Transcripts For CSPAN2 Public Health Officials On Measles Outbreak 20240714

Good morning everybody thank you for coming. The executive director of the bigcity Health Coalition want to say a special thank you to Representative Office for securing the space for us and while i know the congresswoman could not be here today i want to thank her for being a true champion for Public Health also the American Academy of pediatrics for being such a great partner as we planned this event. The Health Coalition started in 2002 is a forum for leaders of the largest metropolitan Health Department for strategies to jointly address issues to promote and protect the health and safety of the residents we have those jurisdictions whose Health Department serves nearly 62 million or one out of five americans well have two jurisdictions here today. You have bios in front of you i will not take up time i want to introduce the panel that i will turn it over to them. The order in which they are presenting doctor kraft is the immediate precedent of aat the commissioner of health in new york city the chief medical officer l. A. County Public Health both came from california so we have a special thank you to them to travel so far. Thank you for finding the time to join us today to share your perspective and now i will turn it over. From the American Academy of pediatrics will do a Measles Outbreak one oh one and why immunization is so important. The American Academy of pediatrics is a nonprofit professional organization with more than 67000 pediatricians we are dedicated to the health and safety and wellbeing of children and adolescents and young adults we publish recommended elimination schedules with the cdc American Academy physicians and gynecologist so lets go back to the history of measles in 1953 it was licensed in a 1968 the vaccine began to be distributed. And then was eliminated so there was no continuous disease transmission for more than 12 months that was due to a highly effective Vaccination Program and better measles control in the United States and the americas. However we have seen measles come back. We had 93 cases in 2010 and now we have 182,019 so it was gone in 2000 and now back with a vengeance. You look at the states reporting in 2019 all of the red states and we see this all over the country it is the acute viral disease by a cough and runny nose red eyes and sore throat and a rash that begins in the face and spread throughout the body common complications include pneumonia ear infections, croup and diarrhea and about one out of four will be hospitalized im old enough to remember to have measles i had them at three years old and so did my two yearold sister, one yearold brother and my infant sister. I remember this as though one time the doctor actually came to our house to cs. I remember a couple of other things also. That my eyes were so sore i can hardly open them my mother kept the shades down and the lights on low because there was so much i paid one i pain. I remember that specifically and also the prayers for my two yearold sister because she got pneumonia and we almost lost her. She was in the hospital and fortunately we covered. We looked at something this very deadly hitting these for little kids at the same time this is very commonplace before vaccination. What we know 130 of those who got them in one night 2019 were hospitalized and 65 had complications like pneumonia like my little sister and encephalitis which is brain swelling acute encephalitis results in permanent brain damage and one out of every 1000 cases and in that era death is respiratory or neurological complications is one or three out of every 1000 cases reported measles is back just as deadly as it was back when i had it. It is extremely contagious so if one person has measles nine out of ten they are in contact with will also get them if they are not protected. The virus is spread through the air when the infected person coughs or sneezes and somebody nearby inhales those infected droplets. That the virus is hearty and it hangs in the air and could be spread for several hours after the infected person has left the room and can be transmitted directly from person to person as well. Was a child gets the measles the first symptoms will not be there between eight and 12 days that they are contagious one or two days before they start with symptoms so you dont even know that they are contagious and then when they finally emerge before the rash breaks out then this will continue for days after the rash appears. Reno where people get them from weather hasnt been the same robust Immunization Program it is commonplace so that is a plane right away for anybody who is not vaccinated if they travel to other places in the world they can come back with measles. Coming back from the ukraine and the philippines and those who got that vaccine one you got to measles were not vaccinated. Is not the most vulnerable but the children less than five years of age in adults aged more than 20 years of pregnant women and women people with compromised immune systems it cannot get the vaccine because of hiv your cancer or other diseases where the immune system is not up to snuff. We recommend the vaccine be given between 12 and 15 months of age and again at four and five years of age. What we know is if you get those two immunizations theres a 97 percent chance you will develop antibodies as a protection i have changed what i had to do a practice because we know during an outbreak mmr should be offered to all people exposed to the outbreak and also we are starting to ask parents of babies between six and 12 months we are starting to immunize our kids if they will be at risk because of the highly contagious nature of measles. There is a concept called herd immunity or Community Immunity because we are not cattle but if we immunize and protect people around us that we will protect that one vulnerable individual who cannot be vaccinated for any reason. Individuals who work in communities with high vaccination rates are protected and those people who cannot get vaccines are protected. Its important for a very Young Children for those that are emu no compromised. If you have healthy non vaccinated