal HIV transmission in Michigan dropped
from 19 percent in 1993 to 3 percent in 2000, and this is credited
to the state's quick adoption of U.S. Public Health Service guidelines
for maternal and neonatal Zidovudine use.
HIV deteriorates the body's immune system. Most people
with HIV look and feel healthy for years but can transmit the virus
to others. Previously, most developed AIDS, the most serious form
and final stage of HIV infection, but treatment advances that slow
the progression of the disease mean that more people are remaining
free of AIDS longer (but the effect's duration is unknown, and as
yet there is no cure for HIV or AIDS). The most widely used treatment
for HIV/AIDS is highly active antiretroviral therapy (HAART)combinations
of antiretroviral drugs. These therapies cost $1,000 to $1,500 a
month and require a rigorous regimen and high patient adherence
(1520 tablets daily with periods of fasting). Low-income patients
without adequate health insurance have access to drug therapy through
AIDS drug-assistance programs that are funded federally and administered
by the state.
Currently, avoiding certain behavior (or, put another
way, engaging in safe behavior) is the only way to prevent new HIV
infection. HIV-prevention programs attempt to elicit safe behavior
or reduction of risk; examples of programs include education and
information, abstinence programs, counseling for risk reduction,
needle-exchange programs, peer training, HIV testing (because counseling
accompanies it), support groups, and media campaigns. No vaccines
to prevent HIV infection currently are approved for use; progress
is being made, but an effective vaccine is still years away.
Generally, there is widespread public support for
community-oriented activities to prevent disease and promote health.
But opinion differs on how much funding should be allocated, which
problems should receive highest priority, and what strategies and
activities should be implemented. Conflict between individual rights
and the public interest, humanitarian and economic considerations,
religious and secular views, and global and local concerns complicate
policy decisions related to controlling and preventing many communicable
Investing in Public Health
In 1988 the Institute of Medicine Committee for the
Study of the Future of Public Health warned that public health
in the United States has been taken for granted, many public health
issues have become inappropriately politicized, and public health
responsibilities have become so fragmented that deliberate action
is often difficult if not impossible. Today, public health
professionals and advocates reiterate these concerns and assert
that investment in the public health system results in lower health
care costs in the long run.
Currently, economic decline has prompted state and
federal budget reductions, affecting monies available to support
public health efforts. But even in good economic times, state expenditures
for public health have dropped: In roughly 10 years, public health
spending has fallen from 2.29 percent of the Michigan budget to
2.02 percent in FY 200102. State and local government officials,
health care providers, consumers, insurers, and employers worry
about the state's commitment to the health of Michigan residents.
Funding for HIV/AIDS
In Michigan, FY 200102 budget cuts resulted
in a 3 percent reduction in funding for HIV/AIDS services and a
$600,000 cut from the $3 million originally set aside for HIV/AIDS
testing and counseling.
AIDS activists say that flat or decreased funding
is inadequate for prevention; the continuing number of new infections
indicates that current prevention efforts are not able to reach
everyone in need. They also point out that level funding for care
and support programs does not meet the growing need for services
as more people live longer with HIV/AIDS.
Conversely, the watchdog group, Citizens Against Government
Waste, maintains that federally funded HIV/AIDS programs are an
epidemic of waste, fraud, abuse and mismanagement and
duplication of funding. They propose that funding be redistributed
to areas where it would be more effective, such as vaccine research,
international efforts, and drug subsidies. AIDS activists and human
rights supporters caution that there continues to be a need for
a comprehensive response to HIV and AIDS that includes prevention,
care, treatment, and research.
Recent Michigan legislative action and policy shifts
intended to contain health care expenditures have fueled debate
over the allocation of resources and effectiveness of efforts. Two
examples are P.A. 209 of 2000 and the Michigan Pharmaceutical Initiative.
