Abstract 
 
 During 1988 through 1990, California experienced its worst measles epidemic in more than a decade, with 16,400 reported cases, 3,390 hospital admissions, and 75 deaths. More than half of the patients were younger than 5 years; the highest incidence was among infants younger than 12 months. The epidemic centered in low-income Hispanic communities in southern and central California. The major cause of the epidemic was low immunization levels among preschool-aged children and young adults. Rates of complications, admission to hospital, and death were surprisingly high. Outbreak control efforts met with indeterminate success. Problems with these efforts included insufficient funding early in the epidemic and disappointing public response to community-based immunization campaigns. The cost of medical care and outbreak control for the epidemic is conservatively estimated at $30.9 million. Unless the level of immunization in preschool-aged children is increased, this type of epidemic will probably recur. ||||| Bill Gates proves that one person can make a difference—if he happens to be the richest person in the world. Since forming the Bill & Melinda Gates Foundation—and especially since leaving Microsoft in 2008 to dedicate himself full-time to the foundation’s work—Gates and his wife Melinda have emerged as two of history’s most powerful philanthropists, funding efforts from polio eradication to sewage-treatment plants, and setting the agenda for aid organizations around the world. They have convinced 127 fellow billionaires to sign their giving pledge, an oath to donate the majority of their wealth to philanthropic organizations. Today, the Gates Foundation has an endowment of $42 billion, almost four times the size of the Ford Foundation, and it distributes between $3 and $4 billion every year. As WIRED Science writer Maryn McKenna put it a few years ago, “Where Gates goes, governments and the media follow.” 
 
 So when Gates releases his annual letter each January, summarizing the foundation’s progress and laying out its priorities for the coming year, the world pays attention. Last year’s edition, a feisty debunking of “myths” about poverty, went viral. This year’s letter, co-written by both Bill and Melinda Gates and released today, is even more ambitious than usual. Titled “Our Big Bet for the Future,” it lays out a series of goals for the next decade and a half—cutting childhood deaths by half, eradicating polio and three other diseases, and making Africa capable of feeding itself, among others. Altogether, the letter predicts, “the lives of people in poor countries will improve faster in the next 15 years than at any other time in history.” 
 
 The letter is modeled on the UN’s Millennium Development Goals, a set of 15-year targets that expire this year and that Gates refers to as “one of the most important documents the UN ever did.” Representatives from every country in the world signed the goals in 2000, pledging among other things to reduce extreme poverty by 50 percent, slash child mortality by two thirds, and cut the maternal mortality rate by three quarters. Although not every target was reached—a full report card can be found here—the document is generally credited with focusing global aid efforts and providing a yardstick against which they can be measured. The UN is set to introduce a new set of development goals this September, and some observers worry that they will be a disappointment rather than an inspiration. Writing for the Guardian, Kevin Watkins frets that the discussions to date have been “hampered by a paralyzing lack of ambition, weak leadership, and the absence of a credible agenda to galvanise public engagement.” 
 
 That certainly does not describe this year’s Gates letter, the most rabble-rousing edition to date. Toward the end, the Gateses announce Global Citizens, a new program to educate and inspire action among the general public. “We want to give global citizens a way to lend their voice, urging governments, companies, and nonprofits to make these issues a priority,” the letter explains. In particular, the Foundation will ask its Global Citizens to push for a meaningful reboot of the UN’s Millennium Goals, and to hold their governments accountable for meeting those targets. It’s a surprisingly populist approach for the Foundation, which has tended to turn to billionaires for the bulk of its support. 
 
 In a wide-ranging phone conversation, WIRED spoke with Gates about this year’s letter, global inequality, and President Obama’s tax proposals. The interview has been edited for length and clarity. 
 
 __The UN is working on its update to the Millennium Development Goals. How do you think it’s going? __ 
 
 We’re definitely on track. It will be a much longer document, and a broader set of goals than the MDGs were. 
 