individuals in a few vaccinated individuals they can get the disease as they are vaccinated that one child that one compromise person who cannot get the vaccine will still be protected because most of the people around them have gotten that immunization. So federal legislation of the vaccines act was introduced by representative doctor schreier who is a pediatrician and doctor burgess who is an obstetrician. This bill is important because it authorizes the campaign on the importance of vaccines. Attitudes towards vaccines and to develop strategies to help us protect more people and vaccinate more kids. So, the reminder before the measles Vaccination Program started in 1963, an estimated three to 4 Million People got measles in the United States. About 50,000 cases were reported to the cdc. Of these people, four to 500 a year died. 48,000, including my baby sister were hospitalized. And since bed, widespread use of the vaccine letter to a greater than 99 reduction in the cases compared with the pre vaccine era. And we dont want to go back to this era. We still need to educate families and communities on the importance of the vaccines. Our enemy is the disease. The way we combat this enemy is by education and vaccination. Thank you. [applause] so now youve learned a little bit about measles. Im going to quickly set the scene about the role of the Health Department and the different branches of government. I should have also said we are going to hold questions until the end but we will have time at the end. Local Health Departments on the fronwere onthe front lines prevd responding to outbreaks. They keep communities healthy and safe and get the communities healthier and safer support example in the outbreak they investigate every case in you will hear more about this and what happened on the ground in new york city and la county. They have Legal Authority for the orders done in both cases. They look to ensure the community is sufficiently vaccinated and they provide the vaccine when necessary. And they also provide simple and accurate messaging on the vaccination and work with part is to do so which is an important part also that we will talk a little bit about. So, the role of the federal government. Local Health Departments and on the ground respond to many or most Public Health issues that are inherently local. The federal government still has a role to play and resources to bear when needed. They can expand the capacity of the locally and state departments for subject matter expertise when needed. They have the bully pulpit and we have the surgeo the surgeon e head of the cdc. Important people that can push out messages to the broader population thats not as localized. And also the federal government can provide reliable dedicated funding. Ive highlighted for funding streams, the Immunization Program, the epidemiology capacity that is a lot easier, the Public Health Emergency Preparedness Funding Program come and the prevention and Public Health funds. And again, both doctors will talk to you about how they use the funding streams in responding to the epidemic of the outbreaks. So, this is a ten year funding history as the site says of the cdc Immunization Program. You can see in 2010 it was at 61, and today the projected number for 2020 from the cdc budget justification is by 33. So, we have come down over ten years, despite the fact that weve had many preventable outbreaks. Also important is that this program is not just include vaccine purchase and infrastructure support to distribute vaccines and communities, but also other activities to achieve National Immunization goals and keep the vaccination rate high to prevent death and disability from these diseases. It also supports what is known as a 317 Immunization Program as well as the infrastructure for the vaccine fo vaccines for chin program. On the graph, the red bar shows dollars from prevention and Public Health fund with cuts to overall appropriations to the Immunization Program. The funding is always on the chopping block and as a way to pay for other priorities. So, this is to illustrate how important it is for the ability of local and state Health Departments to do their job protecting the Public Health. As we are sitting here on capitol hill, its important to speak about what congress can do to move the needle. Its not just about funding and there are numbers introduced on both sides of the capitol with key components to help us move forward to not only try to stop that also address the next outbreak of these diseases. But the really important piece for me is that we need to support activities that focus on prevention and not just response. So, speaking about surveillance of these rates we dont have good numbers how many people were vaccinated. Many cities and localities do, some states do that varies across the country. We need more research on the hesitancy. We talked about the National Campaign to increase awareness with vaccines and combat the misinformation. And then this new piece and i dont know when we stop saying d saying social media is new we need to set the impact of social media in accelerating the vaccines and things like that. Obviously, if any of the programs are implemented, bowers would be needed to support them so that they can be carried out. And now, i will turn over to the doctor to talk about the experience. Good morning, everyone. So, it is my pleasure to talk with you about the response to measles in new york city. Today, im going to cover the following, the epidemiology of the outbreak in the final case count and the response being fought on two fronts. That of the Communicable Disease related specifically to measles and then on the second front, combating the misinformation. I will talk about the funds that were used during the outbreak, Lessons Learned and then future challenges. So, this is to pay a situate us in new york city. These are the two principal communities that were affected by the Measles Outbreak. Here in the top circle williamsburg and the lower circle and bird park. These are both highly populated communities. In new york city, and this is kind of as i like to say a geeky slide helps illustrate a number of things. The outbreak began