Transcripts For CSPAN3 Public Health Officials On Measles Outbreak 20240714

Foerng, everybody. Thank you so much for coming. Im Chrissie Julian ob the executive director of big citys Health Coalition. I want to say a thank you to representative roy allards office for hosting us. While she captor be here today i want to thank her for being a champion of Public Health. I want to thank the American Academy of pediatrics for being such a great partner in planning the event. The big citys Health Coalition was founded in 2002 and is forum for leaders of americas largest metropolitan Health Departments to Exchange Strategies and jointly address issues to promote and protect the health and safety of their residents. We have nearly 30 we have 30 member jurisdictions whose Health Departments serve nearly 62 million, or one in five americans. And were lucky to have two member jurisdictions here today. You all have bioss in front of you. Im not taking you have too much time for me but i want to introduce the panel and then turn it over to them. So in the order which theyll be presenting dr. Colleen kraft, the president past proton of aap, the dr. Oxiris baribeau and jefferily Gunness Hauser. Both dr. Kraft and Gunness Hauser came from california. Thank you to them for traveling so far. Thank you for taking the time to join us today and share your perspectives. And i will now turn it over to you. Dr. Kraft. Okay. Thank you, chrissie. Im dr. Colleen kraft, the immediate past american of American Academy of pediatrics we are going through about Measles Outbreak 101 what happened, when it happened and why immunization against measles and other illnesses so important. The American Academy of pediatrics iks is a nonprofit professional organization with more than 67,000 pediatricians including primary questionnaire, pediatrics subspeciality and medical subspecialists and dedicated to the health and safety and well being of all infants, children, add lessants and young adults, we publish recommended immunization schedules with acip, the cdc, the American Academy of Family Physicians and the American College of objectsens and gynecologists. So lets go back into the history of measles in the United States. In 1963 the measles vaccine was licensed and in 1968 it began to be distributed. And measles was gone, declared eliminated from the United States in 2000. So there was no continuous decease transmission for more than 12 months. And that was due to a highly effective Vaccination Programs and better measles control in the United States and in the americas. However within we have seen measles come back. Due to people not vaccinating children and not getting vaccinated. So in 2010 we saw 93 cases. And in 2019 we have a whopping 1241 cases of measles. So this disease that was gone in 2000 is back. And its back with a vengeance. If you look at the states reporting cases of measles in 2019, all of those red states are the red states where measles is has come about. And we see this all over the country. So what is measles . Its an acute viral disease characterized by fever and cough and runny knows, and red eyes and sore throat and red brownish blotchy rash beginning on face spreading throughout the body. Common combinations include pneumonia, ear infections krup and diarrhea. About 1 in four people contracting measles will be hospitalized. And im actually old enough to remember having measles. So i had measles when i was three years old and so did nigh 2yearold sister, my 1yearold brother and infant sister. And i remember this as the one time that the doctor came to our house to see us. And i remember a couple of other things too. The first thing i remember is that my eyes were so sore i could hardly open them. And my mother kept the shades down and the lights down low because there was so much eye pain with measles. I remember that distinctly. And the other thing i remember were the prayers that we said for my 2yearold sister because she got pneumonia. And we almost lost her. She was in the hospital and fortunately recovered and we looks looked at the diseases as something deadly hitting the four little kids at the same time. And this was very commonplace in the United States before vaccination. What we know is that 130 of the people who got measles this year in 2019 were hospitalized. And 65 of them had complications, including pneumonia just like my little sister. And encephalitis which is brain swelling. Acute encephalitis which results oft nben in permanent brain damage can occur in every 1 out of 1,000 cases process the most measles eliminates elimination era. Death predominantly has occurred in 1 to oufr 1,000 cases in the United States. Its become and just as deadly as it was back when i had it. Its extremely contagious. So if one person has measles, nine out of the ten of the people they are in contact with will get measles if theyre not protected. The virus is spread easily through the air when an infection the person coughs or sneezes and somebody sneesh inheals the drop lets. The measles virus is pretty hardy, hanging in the air and spreads for several hours after the infected person left the room. And then could be transmitted from person to person as well. Once a child gets the measles, exposed and infected, the first symptoms will not be there for eight to 12 days. But the infected children are contagious one to two days before infected. And when symptoms finally emerge three to five days they are contagious before the rash breaks out. The contagious period continues three to four days after the rash appears. We know where people get measles from. In other places in the world where there has not been the same robust Immunization Program measles is commonplace. And so measles becomes a plane ride away for any children not v vaccinated process they travel to other places in let world they can come with measles. Kids have come back from the ukraine, israel and the philippines. Appear the majority of the people getting measles in 2019 were unvaccinated. Who is at most risk for measles . The most vulerable. The children less than 5 years of age. Its adults aged more than 20 years. Its pregnancy women and people with a compromised immune systems who cant get the vaks even who may have cancer other hiv or other diseases where the immune system is not up to snuff. We recommend the measles vaccine be given between 12 and 15 months of age and again at four to five years of age. And what we know is that if you get those two immunizations there is a 97 chance that youll develop antibody and protection against the measles. So vaccine recommendations during the outbreaks ive changed what i had to do in practice because we know during