 But the MDGs were so powerful because they were so succinct. Do you worry that if these goals become too broad, it will be harder to keep people focused? 
 
 That absolutely is a concern that I have. Then again, there are unfinished MDGs, and they will always have a very unique position. Key things like child health are so critical. If you have malnutrition you can’t do education very well. 
 
 I do think the new document will be so long that fewer people will read the whole thing. Then again, when we talk about books like the Koran or the Bible, not everybody reads every word of those things. I think of the MDGs like the Ten Commandments. 
 
 You operate from the belief that the world is radically improving in the fields of health, agriculture, and poverty. But there’s one area that you flick at in this letter where things seem to be getting worse, and that’s climate change. We’ve just learned that 2014 was the hottest year on record. Tech solutions are being developed, but they’re facing headwinds—be it political stagnation or extremely cheap gas prices. Do you have the same sense of optimism when you look at energy? 
 
 I have billions invested in various energy-related things—like battery companies, or cheaper ways of making electricity. I have a company that’s working on something called fourth-gen nuclear, this new super-safe nuclear design. So I think it is feasible to have energy sources that are even cheaper—although, as you say, that benchmark gets tougher as the price of natural gas and oil are so low. 
 
 There’s no doubt that we’re going to have some warming even as we start to deploy these solutions, because of the lags in the system. Nathan Myhrvold has written a few articles on this, about how even if you do the right things you still have some locked-in change. 
 
 I’ve been a big proponent that rich world governments should raise their energy R&D budgets. It is possible—based on the basic science of big energy, nuclear fuels, the photons that hit the earth from the sun—to have cheap energy. In the meantime we have to do some adaptation, which is mostly investing in agricultural systems so that farmers in the areas that will be most affected can have enough productivity and enough storage so that if they have lean years, their kids are not significantly malnourished. 
 
 __You’ve dedicated a ton of resources to delivering vaccines to remote areas of the world. It must drive you nuts when people in the rich world choose not to vaccinate their kids. __ 
 
 I just read this book called On Immunity: An Inoculation—which is so well written, it’s unbelievable—that talks about this. It’s a little bit unsurprising considering you’re saying to parents, “Hey, take this needle and inject it into your kid! Honestly, we’re sure that it does no harm!” It really takes explaining to people why this is not only beneficial to their child but to society as a whole. 
 
 The anti-vaccination crowd, it’s very unfortunate. They create risk and in some cases there have been pertussis-based deaths and measles deaths. Those are the two that show up pretty quickly when you get any group of kids that haven’t been vaccinated. People thought, “OK, we have the Internet, information will get out there.” But misinformation got out there as well. 
 
 I do think we’ll keep vaccination rates high in the US. Rationality will succeed. But it will take cases like this Disneyland thing to remind people how irresponsible it is. The science about the safety is very, very strong. 
 
 Another source of discouraging data: income inequality. You’ve read Thomas Piketty’s Capital, and had nice things to say about it. But you also said that some inequality is built into the capitalist system, and the question is when it begins to do more harm than good. Has inequality become a hinderance? 
 
 I don’t think in some huge way. Of course, at a global level, income inequality is going down, because countries like China and India are getting richer much, much faster than the rich world is getting richer. So the overall picture on income inequality is very, very positive. And yet, each country has to look at the fact that, because of the nature of capitalism, there’s a tendency at the country level to have greater inequality unless you have tax policies to moderate it. So it’s a great democratic debate: What should those tax policies be? For the one country whose tax policies I know, the US, I’ve been in favor of more progressive tax approaches. 
 
 I also think philanthropy, although not a total solution to it, does moderate the problem. Especially if those who have been lucky give of their time and money to causes—like improving education or health—that speak to the most basic inequities. 
 
 So it’s a great topic for debate. A democracy is a self-correcting system, and over time I’d expect them to get it right. The founders were a little worried that the masses would get rid of capitalist incentives by going too far, but at least in the US that certainly hasn’t been a problem. The system has worked well for hundreds of years. 
 