in the beginning of october, 2018. And then on this side of the slide, you will see that it extended until september 23, and even though in each of the bars it represents new cases that were tallied for particular week and generally we dont declare an outbreak over until thereve been two incubation periods, so thats what this shows. The other thing it shows the majority of cases that were seen her in williamsburg. It also helps me to illustrate that in addressing the Measles Outbreak in new york city, we took a measured approach that was intended to meet the epidemiology that we are seeing at a particular time. We didnt jump to the most aggressive measures that we could have taken early on. So this first one really entails addressing issues of transmission within schools. The second phase addresses transmission within the communities. And then the third phase is when we issued our Public Health emergency order, and we havent taken that kind of drastic measure in years in new york city. The last time that was done was during the h. One and one outbreak in 2009. Thankfully, during that time we didnt need to enforce any of the summons and violation measures that we had to do here in this particular outbreak. So the emergency order is essentially calls for immediate vaccination of individuals living in the zip codes that were most affected by the measles and those that were found not to be at risk with financial penalties. What we then saw overall is that our final case count, the final number of individuals affected were 654. You will see from the slider that the majority of them were children from one to four years of age, and that of this group, 49 ended up in the hospital, which i was listening to the numbers, it is about one third of the individuals affected in the United States who were hospitalized in new york city. Additionally, 19 of these individuals required being admitted into the intensive care unit. Many of them were in there because of severe pneumonia. Many require oxygen therapy. So, as she was speaking, remember i am a pediatrician by training as well and in my training ive been in the business about 30 years and ive never seen a case of measles. So, this is the situation for many of the providers. Its something that we thought we had seen the last of, but clearly we have not. So, in the preventable cases you see, the majority of them were children 12 months and older, meaning that this is the age at which most children should be immunized and these children had not been. So that is the bulk of the preventable cases that we saw in the affected outbreak. And so im going to go back. What we did here is we have a very aggressive response collaborating with our Healthcare Delivery partners as well as our Community Partners, and we also lowered the age at which to immunize children so we recommended six months to 11 months which generally we reserve children traveling to these areas but with the situation we wanted to do it for the domestically transmitted pieces. So, the provider outreach you will see was very extensive and included both Technical Assistance and primarily to ensure Healthcare Delivery sites were not ongoing transition of altransmissionall the way throue that there was enough nmr on hand and distributing the educational material in english and yiddish. The bulk of individuals in this particular outbreak that were affected were members of the ultra Orthodox Community in new york city in those neighborhoods in new york city. And so, this is a slide that shows what every Public Health practitioner wants to see. And that is a measures that we put in place had the desired outcome and the measures we put in place for intended to increase the number of individuals that were vaccinated. So, this is a slide that looks at the Previous Year and what we see is typically we have a backtoschool rush. The dark line is the 2018, 2019 period and the dotted line is the year before. Whawhat baseball is at the beginning of the outbreak, when we declared it, we saw a significant spike in the number of individuals who received the mmr vaccine. And then over time, it dropped. We started issuing exclusion letters and walking more aggressively. We saw the spike their independent we have a low and when we issued a Public Health emergency, we saw another spike in the number of individuals who were immunized. What you see here is august and september the number of individuals in this school year getting immunized in the backtoschool rush is lower than the previous and we see this as a good thing because it means that families are not waiting until the last minute to get immunized and that is a good thing for us. So what this ended up resulting in is over 188,000 doses of measles given during the 2018 20182019 outbreak, which is over 23,000 more than the Previous Year in those particular neighborhoods. So, it was a massive effort was led by our department in collaboration with the Healthcare Delivery system that couldnt have happened without the engagement of our Community Part nurse. So, what the outbreak highlighted for us is in certain situations, traditional partners were not enough. When we are up against this information, up against issues that we have never encountered before, it was critical to engage the leaders from within the Orthodox Community. So, this community hav has been targeted by the antivaccination messages, and they were targeted through rowboat calls, direct Mailing House while as social media. So this was not exclusively social media. They use all available funds to disseminate the misinformation and propagate fear which ended up resulting in high numbers of individuals within the community being unvaccinated, susceptible to disease that has significant consequences. So, we met with religious leaders as a result of this community took on the challenge of ensuring vaccination for folks in the new groups that started popping up in the medical association its one that i want to particularly highlight. And these were a group of physicians who took it upon themselves to do house calls to offer vaccinations going back to old school tactics. The importance here is talking about the consequences the vaccine has and the degree