the outbreak, the mmr vaccine should be offered to all people expose ds to the outbreak setting or anybody who doesnt have the measles immunity. And we also were starting now to ask our babies and parents of babies six to 12 months if theyre going to one of the places where measles is endemic. And were starting to immunize our kids under 12 months of age if theyre going to be at risk, because of the highly contagious nature of measles. There is a concept called herd immunity or some people called it Community Immunity since we are not cattle. But this is the idea that if we immunize and protect people around us then were going to protect that one vulnerable individual who cant be vaccinated for any reason. Individuals who live in communities with high vaccination rates are effectively protected. And those people who cannot get vaccine are also protected. So its most important for very young churn and those who are immunocompromised. This is how Herd Community works. If you have healthy none vaccinated individuals and a few vaccinated individuals those are arent vaccinated can get the disease. But with immunization if most are vaccinate the then that one child, the one immunized immunocompromised person who cant the vaccine is still protected, because most of the people around them have gotten the immunization and they are protected. So federal legislation in the vaccine act was becaused by dr. Kim schrier, a pediatrician and michael best of your knowledge he is an objects strishen. Because it is important because it thoeshz ds the evidence based Public Awareness campaign and the awareness of campaign. Very much like the Truth Campaign for smoking, talking about the enemy as the disease and that vaccinations are a way to prevent that enemy from affecting all of us, especially our most vulnerable. The bill allows data to be collected to identify communities with low vaccination ulgtsization or where vaccine misinformation i mab targeted it authorizes grants to understand vaccine hesss tantcy. Attitudes towards vaccens and to help vaccinate more people and more kids. So the remiepder before that measles Vaccination Program started in 1963, an estimated three to four Million People got measles in the United States. About 50,000 cases were reported to the cdc. But of the people four to five hundred a year died, 48,000 including my baby sister were hospitalized. And 1,000 developed that encivilites or brain swelling from measles. But since then widespread use of the measles vaccine led to cigaretter than 99 reduction in measles cases compared with a prevaccine era. And we dont want to go back to the prevaccine era. We still need to educate families and communities on the importance of vaccines. Our enemy is the disease, the way we combat this enemy is by education and vaccination. Thank you. [ applause ] thank you so much. Now you have learned a little bit about measles. Im going to quickly set the scene about the roll of Health Departments and the role of the different brafrms of government. I should have also said were holding questions to the end but we will have time at the end for questions. So local Health Departments are on the front lines of preventing and responding to outbreaks. They keep communities healthy and safe or help get your communities healthier and safer. For example, in an outbreak they investigate every case. And youre hearing more about this. You know what happened on the ground in new york city and l. A. County. They also have Legal Authority to quarantine or issue emergency orders done in both cases. They look to ensure the community is sufficiently vaccinated and provide the vaccines when necessary. And they also provide clear, simple, accurate messagesing on vaccination and work with partners to do so, an important point also i think that dr. Barbot will talk about. The local of federal local Health Departments are on the ground. Response and many Health Issues are local. But the federal government still has an Important Role to play. And they have resources to bear when needed. For example they can extend the kpapts of local or state Health Departments, share subject matter expertise when needed, they have the bully pulp it we have the Surgeon General of the secretary of hhs, the head of the cdc, important people who can put out messages to a broader population. Thats not as localized. And then also the federal government can provide reliable dedicated funding. Ive highlighted four funding streams here, the Immunization Program, the epidemiology and Laboratory Capacity or elc, which is easier to say, the Public Health Emergency Preparedness Funding Program or fepp and the prevention in Public Health fund. Again dr. Barbot and gunzenhauser will talk to you about how they used these funding to this is the 10year history of 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 533. So we have come down over 10 years. Despite the fact that we have had many preventible outbreaks. And also important is that this program does not just include vaccine purchase and infrastructure potter to distribute vaccines in communities. But also other activities to achieve National Immunization goals and keep the vaks vaccination rates high to prevent death and disability from the diseases. The funding supports whats known as the 317 Immunization Program and the infrastructure for the vaccines for children program. Importantly on in graph is that the red bars show dollars from the prevention and Public Health fund and a half back filled cuts to overall appropriations to the Immunization Program. This fund is always on the chopping block as way to pay for other priorities. This is just to illustrate how important it is, the fund is, for the ability of local and state Health Departments to do their job protecting the publics health. So as we sit here on capitol hill its important to think about what congress can do to help move the needle. Its not just about funding. And there are a number of bills introduce on both sides of the capitol that have key components to help us move forward to not only try to stop but also address the next outbreak of vaccine preventible diseases. And dr. Kraft touched on this. But the really important piece for me is that we need support activities that focus on prevention and not just response. So thinking about surveillance of vaccine rates. We dont have good numbers about how many people are vaccinated. Many cities do and localities some states. Pu it varies across the country. We need more research on Vaccine Hesitancy. Dr. Kraft talks about about a National Campaign to combat misinformation. And thn this new piece i dont know when we stopped saying social media is new. But im