Careening in this room for us and i know that the congresswoman couldnt be here today, i want to thank her for being a true champion for Public Health. Also want to thank the American Academy of pediatrics for being such a great partner to us as we start this event. So, Big Cities Health Coalition was founded i was a former leaders for Health Departments to Exchange Strategies and address issues to promote and protect the health and safety of the residents. There we have 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 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 becaus 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 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 childt are emu no compromised. If you have healthy non vaccinated individuals in a 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. And since bed, widespread use of the vaccine letter to a 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 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 diseases. But the really important piece for me is that we need to support activities that focus on prevention and not just respon 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 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 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 majoritrve children tro 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 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 until 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 school 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. Th 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 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 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 emergencye transm 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 b a verg 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. 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 having ready access and the fact that right now we encourage adults to have their information entered into the vaccine registry. We worked with the Health Information exchanges to get that information but we see that moving forward in order to maximize the adults with ready access. Because many of us have no idea where the musician records are and in our lifetime probably we have gotten them from a combination of Health Department and private provider and a travel clinic. We want to ensure that we have replicated a system that is as robust for children as it is for adults. Part of it and then to have their information entered into the vaccine registry on a regular basis. But health and Hospital Services and working to increase that frequency. I would like to add a couple of comments, first in california we dont have the state law like new york does requiring vaccines to be reported to we are even further behind that with all federally funded vaccines have to be reported but as of today many Electronic Health records with that registry so where we recently stood up the Health Record a year and a half ago despite effort, we still dont get data from that registry to see that patient in the clinic. We have a long way to go. Having access to Vaccine Information allows us to see where outbreaks could happen although from colleagues in new york where is it in the county . The data is very helpful and it is primarily one yearold with one Young Children but 1,000,000,004,000,000,000 people have not been vaccinated based on population studies i dont know where it is concentrated so short of that item how to focus but Information Systems are so vital inside the department we first had measles we struggled to put together information on a timely basis so they were quarantines within two or three days but hundreds of cases all over the county doing thing things, that is very challenging. So we fill up that Information System and then to be precise. There is only a handful of big cities and its is critical also hearing from two of the largest thats even with the heightened capacity due to others. I had a couple of questions can you elaborate doesnt that help you identify pockets of susceptibles quick. Yes we do. And our Public School system has above 99 percent immunization rate. With this outbreak this was contained to nonPublic School kids. You dont get data from private schools quick. No. The state oversees them because of the fact we have requirements because of the vaccine registry we do have that information for every child in new york city. With that granular analysis. And with that outbreak. I wonder if through this experience on a National Level of how to communicate of this outbreak gave you information that was scalable . Spirit that is something that can be addressed with the number of individuals to talk about the new york city measles experience and those on the panel to do on the ground work with families that many families did not feel like they had time with their pediatricians or Healthcare Providers to go in depth in those that they heard about those immunizations. So then to go elsewhere for that information and then working with the Provider Community to streamline information. But on the other end to realize to make sure we have incredible messengers within the community to create pockets of correct information that can be sustainable or other issues. And back in 2000 when we did not see measles anymore they dont have the same memories that i do they were much more focused on the vaccine than the disease. So are you do anything of parents of kids who are lawn hospitalized . There always these compelling stories. We know thats not true but thats always the problem is success. We have families within the communities with Public Service announcements talking about the importance vaccination and that is the issue of incredible messengers but to utilize all channels of media to get the information out and then all over the community. And with a vaccines act in with the representatives to say we need that Public Education campaign. And why they should be vaccinated or why your child should be vaccinated. I will take the prerogative. Whether it is you or a policymaker what is the one thing you would do first to turn the trend on the outbreaks . I will take the first stab i very happy with the legislative because were all interested in protecting our children and the laws put us in a good position to safeguard. With the wish we could be fulfilled for l. A. County. We have lots of kids in school that one of those outbreaks to understand which communities. Not really know the vaccine status with that vulnerability. And to have the Adult Vaccinations although the outbreak was primarily concentrated in the pediatric population those that we had to investigate did not know their status. And it could be put to better use. Where they are and where they gather in schools and preschools that they can be protected focused on diseases is a common enemy and we need to spread that two more states in the country. I was on of those adults. With the National Governors association, do you have any recommendation for governors with a shared focus on to reduce the occurrence of the outbreak . Yes but understand the facts. So to get the best information of vaccines you can find the gaps with the hell the children of others. And those that go against vaccination. That is just establishing the baseline. It will be good for governors to understand and those learned by the jurisdictions of the outbreaks and to be vulnerable and so to appreciate what is happened elsewhere to bring those experts it is some quick Technical Assistance for those places who have expertise to canvass the risk give some pointers if you dont have an Information System you dont have a strong vaccination infrastructure or Communication Channels and then to identify two or three quick steps. What i would add to that is there has been a systemic investment in infrastructure and a small percentage and then this is a wakeup call to ensure that we have a robust Public Health infrastructure that can respond with measles as well as others like the opioid epidemic. I would ask governors to show leadership that we have states that are allowing medical exemptions that is the most important way that all children and communities are protected against illnesses. I would just add to that and it takes the lives and health of our children. With that experience that you have had in california so is there a way to study the impact to add more coercion with that approach to vaccination with a response that makes the public less trusting to the vaccination enterprise. That is a worthy study. But with disneyland Public Health for those that oppose vaccinations at the time but i was very happy to see those that stood up as the voice and then to speak positively. You are right to use that Legal Authority whether they require vaccinations or local authority to quarantine people it is extremely important and we always explain that but we have to go beyond that to stay in communication so that we hear what their concerns are in addressing those. Because after all these decisions rest with the public as the Public Health organization with the authority we are given but only with the will of the people to define how far we can go. And then have constant dialogue with parents and everyone involved to bring us together into unity and agreement. We have to learn more in that dialogue. Public health on a daily basis has to balance Civil Liberties with accountability and date back to massachusetts and since that time with the need and the urgency to supersede that of the individual i wouldnt necessarily characterize that it is part of the responsibility with the ongoing basis of Civil Liberties and civic accountability. The interaction between Public Health and practicing physicians and practitioners is so important because they dont have their vaccines to talk about what it is we should be doing what we do to make you feel comfortable. That is the interaction with practitioners and Public Health system that so important. Thats a great note to end on. Thank you to the panel and for being here. We appreciate it. [applause] good morning everybody i believe we are seaspan live. We are now feeling i would call it the airwaves but thank you so much. For joining us today very special
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