to which misinformation here can take hold in certain communities. And its not just the phenomenon that we are seeing here in the United States, the outbreak that began in new york city actually began in israel, the year before and got a big actually began in the ukraine before that. So, this is a worldwide phenomenon, not just in the United States. And the Common Thread is the propagation of fear and lies, so it new york city, there was a pamphlet that was distributed that was filled with really inflammatory and conspiracy based theories about the dangers of vaccines and how it was much safer to get measles than to have to vaccination. The vaccination. So, when we were confronted by them, this is a Communications Material that we put together in collaboration with our part verse and that took each point that each made and refuted that with actual scientific basis and this is distributed throughout the community not only by ourselves but by our partners, and it was clear that there were many opportunities to do both largescale educational efforts as well as the sort of equivalentheequivalent of the ol tupperware parties where there were small gatherings of families to really have time to understand the underlining Science Behind the safety and efficacy of vaccines. As a part of the effort of combating the measles of the second front of this information, we put out a lot of educational materials and emphasized the importance of spreading the truth, not measles. The importance of getting vaccinated, having materials in the edition as well as english. We also have materials in spanish and chinese. And then i think i am particularly this particular graphic i think does a very good job at conveying the herd immunity, and that is with one infected individuals, there are otherothers and the like that at able to get vaccinated that are at risk for illness. By the numbers at the end of the day there were 547 staff that were deployed for this and over 100,000 personnel are spent. 21,000 new yorkers were trucked down to a the exposure and status. 2100 individuals have a more indepth investigation to determine the vaccination status and whether or not they actually did have measles. And it costs us 6 million to address something that is incredibly preventable. And so, these dollars were primarily and let me walk you through this. The topline is the top total dollars. You will see the both of the colors used to address this for city dollars. The next level is the state dollars. You will see this after we declared a Public Health emergency and the lower line, our federal dollars. And even though that is a much smaller curve, it is important because this is where we have the capacity to do our laboratory testing. This is where we have the capacity to do our disease surveillance. We wouldnt have been able to mount a robust aggressive response that we did were it not for these funds. I think the other important thing to note is that this line also includes Emergency Preparedness dollars, so i dont want to lose sight of the fact that often times i think the public thinks that this is like theres a lot of training and preparation and systems that need to be put in place to ensure that we protect and promote the health of new yorkers. So, those funds are critical for us. I have one more slight after this. The Lessons Learned. I think that this was a lesson for the entire country on not taking these victories for granted. But even though the United States has been declared measles free since 2000, this is a clear example of how because of international transmission, we now have measles reintroduced into the population and it is critical for us to a double our efforts to ensure families have appropriate and Accurate Information that we have individuals within a number of different communities and Healthcare Provider communities be it the religious communities armed with information they can share with their neighbors and be trusted messengers about the importance of and the safety of vaccinations and also the ongoing Public Health campaigns regarding the importance of the vaccinations clearly not just with measles old vaccinations. And then the importance of having more granular surveillance because in new york city, we have a 99 Immunization Coverage for children of school age. For this outbreak showed us is that there are pockets where there are high numbers of individuals that are susceptible to the virus and so having more resources to do the granular surveillance is the key for us. And then leveraging the Community Relationships develop new alliances, not just for this particular outbreak, but for Public Health emergencies moving forward. What we clearly have learned through this experience is that the partnerships that weve put in place will also help us with Emergency Preparedness or, you know, ma, manmade as well as natural disasters in the future. So, the challenge is it remains. Given that we had an opinion polling recently in new york city and 21 of the adults that have children between the age of birth and 17 years of age from 17 , excuse me, 21 of that 21 of the adults that had kids zero to 17 reported that they had delayed over refused vaccinations. So, that is a very concerning statistic in light of the fact that we have Ongoing International transmission, in light of the fact that we have transmission and other parts of the country, and it really gives us the urgency to continue the efforts that we put in place. And so, as i mentioned the future challenges also include continued education to spread misinformation. This particular instance with the ultraOrthodox Community but in other parts of the country its been other communities that have been targeted by the misinformation. So i do not in any way, shape or form want to give the impression this has anything to do with religiousness. It has to do with the misinformation taking hold in not having to messengers to counter it. For the funding to sustain the educational efforts and response efforts. Thank you very much. [applause] from Los Angeles County i do want to thank you for helping set this up and christy and her team from the coalition to get this organized. Its a pleasure to be here. Weve