going with it new today. We really need to assess the impact of social media and accelerating or mitigating Public Health crisis, antivaccines things look that. And obviously if any of these programs are implemented dollars would be needed to support them so that they can be carried out. And now i will turn it over to disinterest barbot to talk about new york city. Irrelevant. Good morning, everyone. So its my pleasure to talk with you about the response to measles in new york city. Today im going to cover the following. Im talking about the epidemiology of the outbreak appear the final case count. Im talking about the response be fought on two fronts, that of a of the Communicable Disease related specifically to measles and then on the second front combatting measles misinformation. Ill talk about the funds that were used during the outbreak, lessons learn and then future challenges. So this is to kind of situate us in new york city. These are the two principal communities affected by the Measles Outbreak. Here in the top circle, williamsburg. And here in the lower circle borough park. And these are both highly populated communities. In new york city this is kind of a as i like to say a geeky slide. But it helps to illustrate a number of things. One is that the outbreak began in the beginning of october 2018. And that on this side of the slide you see it extended until september 3rd. And even though in each of these bars represents new cases for a particular we can. So generally we dont declare an outbreak over until there have been two incubation periods. Thats what this shows. The other thing it shows is the majority of cases seen were in williamsburg. It also helps me to illustrate that in address the Measles Outbreak in new york city we took a measured approach that was intended to meet the epidemiology that we are seeing at the particular time. We didnt jump the most aggressive measures that we could have taken early on. So this first phase really entailed addressing issues of transmission within schools. The second phase addressed transmission within communities. And then this third phase was when thank you was when we issued our Public Health emergency order. And we hadnt taken that kind of drastic measure in years in new york city. The last time that it was done was during the h 1 n 1 outbreak in 2009. But 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. And so the emergency order essentially called for immediate vaccination of individuals living in the four stip codes that were most affected by the measles and individuals found not to be immunized were at risk for financial penalties. With we then saw overall is that our final case count, the final number of individuals affected were 654. Youll see from this slide that the majority of them were children 1 to 4 years of age. And that of this group 49 ended up in the hospital, which i was listening to dr. Krafts numbers, which is about a third of the individuals affected in the United States, who were hospitalized were 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 requiring oxygen therapy. And as dr. Kraft was speaking inch im a pediatrician by training as well. In my training ive within in this business about 30 years. Ive never seen a case of measles. So this was a situation for many our providers as well. Its something that we thought we had seen the last of. But clearly we have not. And so in the preventible cases you see there, 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 are not been. So thats the bulk of the preventible cases that we saw in the affected outbreak. And so actually im going back. What we did here was we had a very aggressive response collaborating with our Health Care Delivery partners as well as our Community Partners. And we also lowered the age at which to immunize children. So we actually recommended 6 months to 11 months, which general will i we reserve for children traveling to areas with ongoing transmission. But in this situation we wanted to do it for domestically transmitted cases. So the provider outreach youll see there was very extensive. And including both Technical Assistance and primarily to ensure that Health Care Delivery sites were not sites of ongoing transmission all the way through to ensuring there was enough mmr on hand and dribing educational materials in english and yiddish, the bulk of the members attacked were the ultraorkt docks community in new york city, in the neighborhoods of new york city. This is a slide that shows what every Public Health practitioner wants to see, that is the measures we put in place had the desired outcome. And the measures we put in place were intended to increase the number of individuals that were vaccinated. This is a slide that looks at the Previous Year and this year. And so what we see is that typically we have a back to school rush. The dark line is the 20182019 period. The dotted line is the year before. And what we saw is that at the beginning of the outbreak, when we declared it we saw a significant spike in the number of individuals receiving the mmr vaccine. And then over time it dropped. We started issuing exclusion letters and working with schools more aggressively. We saw the spike there. And then we had a lull. And then when we issued the Public Health emergency we saw another spike in the number of individuals who were immunized. And what you see here is since august and september the number of individuals in this school year getting immunized during what we call the back to school rush is lower than the Previous Year. And we see this as a good thing, because it mean that is families are mot waiting until the last minute to get immunized. Thats a good thing for us to see. What this ended up resulting in was in over 188,000 doses of measles given during the 20182019 outbreak, which is 23 over 23,000 more than the Previous Year in those two particular neighborhoods. So it was a massive effort that was led by our department in collaboration with the Health Care Delivery system. But that could not have happened without the engagement of our Community Partners. And so what this outbreak highlighted for us is that in certain situations traditional partners are not enough. And when we are up against misinformation be up against issues that really we have never encountered before, it was critical to engage Leaders Within the orthodox community. And so this community had been targeted by the antivaccination messages. And they were targeting through robo calls, direct mailings, as well as social media. So this was in the exclusively social media. They used all available fronts to disseminate misinformation, propagate fear within really resulting