 We’re speaking the day of the State of the Union. What do you think of the President’s tax proposals? 
 
 I don’t know the specifics very well so I really can’t comment. Just being pragmatic, the likelihood of a change in the tax system is fairly low. But I’ll be very interested. He no doubt will be promoting things that are progressive in nature so it’ll be interesting to see what he picks. 
 
 Let’s talk about your Global Citizen Initiative. This seems like a departure for you. How did it come about? 
 
 Some 6.5 million children die every year. There’s a subset of that where there’s an earthquake or flood, and people are so anxious to give and help. It reminds you that when people can connect and have an image of what’s going on, in those acute situations, they care and are willing to get involved. But 98 percent of childhood death comes from chronic, ongoing things, not those headline, one-time events. It’s malaria every day, diarrhea every day, pneumonia every day. The idea is that, if you sign up, on an ongoing basis, a few times a month we’ll give you an update on how things are going. It won’t just be a headline about an earthquake. 
 
 The idea is getting people to use their voice to say their governments should continue to be generous on aid. We're dealing with tight budgets. Even countries that have been generous, like the Netherlands or Australia, have made cuts to their aid budgets. And within the universe of NGOs, some are agricultural, some are environmental, some are health, you can pick one of those that you want to dive down into and get involved with. 
 
 That is a new thing. We’re not sure how well that will resonate. But we do think people’s basic morality, the desire to care about humanity broadly, that it’s fairly timely. There’s a bit of a vacuum there. There’s not an alternate way for people to grab on and see how they might contribute more. 
 
 At the same time, critics have grown dismissive of “clicktivism,” little bursts of online activity that don’t result in any sustained commitment or change. How do you keep this from being a mile wide and an inch deep? 
 
 The starting point is very shallow. But the beauty is you can use that to get in more deeply. If you sign up to be a global citizen, we won’t send you too much email but we’ll say, “Hey, if you’re interested in going to Africa, not only can you do some interesting fun things, but you’d have a chance to get exposed to these issues, see this stuff on the ground.” Once you do that, people tend to get hooked. They’ll see something and latch onto it—a particular village or disease. 
 
 But you’re right. Just because we have 10 million global citizens who give us their email address, that’s not our final metric. That’s a starting metric. The metric I care about is people who get involved in real activism, really take trips, really start donating and volunteering. This is just a gateway toward deeper involvement, if we do our job right. ||||| The vaccination exemption rate among kindergarten students in California — cases in which parents said they did not want their children vaccinated for health, religious or other reasons — was 3.1 percent in the 2013-14 school year, according to the C.D.C. report. Oregon had an exemption rate of 7.1 percent, the nation’s highest, the report found. Health officials said the vaccination rate needed to be above 95 percent in all communities to prevent outbreaks. 
 
 Still, the California figure can be deceiving. Health officials said there were pockets across the state, including wealthy neighborhoods in Los Angeles and Orange Counties and enclaves in Northern California, where the exemption rate jumped into the double digits. California has long been viewed as particularly prone to this kind of outbreak because of its population size and the number of people arriving from overseas. 
 
 “The problem is that there are these pockets with low vaccination rates,” said Dr. Jane Seward, the deputy director of the viral diseases division at the C.D.C. “If a case comes into a population where a lot of people are unvaccinated, that’s where you get the outbreak and where you get the spread.” 
 
 Organizations that have led the campaign of doubts about vaccinations suggested that it was too soon to draw such a conclusion. The groups cautioned parents not to be pressured into having their children receive vaccinations, which the organizations say have been linked to other diseases. Health professionals say those claims are unfounded or vastly overstated. 
 