not yet had to make the same Los Angeles County but the three of us are united in prevention to try to keep the Community Safe and healthy. So, this morning as i talk i hope we have an understanding of the challenges we face and what weve done to address the challenges and how you might help us Going Forward to keep the Community Safe. I have a few things that i will cover and i want to make sure you know about Los Angeles County. But i also want to talk about the Measles Outbreaks that weve experienced in the last five years and i want to highlight the bills that were passed by the California Legislature to protect the residents against this disease, and finally i will summarize some of our challenges and successes. Los angeles county is far and away with more than 10 million residents the largest county in the United States. Covering more than 4,000 square miles, which is a very big area, having 88 Incorporated Cities including los angeles, which is a little over 14. 4 billion other cities over 100,000. And in the location wit a locatn 200 languages spoken. You can imagine the Communicable Diseases and outbreaks can be a challenge to control when they occur. And we see measles as a serious threat to the residence, so we are addressing this as strongly as we can. As of today, our department has been successful at containing three Measles Outbreaks in the last five years. This has not been easy, and it has been very costly. The first is the wellpublicized disney land associatedisneylandk in which a single individual infected about 40 other persons late in december of 2014. This resulted eventually in about 148 cases, which occurred in many counties throughout the state of california. About a half dozen other states and also 50 people who lived in canada and mexico. This is that nerdy epidemic curve slide that shows the cases over time. You can see on the left side there is a cluster of about 12 blue cases. This is the wave of cases in early january that we found we had an los angele in los angele. And you can see that this outbreak extended over three additional waves. Into march oand the march of thd a total of 28 cases in total. This massive outbreak consumed many resource hours of Public Health work, including, as mentioned, we have to identify people who were contacts and interview them, many of them we had to test and restrict their movements without if they were incubating that they wouldnt affect others. In total, we had more than 2200 contacts we had to interview for the process. Fortunately, due to the herd immunity or Community Immunity, ended in early 2015. So, about two years after that outbreak almost to the day, we had another outbreak which was somewhat different. And i do want you to understand there are these different kind of outbreaks that can occur. So disneyland was a massive exposure that affected 4 40 peoe that were suddenly affected and traveled around the state in other parts of the country. Whereas this one is one individual, similar, from new york coming back into a group that was unvaccinated. So single, unvaccinated individual is a member of a largely unvaccinated group. Infection spread through several families come each with multiple unvaccinated children. Eventually causing the total of 18 cases in our county and six cases in other nearby jurisdictions. The social Group Despite a lot of communication outreach was largely unwilling to cooperate with our investigation and refused to accept any of our offers of vaccination. This light is a little bit detailed, but it gives an idea of the kind of information we are tracking on a daily regular basis. You do see how well our efforts are going. This is our final summary of this outbreak and it displays the amount of work that we performed to prevent further spread. Shown on the case timeline at the bottom, they were spread out again over for waves and similar to the disneyland outbreak, even though the number of cases in the county was lower, only 18, weve identified more than 2200 contacts. Again, about a thousand of these were in Healthcare Facilities alone. Where again, we have to identify, interview and restrict movements. More than 50 people we were able to identify early and we provided either nmr or for the potential illness. And finally, this is the third outbreak. So, this is now 2019, which has been an extraordinary year for measles in Los Angeles County. And again, this is a completely different form of outbreak from the two prior episodes. About 4000 contacts this year from the 27 cases per ago to place hundreds of people in quarantined to restrict their movements many are familiar with the work we do with Public Health then suddenly they find out they cannot go back to school or go back to work and they are restricted to their home others can be very disruptive to peoples lives i thank you heard in the news how we had to quarantine students at ucla we have a lot of support at those universities. What have we learned from this outbreak . Measles can affect the individual community in differing ways and yes the disneyland outbreak which was the explosive point of the worstcase scenario but fortunately Heard Community prevailed. s second in my professional view it was due to that prevailing level of Heard Community and eventually while they may have had contact with other people almost all of those were immune. Third come i cannot stress enough how challenging it is to respond to these types of outbreaks that we are confident in this area and unless you work in a Public Health department have an appreciation for the activities required is difficult to describe the complexity and organizational efforts. Fourth, want to mention the increase prevailing that herd immunity is what we really need. Touching briefly on a couple of bills passed by the legislature i thank you have heard about these the disneyland outbreak brought attention that more than a few Public Schools had high levels of non vaccination and some more than 25 percent or more than 40 percent of students were not vaccinated with parents claiming personal belief exemptions so the children could avoid mandatory vaccinations. In response senate bill 277 was introduced to eliminate personal and