in high numbers of individuals within the community being unvaccinated, susceptible to a disease that has significant consequences. And so we met with religious leaders. As a result of this the community took on the challenge of ensuring vaccination for folks. And new groups started popping up, the jewish orthodox womens medical association is one i want to highlight. And these were a group of physicians who took it upon themselves to do housecalls to offer vaks aches going back to old school tactics. The importance here is talking about the consequences of Vaccine Hesitancy and the degree to which misinformation fear really can take hold in certain communities. And its not just a phenomenon we are seeing here in the United States. The outbreak that began in new york city actually began in israel the year before. And that outbreak actually began in 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 in new york city there was a pamphlet called that was distributed by peach, which was filled with really inflammatory conspiracy based theories about the dangerous of vaccine and how it was much safer it was to get measles than the vaccination. So when we were confronted by p. E. A. C. H. We made p. I. E. This is Communications Material that we put together and in collaboration with our Community Partners that took each point that p. E. A. C. H. Made and refuted that with actual scientific basis. 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 sort of the equivalent of the old school tupperware parties, where there were small gatherings of families to really have time to understand the underlying Science Behind the safety and efficacy of vaccines. As part of our efforts of combatting the measles on the second front of combatting misinformation we put out a lot of educational materials and emphasized the importance of spreading the truth, not measles, the importance of debting vaccinated, having material in yiddish and english and materials in spanish and chinese. And im particularly this particular graphic i think does a very good job at conveying what dr. Kraft was talking about in terms of herd immunity. And that with one affected individual there are others in the light gray unable to get vaccinated and are at risk for illness. So by the numbers,ty end of the day there were over 547 staff deployed for this. Over 100,000 person hours spent. 21,000 new yorkers were tracked down to confirm exposure and immunity status. 2,100 individuals had a more indepth investigation to determine vaccination status and whether or not they actually did have measles. And it cost us 6 million to address something that is incredibly preventible. And so these dollars were primarily and let me just walk you tlup. The top line is the total dollars. You will see that the bulk of dollars that were used to address this were city dollars. The next level was state dollars. Youll see that this was after we declared the Public Health emergency. And that this lower line, are federal dollars. Even though that is a much smaller curve, its a very important curve, 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 when we would not have been able to mount the robust aggressive response we did were it not for these funds. The other important thing to note is that this line also includes Emergency Preparedness dollars. I dont want ups to lose sight of the fact that often times i think the public thinks that this is like jiffy pop, right . No there is training and preparation and systems need to be in place in order to ensure that we protect and promote the health of new yorkers. So those found are critical for us. And so i want to just end on or actually have one more slide after this. The Lessons Learned. I think this was a lesson for the entire country on not taking Public Health victories for granted. That even though the United States has, you know, been declared measlesfree since 2000, this is a clear example of how because of International Transmission we now have measles reintroduced into our population. And its critical for us to redouble our efforts on ensuring that families have appropriate and accurate information, that we have individuals within a number of different communities, be it the Health Care Provider commune, the religious communities, armed with information that they can share with their neighbors and be trusted messagers about the importance of en a the safety of vaccinations. And also ongoing Public Health campaigns regarding the importance of vaks aches, clearly not just of measles but of all vaccinations. And then the importance of having more granular surveillance. Bus in new york city we have a 99 Immunization Coverage for children nar school age. But what this outbreak showed us was that there are pockets where there are a high number of individuals susceptible to this virus. And so having more resources to do that granular surveillance is key for us. And then leveraging Community Relationships to build new alliances, not just for this particular outbreak but for Public Health emergencies moving forward. What we clearly have learned threw this experience is that the partnerships that we have put in place will also help us for Emergency Preparedness for, you know, manmade as well as natural disasters in the future. And so the challenges for us remain with Vaccine Hesitancy. Given we did with o a Health Opinion poll recent in new york city. And 21 of the respondents adults with children between the age of birth and 17 years of age 17 excuse me 21 of them let me say that correctly. 21 of the adults with kids zero to 17 reported that they had delayed or refused vaksitions. Light of the fact we have International Transmission and transmission in other parts of the country its concerning. And is gives us the urgency to kin the efforts we put in place. As i mentioned was the future challenges include continued education to prevent misinformation. In this case it was the ultraorthodox community. But in other parts of the country its other communities targeted by misinformation. I dont in any which shape or form want to give the impression this has to do with religion. This is misinformation taking hold and not having enough credible messagers to counterit. Then 80s the need for funding to sustain these educational efforts and response efforts. So thank you very much. [ applause ] good morning. Im Jeff Gunzenhauser from Los Angeles County. I want to thank the representative for helping us set this tim the big cities Health Coalition is get this organized. Its a pleasure to be here with dr. Kraft and dr. Barbot. Weve had had not yet to make p. I. E. In the Los Angeles County. But the three of us are united in prevention