 “It’s premature to blame the increase in reports of measles on the unvaccinated when we don’t have all the facts yet,” said Barbara Loe Fisher, the president of the National Vaccine Information Center, a group raising concerns about inoculations. “I do know this: Fifty-seven cases of measles coming out of Disneyland in a country with a population of 317 million people is not a lot of cases. We should all take a deep breath and wait to see and get more information.” 
 
 A handful of doctors seem sympathetic to these views. Dr. Jay Gordon, a Santa Monica pediatrician who has cautioned against the way vaccines are used, said he had “given more measles vaccines” than ever before but did not like giving the shot to younger children. 
 
 “I think whatever risk there is — and I can’t prove a risk — is, I think, caused by the timing,” he said, referring to when the shot is administered. “It’s given at a time when kids are more susceptible to environmental impact. Don’t get me wrong; I have no proof that this vaccine causes harm. I just have anecdotal reports from parents who are convinced that their children were harmed by the vaccine.” ||||| LOS ANGELES (AP) — Seventy people have been infected in a measles outbreak that led California public health officials to urge those who haven't been vaccinated against the disease, including children too young to be immunized, should avoid Disney parks where the spread originated. 
 
 FILE - This Nov. 20, 2009 photo shows Sleeping Beauty's Castle in winter dress with the iconic "Partners" statue featuring images of Walt Disney and Mickey Mouse in the foreground, at Disneyland in Anaheim,... (Associated Press) 
 
 New infections linked to the theme parks emerged Wednesday in the outbreak that has spread to five U.S. states and Mexico, though the vast majority — 62 — occurred in California. 
 
 Because measles is highly contagious, people who have not received the measles-mumps-rubella, or MMR, vaccine are susceptible and should avoid visiting Disney "for the time being," state epidemiologist Gil Chavez said. 
 
 The same holds true for crowded places with a high concentration of international travelers, such as airports, Chavez said. People who are vaccinated don't need to take such precautions, he said. 
 
 Disneyland Resorts spokeswoman Suzi Brown said officials agreed with the advice that "it's absolutely safe to visit if you're vaccinated." 
 
 The people who have been infected range in age from 7 months to 70 years old. The vast majority were not vaccinated, and a quarter had to be hospitalized. 
 
 Among those sickened were five Disney employees. Three have since returned to work. The company previously said park employees who may have been in contact with those infected were asked to show proof of vaccination or have a blood test to show immunity against measles. Those with pending results were put on paid leave. Vaccinations are also being offered to all employees. 
 
 Measles has hit California hard recently. The state typically sees four to 60 measles cases a year. 
 
 "We are off to a bad start in 2015," Chavez said. 
 
 Since the outbreak, two dozen unvaccinated students at an Orange County high school were sent home for three weeks after an infected pupil showed up. 
 
 Measles is a highly contagious respiratory illness that can spread by air through coughing or sneezing. Symptoms include fever followed by cough, runny nose and a blotchy rash. Though the virus has been eradicated in the U.S. since 2000, it can still enter the country through an infected traveler. 
 
 While health officials said they likely may never find "patient zero" or the trigger of the outbreak, they believe it was either a resident from a country where measles is widespread or a Californian who went abroad and brought home the virus. 
 
 People at highest risk are those who are unvaccinated, pregnant women, infants under 6 months old, and those with weakened immune systems. 
 
 ___ 
 
 Contact Alicia Chang at http://twitter.com/SciWriAlicia ||||| Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail. 
 