religious belief exemptions to allow only medical exemptions as a reason for exclusion from the mandatory vaccination requirement. This slide is busy but it shows the data in the red area than the green area so you can see a couple of lines that we call uptodate those who have completed the vaccinations and you can see on the left it was only 86 percent we had over 100,000 children entering kindergarten or first grade that by the end the up to date rate was 95 percent which is fantastic from my point of view but i do want to highlight the last row of data permanent medical exemptions you can see before the bill you would expect about one per thousand but interestingly somehow that medical exemption rate increased sevenfold last year. So this is somewhat concerning with that rise of that vaccination rate just over 95 percent and the private schools shown in green consistently for the overall average and statewide data of major concern was the state wide increase of the medical exemption rate of about zero. 8 percent with students in private schools it jumped at two. 5 percent. So i came to attention as the communities a small number of physicians have medical exemptions have been made relatively easy to acquire those Health Officers at the california medical board to interrupt these exemptions were unsuccessful so in response to the monetization of fraudulent medical exemptions by a small number of physicians to introduce the new bill senate bill that requires the exempted physician to state the specific medical reason to certify an actual medical examination has been performed. The law requires California Department of Public Health review all medical exemptions from schools where the overall rate is less than 95 percent and to review all exemptions from any physician that have five or more within one year. Although highly contested it was just signed into law. Let me briefly look at to be successful in the outbreaks we have had with the legislation that the worldwide outbreak continues and we have one. 5 million persons, mostly adults. The cost Analysis Shows even if they dont affect anyone else cost about 30000 to investigat investigate. And each contact we have to reach out and assess cost on average between 501,000 to investigate a response with more than the 8000 contacts we have investigated over the last five years we have spent three or four or 5 million responding to less than 100 cases of measles that are occurring me to find ways to strengthen the Adult Vaccination it also your appreciation and your support with the safety and efficacy around vaccinations. Is a lifelong Public Health professional i am grateful for those legislative efforts to cause against vaccine preventable diseases to highlight the indispensability the others have mentioned of the Emergency Preparedness with local Health Department simply cannot organize our response to Public Health emergencies. These funds are critical to protect Public Health. And also i do want to emphasize appreciation l. A. County has four the funding we have received for the Public Health and Prevention Fund and those Vaccination Efforts and in particular the 317 Immunization Program that has given us thousands to protect residents which otherwise we would not have the money and we would take a long time to find those vaccine doses. With that, thank you for your attention and we look forward to your questions. Thank you. I dont know about the rest of you but i am exhausted. We were telling somebody said isnt it over but yes they are trying to tell us what happened. We appreciate it so important to hear the Public Health story from people on the ground. So we do have time for questions. And then to identify yourself. I am with hhs chief technology officer. Can you talk about how immunization systems and what role they played in your prevention efforts to identify people at risk and how they played a role in the outbreak response. We had one of the roma one robust industries in the country and all providers they are required to report into that so during the outbreak we could do a lot of geocoding to determine and those efforts and then to really understand the efforts, basically to make best use of our resources. Where we found challenges is in terms of in terms of having ready access to immunization information and the fact that right now we encourage adults to have their information and vaccine registry, a small percentage, we work with our Health Information exchanges to get that information but we see that moving forward, it will be a focus of attention to maximize adult to have ready access. Many of us have no idea of that. In our lifetime we got them from a combination of your private provider and travel clinic so we want to ensure that we replicated a system that is as robust as we have for children or adults. What is the most challenging consent . Part of it is getting providers to act on a regular basis if adults are willing to have their information entered into the registry. Once they are asked, the vast majority say yes, health and Hospital System does this routinely. We are working with others to increase the pregnancy. I would like to add a couple comments. In california we dont have state law like new york does to be reported so even further behind, we have the california registry so all the vaccines have to get reported into that but as of today many of the Electronic Health records dont speak to immunization registry. In my department we stood up Electronic Health records a year and a half ago despite a lot of effort we still dont get data from the immunization registry coming in 2 hours so the patient im seeing at a clinic, we have a long way to go on this. Having access to Vaccine Information would allow us to see where outbreaks would happen. Looking at la county and thinking where is it in the county we might have these unvaccinated groups. We have the school data which is helpful and primarily oneyearolds or Young Children but in la county we have between 1 billion, and 1. 