and trying to keep our communities healthy and safe. I think you have understanding what we face and what we have done to address the challenges and how you might help us Going Forward to keep our communities safe. I have a few things im going to cover. I want to make sure you know a bit about Los Angeles County. But i also want to talk about three Measles Outbreaks we sprnsed in the last five years and i want to highlight two bills recently passed by the california legislatures to protect our residents against the disease annan finally i will highlight 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 squour miles, a very big area, having 88 incorporated cities, including los angeles, which is a little over 4,000,005 other cities over 100,000. And in a location where more than 200 languages are spoken, you can imagine that Communicable Disease outbreaks can be a real challenge to control when they occur. And we see measles as a serious threat to our drents so we address this as strong willy 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 was the well publicized Disneyland Associated outbreak in which a single individual infected by 40 other persons late in december of 2014. Which resulted eventually in about 148 cases, which occurred in many counties throughout the state of california, about half dozen other states and also affected people who lived in canada and in mexico. This is that nerdy ep dem ib curve slide haste thats so frequently referred to but it shows the distribution of cases over time. You can see on the left side of the slide a cluster of about 12 blue cases, the first wave of case that is suddenly in early january we found we had in Los Angeles County. And you can see that this outbreak extended over three additional waves. Into march of that year. We had a total of 28 cases in total. This massive outbreak consumed many resource hours of Public Health work, including as dr. Barbot mentioned we had identify people who were contacts. Interview them. Many we had to test. And many of them we had to restrict movements so that if they were incubating it they wouldnt affect others. In total we had more than 2,200 contacts that we had to interview for this process. And fortunately due to herd immunity or Community Immunity the outbreak ended early in 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 different kinds of outbreaks that can occur. The disneyland was a massive pinpoints points order exposure that affected 40 people traveling around the state and other parts of the country. Whereas this one was one individual similar to new york who is coming back into a group. That was unvaccinated. Here a single unvaccinated member, a member of a closed largely unvaccinated social group developed measles. The infection spread through several families each with multiple unvaccinated children, eventually causing a total of 18 cases in our county and six cases in other nearby jurisdictions. Of note, the closed social Group Despite a lot of communication and outreach was unwilling to cooperate with our investigation. And rfrzed to accept any of our offers of vaccination. This slide is a little bit detailed but it does give a idea of the kind of information that we are track tracking on our daily or regular basis. To see how well our efforts are going. This is our final summary dash board of the outbreak appear dpla zplis the amounting of work we performed to prevent spread. Showing in the case time line the case price were spread out over four waves and similar to the disneyland outbreak even thoep the number of cases in county was lower only 1 we had identified more than 220 oh contacts again about a thousand in Health Care Facilities aloner and finally this is the thid outbreak. 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. And as the others described the driving factor behind this has been the explosives outbreaks of measles occurring in other parts of the world, leading to a total of 19 persons who picked up this infection somewhere else in the world and during this year then came into Los Angeles County. 11 of these were temporary nonresidents visitors, Los Angeles County is a popular tourist designation. We had a traveler from new zealand who recently came in and saw a bunch of sites and exposed a lot of people. This has been a common occurrence this year eight of the cases occurred amongst residents and two of the residents spread the infection to eight ears. In total we have investigated about 4,000 contacts this year. From the 27 cases. And we have placed hundreds of people either in quarantine or restricted their movements. Many people are unfamiliar with some of the work we do in Public Health. When sawedly they find out they cant go back to school, cant go back to work and in some case we restrict them to their home, this can be very disruptive to peoples lives. I think you all heard in the news we to quarantine students at ucla and cal state. We had support from the universities. But again this was very disruptive. So what have we learned from the outbreak . I hope you can appreciate that each of these was very different. Measles can affect an individual community in very different ways. Yes that disneyland outbreak which was an explosive point source outbreak is sort of the worstcase scenario. But fortunately herd immunity prevailed and eventually that outbreak was over. Second at least in my view the main reason the outbreak ds end was due primarily to the prevailing level of herd immunity in our communities. Eventually those final cases while they may have had contacts with other people almost all of those contacts were immune due to vaccination. And thats what aboerted the outbreaks. Third, i cant stress enough how costly and how challenging it is. Our ability to respond to these outbreaks has really grown. And i feel we are very competent in this area. But unless you work in a Public Health department and have a appreciation for all the different activities required its difficult to describe the complexity and organizational efforts that are needed. And fourth i do just want to mention that to increase the prevailing level of herd immunity is what we really need. Okay so now i want to touch briefly on a couple of bills that were passed recently by the california state legislature. I think you heard about these. The disneyland outbreak beirut to you can attention the fact that more than a for a few Public Schools had high levels of nonvaccination. In some schools more than 25 or more than 40 of students were not vaccinated, owing largely to parents claim personal belief kefrpgss so the children could avoid the mandatory vaks iks as such as mmr to protect against