 Measles — United States, 2011 
 
 In 2000, the United States achieved measles elimination (defined as interruption of year-round endemic measles transmission) (1). However, importations of measles into the United States continue to occur, posing risks for measles outbreaks and sustained measles transmission. During 2011, a total of 222 measles cases (incidence rate: 0.7 per 1 million population) and 17 measles outbreaks (defined as three or more cases linked in time or place) were reported to CDC, compared with a median of 60 (range: 37–140) cases and four (range: 2–10) outbreaks reported annually during 2001–2010. This report updates an earlier report on measles in the United States during the first 5 months of 2011 (2). Of the 222 cases, 112 (50%) were associated with 17 outbreaks, and 200 (90%) were associated with importations from other countries, including 52 (26%) cases in U.S. residents returning from abroad and 20 (10%) cases in foreign visitors. Other cases associated with importations included 67 (34%) linked epidemiologically to importations, 39 (20%) with virologic evidence suggesting recent importation, and 22 (11%) linked to cases with virologic evidence of recent importation. Most patients (86%) were unvaccinated or had unknown vaccination status. The increased numbers of outbreaks and measles importations into the United States underscore the ongoing risk for measles among unvaccinated persons and the importance of vaccination against measles (3). 
 
 Confirmed measles cases in the United States are reported by state and local health departments to CDC using a standard case definition.* A measles case is considered confirmed if it is laboratory-confirmed or meets the clinical case definition (an illness characterized by a generalized rash lasting ≥3 days, a temperature of ≥101°F [≥38.3°C], and cough, coryza, or conjunctivitis) and is linked epidemiologically to a confirmed case. Laboratory confirmation of measles is made by detection in serum of measles-specific immunoglobulin M (IgM), a significant rise in measles immunoglobulin G (IgG) level, isolation of measles virus, or detection of measles virus by nucleic acid amplification from a clinical specimen. Cases are considered importations if exposure to measles virus occurred outside the United States 7–21 days before rash onset and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time. 
 
 For this report, U.S. residents were classified as eligible or ineligible for measles, mumps, and rubella (MMR) vaccination according to the Advisory Committee on Immunization Practices recommendations for measles vaccination (3). Vaccine-eligible patients were defined as U.S. residents who 1) were unvaccinated or had unknown vaccination status, 2) did not have any contraindications for vaccination, and 3) were either born after 1957 and aged ≥12 months without previous documentation of presumptive evidence of immunity to measles† or aged 6–11 months with recent history of international travel. 
 
 During 2011, a provisional total of 222 measles cases were reported from 31 states (Figure 1). The median age of the patients was 14 years (range: 3 months to 84 years); 27 (14%) were aged <12 months, 51 (26%) were aged 1–4 years, 42 (21%) were aged 5–19 years, and 76 (39%) were aged ≥20 years. Most patients were unvaccinated (65%) or had unknown vaccination status (21%). Of the 222, a total of 196 were U.S. residents. Of those U.S. residents who had measles, 166 were unvaccinated or had unknown vaccination status, 141 (85%) were eligible for MMR vaccination, 18 (11%) were too young for vaccination, six (4%) were born before 1957 and presumed immune, and one (1%) had previous laboratory evidence of presumptive immunity to measles. Among the 141 patients who were unvaccinated and eligible for MMR vaccination, nine (6%) were infants aged 6–11 months and had recent history of international travel; 14 (10%) were aged 12–15 months, the age recommended for receiving the first dose of MMR vaccine; and 66 (47%) were aged 16 months through 19 years. Of those 66 patients, 50 (76%) had not been vaccinated because of a philosophic, religious, or personal objection. 
 
 Among the 70 (32%) measles patients who were hospitalized, 17 (24%) had diarrhea, 15 (21%) were dehydrated, and 12 (17%) had pneumonia. No cases of encephalitis and no deaths were reported. 
 
 Of the 222 U.S. measles cases, 200 (90%) were associated with importations, of which 72 (36%) were importations from other countries, 67 (30%) were linked epidemiologically to importations, 39 (20%) had virologic evidence (i.e., isolation of a viral genotype known to circulate in a country with measles) that suggested recent importation, and 22 (11%) were linked to cases with virologic evidence of recent importation. The source of measles acquisition in 22 cases was not determined through contact tracing or viral isolation (i.e., linking the patient to a country with measles or isolation of a viral genotype known to circulate in a country with measles). Importations were reported during 31 of the 52 reporting weeks (Figure 2). Among the 72 cases of measles importation, 52 were linked to U.S. residents who had traveled abroad, and 20 were linked to foreign visitors. Almost half (46%) of the 72 measles importations occurred among persons who acquired the disease in the World Health Organization (WHO) European Region (Table). 
 