4 Million People who havent been vaccinated based on population studies i dont know where it is concentrated. I dont have a focus on that. The other thing is Information Systems are so vital to how we run things in the department. When we had the Measles Outbreak in disneyland we struggled, put together complicated information on a timely basis to know where people were and make sure people who needed the quarantine it, when you have hundreds of cases, hundreds of nurses all over the county doing things, pull that information together was very challenging but now the funding has been so helpful we have been able to fund and stand up to Information Systems and in a couple days track our response efforts and be precise where we are doing our work. There are only a handful of big cities, locals that direct that funding, you are hearing from 2 of them and it is critical. You are hearing from two of the largest local Health Departments in the country and these are the challenges they exhibit even with the heightened capacity compared to others. I had a couple questions. I wondered if you could elaborate on the data. You have school by school records. Doesnt that help you identify pockets of susceptibles . Yes, we do. As i mentioned, our Public School system has above 99 immunization rate. In this particular outbreak, the outbreak was contained to nonPublic Schoolkids beyond the age of school enrollment. Private schools dont come you dont get data from private schools . It is the state that oversees them but because we have requirements for entering immunization information into the vaccine registry we do have all of that Vaccine Information for every child in new york city. We dont have the resources to do the more granular analysis to look for those smaller pockets and that was one of the Lessons Learned in this outbreak and we are looking into doing more of that. The other question i had, i wondered if through this experience if on a National Level a lot of people, theres a lot of doubt how to communicate with parents and if you feel like the experience of this outbreak gave you information that is solid and scaleable and applicable to a variety of sessions. I can start but that is something doctor kraft can address. I will say i was on a panel with a number of individuals talking about the new york city measles experience and one of the individuals on the panel was a nurse who was doing work with families and talking directly with them about what the issues were and one of the things that surfaced was many families didnt feel they had the time with their pediatricians or Healthcare Providers to go in depth in terms of addressing questions and concerns that they heard about the immunizations so then resorted to going elsewhere for that information and what we have been working on is working with our Provider Community in terms of streamlining information with the aap as well. On the other end is realizing it is as important to ensure we have credible messengers within the community so that we create pockets of correct information that can be sustainable, whether it is the measles or other issues and that is what new groups that popped up have taught us. I think to add to that, people forget that the common enemy is the disease. Back in 2000 when we didnt see measles around anymore people didnt worry so much about the disease and dont have the same memories i do about measles. So when people came in and talked about this with the vaccine they were much more focused on the vaccine and on the disease and sadly we are seeing the disease act again, an opportunity to talk about the common enemy. Are you doing anything like you have any of the parents of kids who were hospitalized, you are trying to enlist this . As you say theres always these compelling stories from parents who claim their kid got artistic after the vaccine, we know that is not true but makes a huge impact. Do you have that is the problem with success of vaccination. We have families within the affected community that have agreed to be part of Public Service announcements talking about the importance of vaccination for them and that goes to the issue of having credible messengers. Not that it includes utilizing all channels of media to get that information out and those have gone out on social media as well as billboards and kiosks all over the community. This supports the need for the vaccine fact we discussed here that was put forward by representatives schreiner and burgess. We need the Public Education campaign. And the parents who talk about why their child should be vaccinated and why your child should be vaccinated. Other questions . I will take the prerogative to ask. If you could do one thing moving forward out of these Lessons Learned, whether it is you or policymaker, what is the one thing you would do first to turn the trend on . These outbreaks increase vaccines. I didnt prep them for this. I will take a first step. Im happy with the legislation we had in california. We are all interested in protecting children and i do think the laws we now have on the books put us in good position to safeguard moving forward but i think if i had a wish that could be fulfilled for la county i wish i had the data on vaccine prevalence in the county because i have lots of kids in school, one of the outbreaks primarily affected older children and understanding which community so we have a lot of immigrant communities where folks have come in and i dont know their vaccination status. If i had that information we would be doing outreach today better understand they are vulnerability and trying to protect them. What i would add is wanting to have the information on Adult Vaccination because though the outbreak was primarily concentrated in the pediatric population a lot of the number in terms of people we had to investigate were adults who didnt remember their vaccination status and that wasted a lot of time and it ate up a lot of resources that could be put to better use. Finally, really requiring where kids are and where they gather, school and preschool, these children be protected against the diseases, focusing on the disease is our common enemy. It has been effective and we need to spread that to more state in the country. I was one of those adult asking if i should get an mr bar and she laughed. I am serious. I went into a meeting and she was like okay. I think there was another