measles. In response senator rich pan a physician introduced senate bill 277 which eliminated personal and religious belief exemptions and allowing only medical exemptions as a reason for exclusion from the mandatory vaccination requirements. This slide is a little bit busy. But the table shows our data from prior to sb 277, in the red area and then in the green area is results for the post277 era. You can see a couple of lineups. The one highlighted in black, the third row of data is with we call up to date, students who completed vaccinations. You can see on the left, in 20142015, this rate was only 86 of our students. We have over 100,000 children entering kindergarten or first grade each year. But you can see by the end after sb 277 on the right you can see in 2018 and 2019, the up to date was about 97 . Fantastic from my point of view. I want to nightly in the second to last roe you can see pme standing for permanent medical kefrpgss. You can see before sb 277 theets were at the rate we would expect about 1 per thousand or 0. 1 . Pu interestingly somehow after the law went into effect that medical exemption rate increased seven fold up to 0. 7 last year. This is somewhat concerning. But anyway this is summary data. Showing the vaccination rate up to 9 . You can see the private schools shone in green lag behind Public Schools in the overall average. In this slide, again, statewide sedate data of major concern was the increase in the medical exemption rate to sedate body about 0. 8 and particularly students in private schools in rate jumped to 2. 5 . So what came to attention was the fact that in a number of communities, a small number of physicians appear to have made medical kefrpgss relatively easy to acquire efforts of local Health Officers in the extra medical board to interrupt the exemptions were unsuccessful. So in response to address what was described as the monetization of fraudulent medical exemptions by a small number of physicians, senator pan introduced a new bill, senate bill 276, requiring an exempting physician to state the specific medical reason for the exemption and certificate that examination had been performed. The law requires that the California Department of Public Health review all medical exemptions from schools where the overall medical exemption rate or the vaccination rate is less than 95 , and also to review all exemptions from any physician who has submitted five or more of these exemptions within a year. Though highly contested, this bill was just recently signed into law by governor nus um. Let me briefly summarize our challenges and successes. As ive said, weve been successful in controlling the outbreaks that weve had in l. A. County and with the recent legislation, our children are increasingly protected, but the worldwide outbreaks of measles continue, and in our county we have nearly 1. 5 million persons, mostly adults, who remain unimmunized against this disease. Our cast Analysis Shows that each arriving infected traveller costs us about 30,000 to investigate, and each contact that we have to reach out and assess their immunity costs us on average between 500 and perhaps in some cases up to 1,000 to investigate and respond to. So given more than the 8,000 contacts that weve investigated in the last five years, weve easily spent 3, 4 or 5 million responding to what is less than 100 cases of measles in our economy. So we need ways to strengthen our Adult Vaccination and we need your appreciation and support in Building Trust around the safety and efficacy of vaccinations. As a life long Public Health professional, i am very grateful for all the legislative efforts that have supported our cause to protect against vaccine preventable diseases. I also want to highlight the in dispensability as the others have mentioned of the Public Health emergency prepreparedness funding, which simply cannot organize our responses to Public Health emergencies. We have many of these far beyond the Measles Outbreaks and these funds are critical to our efforts to protect the publics health. And also i really do want to emphasize the appreciation that l. A. County has for the funding that weve received through the Public Health and Prevention Fund and the Vaccination Efforts that have been funded in the county, and in particular the 317 Immunization Program, which has given us thousands of doses on a very timely basis to protect our residents, which otherwise we wouldnt have had the money and it would have taken a long time to find those vaccine doses and abort these outbreaks. So with that, i want to say thanks for your kind attention and i think well look forward to your questions. Thank you. [ applause ] i dont know about the rest of you, but im exhausted just hearing about what these folks have been doing for the past year. I was telling somebody that we were doing this briefing and they said why are you doing a measles briefing . Isnt it over . And i said yes, but people finally have time to tell us what happened. So thank you, i really appreciate it. So important to hear the Public Health story, the local Public Health story from people on the ground. So with that, we do have time for questions. I have a microphone, so if anybody has a question, i would love for you to identify yourself, also, so that we know who is asking what. My name is jim daniel and im with health and human services, the chief technology officer. And i was wondering, im getting a little geeky, if you could talk about how immunization systems, what role they played in your prevention efforts and in identifying people at risk, how they really played a role in your overall outbreak response. Sure. So we have one of the most robust immunization registries in the country and all providers that receive vfc funds are required to report into that. And so during this outbreak, we were able to do a lot of geocoding to determine baseline immunization rates, and in the beginning it was Something Like 83 and then most efforts immunization rates and we bumped those up to ruffoughly 93 in t affected communities. So really understanding that our efforts were targeted. Basically we were efficient, effective and made best use of our resources. Where we then found challenges, and jeff and i were talking about this earlier, is in terms of having ready access to adult immunization information, and the fact that right now we encourage adults to have their information entered into the vaccine registry. Its a very small percentage. We worked with our Health Information exchanges to try and get that information. But we see that moving forward its going to be a focus of attention in order to maximize the number of adults who have ready access