Public Act 209 eliminated the requirement for premarital
counseling of couples applying for a marriage license and requires
instead that they be given written educational materials on prenatal
care and on the transmission/prevention of venereal disease and
HIV infection. Opponents of this change argue that required counseling
was an opportunity to encourage risk-reduction behavior and provide
information on HIV and STD for many who otherwise would not get
the information, and they suggest that most individuals will not
read written materials. Supporters of the law contend that requiring
counseling was an ineffective use of prevention resources and placed
an unnecessary burden on the marriage-licensing system.
The legislature directed the MDCH to develop the Michigan
Pharmaceutical Initiative, a state-approved formulary (drug list)
from which prescriptions paid for by state-sponsored medical programs
must be selected. Opponents fear that only the least expensive drugs
will be on the list, and, depending on the patient, may not be as
effective as others or may have more serious side effects. AIDS
advocacy groups point out that treatment with combinations of antiretroviral
medications is very complex, and a drug formulary may restrict the
flexibility to make the adjustments patients need. The plan's supporters
contend that it will help the state to control rising drug costs,
and patients will be able to obtain prior authorization if an unlisted
drug is medically necessary.
Meningitis: The Power of Public Attention
The level of public concern about a particular health
problem often drives health policy and legislation. While deaths
from meningococcal disease are many fewer than from some other communicable
diseases (AIDS, hepatitis C), the sudden death of an apparently
healthy, young adult due to meningitis captures public attention,
raises fears, and stimulates a call for a response.
Public Act 163 of 2001 requires the MDCH to promote
dissemination of certain information about meningococcal disease
(and other vaccine-preventable diseases) to Michigan high schools
and colleges. Supporters point out that the legislation implements
some of the ACIP's recommendations. Some argue that the new law
does not go far enough, contending that all entering freshmen who
live in dormitories or residential halls should be vaccinated. Yet
the infection rateeven though it is higher than that of the
general populationstill is less than half the threshold that
the CDC recommends for initiating a meningococcal vaccination campaign.
Meanwhile, complacency regarding the HIV/AIDS epidemic
and lack of awareness about the spread of hepatitis C frustrate
public health officials and advocates who see a need for stronger
action on these issues.
Immunizations: Maintaining Public Health
Many of the advances against public health problems
are taken for granted, such as safe water and protection against
former epidemic diseases, but public health officials warn that
continuing vigilance is needed to preserve the gains that have been
won. The national increase in TB during the mid-1980s is attributed
in part to reduced TB control activities. Measles outbreaksfor
which effective vaccination is availablecontinue to occur
in populations where the immunization level is low.
Michigan law requires children to be inoculated before
or upon school entry against polio, measles, mumps, rubella, hepatitis
B, diphtheria, tetanus, pertussis, and, beginning with the 200203
school year, chickenpox, In addition, children entering sixth grade
or enrolling in a school for the first time must present documentation
that they have received, are receiving, or object to certain immunizations.
Schools must report student immunization status to public health
As a result of a supply shortage in the United States
for some childhood vaccines, the 2002 ACIP guidelines recommend
deferring some doses of tetanus, diphtheria, pertussis, and pneumonia
vaccines until the supplies have been restored. The CDC indicates
that the shortages may lead to increased illness and are a cause
for concern but not panic. Health providers are frustrated because
they see their attempts to increase immunization levels being undermined,
and they fear that parents will not return to get their children
immunized when the vaccines are available. Some providers call for
developing backup systems to guarantee adequate supplies in the
future, particularly when there is only one manufacturer of a vaccine.
They point out that money spent on vaccinations saves much more
in health care costs.
Sometimes concerns are raised about adverse effects
from vaccines. Some health professionals fear that these concerns
may threaten the gains made in immunization levels. They point out
that while no vaccine is entirely free from side effects, vaccines
are held to a higher standard of safety than other medicines, and
numerous studies demonstrate their safety and effectiveness.
Preventing STD, HIV, and Hepatitis C
Because STDs, HIV, and hepatitis C are transmitted
through sexual contact and/or injecting drug use, prevention strategies
Sexual Abstinence versus Safer Sex
Some people advocate abstinence-only education while
others promote both abstinence-based education and safer-sex education
(e.g., effective condom use). As evidence of the success of abstinence-only
education, Michigan Abstinence Partnership (MAP) supporters point
to Michigan's significant drop in its teen pregnancy rate since
the MAP began, in 1993.