 Seventeen outbreaks accounted for 112 (50%) of the 222 cases. The median outbreak size was six cases (range: 3–21 cases), and outbreaks lasted a median of 18 days (range: 6–69 days). 
 
 Measles was laboratory confirmed in 200 (90%) cases: 94 (47%) by detection of measles-specific IgM and measles virus nucleic acid, 69 (35%) by detection of IgM only, and 37 (19%) by detection of measles virus nucleic acid only. Six genotypes of measles virus were identified among samples collected: D4, D9, D8, B3, G3, and H1 (Table). 
 
 Reported by 
 
 Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Huong McLean, PhD, hmclean@cdc.gov. 
 
 Editorial Note 
 
 Measles elimination has been maintained in the United States for more than a decade through high population immunity secondary to high MMR vaccination coverage. Coverage with 1 dose has been >90% among children aged 19–35 months since 1996. The increase in measles importations and outbreaks during 2011 serves as a reminder that measles remains endemic in many parts of the world and unvaccinated U.S. residents continue to place themselves and others in their communities at risk for measles and its complications. 
 
 The increase in importations reflects recent increases in the incidence of measles in countries visited by U.S. travelers. The source of almost half of the measles importations in 2011 was the WHO European Region, which reported >30,000 cases of measles, including 27 cases of measles encephalitis, a complication that often results in permanent neurologic sequelae, and eight measles-related deaths in 2011. Five countries (France, Italy, Romania, Spain, and Germany) accounted for more than 90% of cases reported to the European Centers for Disease Prevention and Control (4). Although measles has been eliminated in the Region of the Americas since 2002 and considerable progress has been achieved in global measles control, measles is still common in many countries. Importations of measles virus into the United States will likely continue and cause outbreaks in communities that have clusters of unvaccinated persons. Maintenance of high MMR vaccination coverage is essential to prevent measles outbreaks and sustain measles elimination in the United States. Despite the relatively small number of reported cases in the United States, the public and the health-care providers must remain vigilant. A drop in MMR vaccination coverage in a community can increase the risk for large, sustained measles outbreaks, as experienced recently in Canada and France (4,5), or reestablishment of endemic transmission, as experienced in the United Kingdom (6). 
 
 Occasionally, measles cases are reported without apparent links to importations, but virologic evidence suggests recent importation of an undetected case or chain of cases. Given travel patterns, the highly infectious nature of measles virus, and limitations of surveillance systems, not every importation of measles virus into the United States is detected. Therefore, collection of samples for virus detection is extremely important. Genetic characterization of viruses can help to confirm or suggest the likely source of imported viruses because measles genotypes are distributed heterogeneously in regions that have not yet eliminated measles (7,8). 
 
 Health-care providers play an important role in maintaining elimination of measles in the United States. Patients with measles frequently seek medical care; therefore, health-care providers should maintain a high awareness of measles and suspect measles in persons who have a febrile rash illness and clinically compatible symptoms (e.g., cough, coryza, or conjunctivitis) and who recently have traveled abroad or have had contact with travelers. Providers should implement isolation precautions immediately and promptly report suspected measles cases to their local health department to limit spread to other susceptible persons, including those who cannot be vaccinated because of medical contraindications or those too young for vaccination. In several outbreaks during 2011, despite seeking medical care, the source case was not identified until after the first or second generation of cases was reported. Misdiagnosis and delayed reporting resulted in missed opportunities to prevent additional cases because of delayed implementation of control measures. Nevertheless, for most cases, early reporting by providers and rapid control efforts by state and local public health agencies have prevented measles transmission and limited the size of outbreaks. 
 