to their Vaccine Information, because many of us, myself included, have no idea where our immunization records are. And in our life time have probably gotten them from a combination of the health department, your private provider, and a travel clinic. And so we want to ensure that we have replicated a system that is as robust and detailed as what we have for children for adults. Whats the most challenging part of getting the adult data . Is it consent or part of it is getting providers to ask on a regular basis if adults are willing to have their information entered into the vaccine registry. We find that once theyre asked, that the vast majority say yes. Our health and Hospital System does this routinely. Were working with other Health Systems to increase that frequency. I would like to add just a couple of comments. First, in california we dont have the state law like new york does that requires that vaccines be reported, so were further behind. We do have the california immunization registry, to all the federal real funded vaccines have to get reported into there. But as of today, many of the Electronic Health records dont speak with the immunization registry. For example, in my department where we rescently had an Electronic Health record a year and a half ago, we still dont get data from the immunization registry coming into ours so i can see that a patient im seeing in a clinic has been immunized. Weve got a long way to go on this. Having access to the Vaccine Information would allow us to see where outbreaks could happen. So as weve talked about our colleagues in new york, were looking at l. A. County thinking where is it in the county where we might have these highly unvaccinated groups. We have the school data, which is very helpful. And as you can see there, it was primarily 1 year olds or very young children, but in l. Hachlt county where i have 1 almost and 4 Million People who havent been vaccinated, i really dont know where its cons tratd. So short of having that, i really dont know how to focus our efforts. The other thing i will say the Information Systems are so vital to how we run things inside the department. When we first had the Measles Outbreak from disneyland, we sort of struggled to put together complicated information on a timely basis so i could know where people were and make sure within two or three days people that needed to be quarantined, it was happening. When youve got hundreds of cases, hundreds of nurses all over the county doing things, to pull that information together has been very was very challenging. But now the funding has been so helpful and weve been able to fund things so weve built an Information System and within a couple of days we can track our response efforts and really be precise in where were doing our work. So its really been very helpful. There are only a handful of big cities that directly get the funding. Youre hearing from two of them. And its really critical. Youre also hearing from two of the largest local Health Departments and wellresourced Health Departments in the country and these are the challenges that they exhibit, even with the heightened capacity compared to others. Arthur allen from politico. I had a couple of questions. I just wondered if you can elaborate a little bit on the data thing, because you have schoolbyschool records, so doesnt that help you identify pockets of susceptibles . Ill start. Yes, we do. And as i mentioned, our Public School system has above a 99 immunization rate. And so in this particular outbreak, the outbreak was contained to nonPublic School kids who were below the age of school enrollment. So the private schools, you dont get data from private schools . No, its the state that oversees them. But again, because of the fact that 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. What we dont have is the resources to do sort of the more granular analysis to look for those smaller pockets. And that was one of the Lessons Learned in this outbreak, and were looking into doing more of that. The other question i had was about hesitancy, and i just wondered if you, through this experience, if you i think on a National Level a lot of people, theres a lot of doubt about really how to communicate with parents, and if you feel like the experience of this outbreak gave you information thats solid and scaleable or applicable in a variety of settings. Yeah, you know, i can start but i think that might be something that dr. Kraft can address. I think what ill say is that 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 onthegroundwork with families and talking directly with them about sort of what the issues were. And one of the things that sort of surfaced was that many families didnt feel like they had the time with their pediatricians or with their Health Care Providers to really go indepth in terms of addressing the questions and the concerns and the myths that they had heard about the immunizations. And so then resorted to going elsewhere for that information. And i think what we have been working on is working with our Provider Community in terms of, you know, streamlining information. Weve reached out to the aap as well. But i think on the other end, its realizing that its as important to ensure that we have credible messengers within the community so that we create pockets of correct information and that can be sustainable whether its for the measles or whether its for other issues. And thats what some of these new groups that popped up have really taught us. I think to add to that, people forget that the common enemy is the disease. And back in 2000 when we didnt see measles around anymore, people didnt worry so much about the disease and they dont have the same memories that i do as a child about measles. So when people came in and talked about myths with the vaccine, they were much more focused on the vaccine than on the disease. And sadly, were seeing the disease back again. Its an opportunity for us to talk about the common enemy. So are you doing anything, like do you have any of the parents of kids who were hospitalized who youre trying to enlist as because as you say, theres always these compelling stories from parents who claim that their kid got autistic after they took a vaccine. We know thats not true, but it makes a huge impact. So thats always the problem with the success of vaccinations. So we have families within the affected community that have agreed to be part of Public Service announcements talking to the importance of vaccination for them. And that really goes to the issue of having credible messengers, that it includes, you know, utilizing all channels of media to get that information