question in the back. Lee taylor with the National Governors association. Do you have any recommendation for governors on what they should focus on, thinking about how to prevent or reduce the occurrence of outbreaks . Yes. First, understand the facts. You heard a lot of information today. If theres a way we can get the best information about the effectiveness of vaccines and understand the toll, the gaps in those vaccinations are having on the health of children and others in our communities today and understand the efforts that are going on against vaccination and information that is incorrect would be helpful. That is establishing a baseline of the facts. Beyond that, it would be good for governors to understand where there has been good success in other states. A lot of lessons have been learned well by jurisdictions of these outbreaks because if they havent had that experience they are vulnerable so to appreciate what has happened elsewhere, to bring those experts with the lessons that have been learned, quick Technical Assistance from places that have expertise to canvass the risk in their state and give a couple of pointers on if you dont have an information system, you dont have a strong vaccination infrastructure, good Communication Channels to reach families and others at risk, you can identify two or three quick steps. What i would add to that are two things. One is since the Great Recession of 2009 there has been a systemic investment in Public Health infrastructure and it is critically important that governors look at their budgets and see what is allocated to Public Health. A small percentage compared to Healthcare Delivery systems and other sectors but i think this is a wakeup call for all of us to ensure that we have a robust Public Health infrastructure that can respond to what i call brushfires like measles as well as other epidemics like the opioid epidemic. The second thing is i would ask governors to show leadership and courage in terms of ensuring that we have more states that are only allowing medical exemptions for vaccinations. I think that is the best and most important way to ensure that all our children and all of our communities are protected against vaccine preventable illnesses now and in the future. I would add to that and say to keep on the message that the diseases taking the lives and health of our children. Any last questions . I was wondering about the experience you had in california with protests and if that gives you any positive. Is there a way to study what the impact of adding more coercion, i dont mean that in a negative way but adding a coercive approach to conservation whether that has any risk of blowback . Response that the public is less trusting in the vaccination enterprise . That is a really worthy study. Looking over the Measles Outbreaks that we had, with the disneyland outbreak Public Health was not in the communication space where those who oppose vaccinations were at the time but i was happy to see a lot of other groups to as the voice, parents included, to start to speak positively about vaccinations. You are absolutely right. As we use our legal authorities whether state laws require vaccination, we use local authority to quarantine people and so on and so forth, extremely important, we always explain to people because it is a very coercive approach at some times but we have to go beyond that and stay in communication with folks so we hear what their concerns are and are addressing those with facts and information. After all these decisions about which way we go as a society rests with the public. It really does. Our role as a Public Health organization push for prevention to the limit we can with authority you are given but only the will of the people and legislators in terms of defining how far we can go that way but we need that constant dialogue with people, residents, parents, everyone involved so they understand what we are doing and hopefully bring us together to prevent these diseases. We have got to learn more about what people are thinking and what they have to say in that dialogue with them. I will add to that, almost on a daily basis, has to balance Civil Liberties with accountability and the power we have dates back to jacobson versus massachusetts and smallpox and since that time it is clear the needs and urgency of the Broader Community supersede that of the individual in certain cases when there is a risk to human life. I wouldnt necessarily characterize it as coworkers it. It is our response ability as public authorities to make that judgment on an ongoing basis balancing Civil Liberties and civic accountability. Finally, that interaction between Public Health and practicing physicians and practitioners that is so important because when that child cant go to school because they dont have their vaccines they come to me and we talk about what it should be doing and what are your fears, how can we make you feel comfortable with this process . That is the interaction between our practitioners and the Public Health system that is so important. That is a great note to end on. Thank you to the panel, thanks for being here, appreciate it. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations] live tuesday on the cspan networks donald trump makes remarks at the Un General Assembly in new york city. Our coverage begins at 10 am eastern on cspan. At noon eastern the u. S. House returns for general speeches was at 2 00 pm the house takes up several bills looking at humanitarian aid. On cspan2 at 10 am the u. S. Senate continues debate on executive nominations with votes expected to. On cspan3 a House Oversight subcommittee examines the outbreak of lung disease among ecigarette users with testimony from a senior cbc official at 10 00 eastern. Later at 2 30 eastern a Senate Foreign relations subcommittee looks at us policy towards syria. Next, a joint house hearing with the Agriculture Department undersecretary for farm and conservation programs. He was asked about implication of the farm bill, trade relations with china and the status of disaster aid programs. This is just over an hour. [inaudible conversations] this joint hearing of the subcommittee on Risk Management and