Supporters of safer-sex education argue that Michigan's
declining teen pregnancy rate could be due to factors other than
MAP; they contend that it is a fact that many teens engage in sex
and, to prevent pregnancy as well as STDs and HIV, they should be
educated about how to protect themselves. Supporters of abstinence-only
education fear that teaching students how to engage in safer sex
promotes sexual activity; opponents point to evidence that after
being educated about condom use, youths do increase condom use but
not their sexual activity.
Supporters of abstinence-only education point out
condoms are not 100 percent effective (due to improper use, breakage,
and slippage) in preventing HIV and STDs and claim that promoting
condom use is misleading if not dangerous. Supporters of safer-sex
education respond that condoms do prevent transmission when used
correctly, and people who are sexually active should be taught to
use all the means available to protect themselves. They point to
the gonorrhea decline as evidence that safer-sex education programs
Syringe and Needle Exchange
Since intravenous drug users make up a sizable proportion
of HIV/AIDS and hepatitis C populations, prevention among this group
is vitally important in slowing transmission of HIV and HCV. Syringe/needle-exchange
programs are proven successful in reducing the risky behavior (sharing
dirty needles and syringes) among intravenous drug users, but such
programs rarely are supported with public funding because the risky
behavior involves illegal drug use. The two programs operating in
Michigan are supported by private funding. In support of public
funding, advocates point to the programs' success. Opponents argue
that the programs, by providing drug paraphernalia, are at the very
least evincing a benign view of illegal and destructive behavior
if not actually promoting it.
Individual Privacy and Disease Surveillance
All states require that AIDS cases be reported to
public health authorities, but only someincluding Michiganrequire
HIV cases to be reported as well. Some health authorities and others
call for national HIV reporting (using names or codes), but others,
and many people living with HIV/AIDS, fear that this could erode
confidentiality rights. Proponents of wider reporting argue that
not having a full HIV-surveillance system deprives health authorities
of reliable information about the incidence, prevalence, and trends
in HIV infection, types of behavior that increase transmission risk,
or trends in specific subpopulations (e.g., minorities, women).
Because of the stigma associated with HIV/AIDS, opponents fear that
stricter monitoring and reporting could increase the risk of discrimination
in housing, insurance, and employment as well as invade personal
privacy. Opponents also worry that increased monitoring and reporting
will deter people from being tested, which could result in more
transmission, delayed treatment, and higher costs. The same arguments
apply to reporting of other communicable diseases such as STDs and
State and local policymakers addressing communicable
disease issues must deal with increasing complexity because of the
permeable nature of local, state, and international borders. In
an age of rapid transit and increasing mobility worldwide, a communicable
disease outbreak in one country can quickly become a local threat
See also Emergency Preparedness and Response;
FOR ADDITIONAL INFORMATION
AIDS Education Global Information System (AEGIS)
[one of the largest Web HIV/AIDS information sources]
AIDS Partnership Michigan
2751 East Jefferson Avenue, Suite 301
Detroit, MI 48207
(313) 446-9839 FAX
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
1600 Clifton Road
Atlanta, GA 30333
Division of Communicable Disease and Immunization
Bureau of Epidemiology
Michigan Department of Community Health
3423 North Martin Luther King, Jr. Boulevard
P.O. Box 30195
Lansing, MI 48909
(517) 335-8165 or 335-8195
HIV/AIDS Prevention and Intervention Section
Division of HIV/AIDSSTD
Michigan Department of Community Health
2479 Woodlake Circle, Suite 300
Okemos, MI 48864
(517) 241-5911 FAX
Michigan Association of Public Health and Preventive
Reportable Disease Data
Midwest AIDS Prevention Project
Ferndale, MI 48220
(248) 545-3313 FAX
CONTENT CURRENT AS OF APRIL 1,
© 2002 Public
Sector Consultants, Inc.
Sponsored by the Michigan Nonprofit Association and the Council
of Michigan Foundations