 Health-care providers should encourage vaccination of all eligible patients, including children and adults. MMR vaccine is recommended routinely for all children at age 12–15 months, with a second dose at age 4–6 years. Two doses of MMR vaccine also are recommended for unvaccinated health-care personnel, international travelers, and students attending post–high school educational institutions. Other adults without evidence of measles immunity should receive 1 dose of MMR vaccine (3). In addition, providers should remind their patients who plan to travel internationally of the increased risk for measles and potential exposures during bus, train, or air travel and at large international events or gatherings (e.g., Euro 2012 and the 2012 Summer Olympics), and of the importance of vaccination. All persons aged ≥6 months who will be traveling outside the United States and are eligible to receive MMR vaccine should be vaccinated before travel. Children aged ≥12 months should receive 2 doses of MMR vaccine separated by at least 28 days, before travel (3). 
 
 References 
 
 What is already known on this topic? Achievement of measles elimination was declared in the United States in 2000, but the disease remains poorly controlled in much of the world. Cases of measles are imported regularly into the United States. What is added by this report? During 2011, 222 cases of measles and 17 outbreaks were reported in the United States, an increase compared with cases and outbreaks reported during 2001–2010. Importations accounted for 72 (32%) cases, including 52 (72%) cases among U.S. residents who had traveled abroad recently. Among patients who were U.S. residents, 85% were unvaccinated or had unknown vaccination status and were eligible for measles, mumps, and rubella (MMR) vaccination. What are the implications for public health practice? MMR vaccine is highly effective in preventing measles and its complications. Rapid public health response and high 2-dose MMR vaccine coverage are essential in preventing measles outbreaks and sustaining elimination in the United States. One dose of MMR vaccine is recommended routinely for all children at age 12–15 months, with a second dose at age 4–6 years. Adults without evidence of measles immunity should receive 1 MMR vaccine dose, whereas 2 doses are recommended for unvaccinated health-care personnel, international travelers, and students attending post–high school educational institutions. 
 
 FIGURE 1. Origin of reported measles cases (N = 222) — United States, 2011 Alternate Text: The figure above shows the origin of reported measles cases in the United States during 2011. During 2011, a provisional total of 222 measles cases were reported from 31 states. 
 
 FIGURE 2. Number of measles cases, by import status and week of rash onset (N = 222) — United States, 2011 Alternate Text: The figure above shows the number of measles cases, by import status and week of rash onset in the United States during 2011. Importations were reported during 31 of the 52 reporting weeks.
– From 1988 to 1990, California was slammed with a measles epidemic that affected at least 16,000 people, per the Western Journal of Medicine. Now public health officials are trying to avoid a similar scenario, encouraging people in the Golden State to a) get vaccinated, and b) stay away from Disney parks where the current outbreak started if they're not. Although a Disneyland spokeswoman tells the AP "it's absolutely safe to visit if you're vaccinated," a state epidemiologist warns that those who haven't received the measles-mumps-rubella (MMR) shot should keep away for "the time being." Seventy people—the "vast majority" of them unvaccinated, notes the AP—have reportedly been infected so far in the outbreak. Measles has officially been eradicated since 2000 in the US; California officials speculate the current outbreak was caused by a foreign visitor or a resident who traveled overseas. The vaccination debate has been renewed, with many health officials lambasting those who refuse to get their shots due to fears about risks. "[These cases] wouldn't have happened otherwise. … There are some pretty dumb people out there," an infectious disease specialist tells the New York Times, while a deputy director at the California Center for Infectious Diseases urges "unvaccinated Californians to consider getting vaccinated against measles." Even Bill Gates, who has lobbied for vaccinations around the globe, tells Wired, "It will take cases like this Disneyland thing to remind people how irresponsible [not being vaccinated] is." The head of the National Vaccine Information Center, however, says it's all overblown. "Fifty-seven cases of measles coming out of Disneyland in a country with a population of 317 million people is not a lot ... . We should all take a deep breath," she says.