out. And those psas have gone out on social media, as well as on billboards and kiosks all over the community. This also supports the need for the vaccines act that we discussed here thats been put forward by representative burge es, we need the education campaign, we need the child who had the disease and the parents who talk about why their child should be vaccinated and why your child should be vaccinated. Other questions . Ill take the prerogative to ask a question. If you could do one thing moving forward out of all these lessons, whether its you or a policy, maker, what is the one thing you would do first to sort of turn the trend on these outbreaks or increase vaccines . And i didnt prep them for this. Well, ill take the first stab. Im very happy with the legislative support weve had in california because i think were all interested in protecting our children and i do think the laws we now have on the books put us in a good position to safeguarding those children Going Forward. But i think if i had a wish that could be fulfilled for l. A. County, i wish i really had the data on the vaccine prevalence in the county, because i have lots of kids that are later in school that one of those outbreaks primarily affected older children. And understanding which communities because we have a lot of immigrant communities where folks have come in and i dont really know their vaccination status. And if i had that information, we would be doing outreach today better understanding our vulnerability and trying to protect those communities. I think 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 that 21,000 number in terms of people we had to investigate were adults who didnt remember their vaccination status. And so that wasted a lot of time and that ate up a lot of resources that could have been put to better use. I think finally, really requiring that where kids are and where they gather, schools, preschools, that these children be protected against the diseases. Focusing on the diseases, our common enemy is where its been effective and i think we need to spread that to more states in the country. I was one of those adults who was asking dr. Barbot if i should get a booster and she laughed and i said im serious. I think there was another question in the back. Taylor pen with the National Governors association. So do you have any recommendations for governors on what they should focus on when thinking about how to prevent or to reduce the occurrence of outbreaks . Yes. First its to understand the facts. So youve heard a lot of good information today. If theres a way we can get the best information about the effectiveness of vaccines, they can understand the toll that gaps in those vaccinations are having on the health of children and others in our communities today. And also understand some of the efforts that are really going on against vaccination and how theyre promoting information thats incorrect would be very helpful. So thats just establishing the baseline of the facts. And then i think beyond that, it would be good for governors to understand where maybe theres been really good successes in other states, because a lot of the lessons have been learned very well by jurisdictions that have had these outbreaks, because i would say if they havent had that experience, theyre vulnerable. And so to appreciate what has happened elsewhere, to bring those experts with the lessons that have been learned, perhaps get some quick Technical Assistance from places that have expertise to sort of canvass the risks in their state and give a couple of pointers, if you dont have an Information System, you dont have a strong vaccination infrastructure, if you dont have good Communication Channels to reach families and others at risk, you could identify a few quick steps to sure up protection in their states. What i would add to that are two things. One is since the Great Recession of 2009, theres been a systemic disinvestment in Public Health infrastructure, and i think that its lit clee important that governors look at their budgets and see how much is being allocated to Public Health. Its always been a small percentage as compared to health care drielivery systems in othe 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 like to call brush fires like measles, as well as other simmering epidemics like the opioid epidemic. The second thing is that i would ask governors to really show leadership and courage in terms of ensuring that we have more states that are only allowing medical exemptions for vaccinations. I think that that is the best and most important way to ensure that all of our children and all of our communities are protected against vaccine preventable illnesses, both now and in the future. Do you have anything to add . I would just add to that and say to keep on the message that its the disease thats our enemy and its the disease thats taking the lives and health of our children. Any last questions . I just was wondering if the experience that youve had in california with protests, if that gives you any pause i mean, is there a way to study what the impact of adding more co ergz and i dont mean that in a negative way, but it is adding a course of approach to a vaccination, whether theres any risk of im not using the right word, but a response that makes public less trusting in the vaccination enterprise . I think thats a really worthy study. In looking back over the Measles Outbreaks that we had, you know, with the disneyland outbreak Public Health was not in the communication space where those who opposed vaccinations were at the time. But i was very happy to see that a lot of other groups stood up as the voice, parents included, to start to speak positively about vaccinations. And youre absolutely right. As we use our Legal Authority, whether there are state laws that require vaccination or we use our local authority to quarantine people or so on and so forth, its extremely important, we always explain that to people because it is seen as a very coercive approach sometimes. But weve got to go beyond that and constantly stay in communication with folks so that were hearing what their concerns are and were addressing those with facts and information. Because after all, these decisions about authority and which way we go as a society rests with the public. It really does. So our role as a Public Health organization is to push prevention to the limit that we can with the authority we are given, but only at the will of the people and our legislators in terms of defining how far we can go that way. We need to have that constant dialogue with the people, with our residents, with parents, with everyone involved so they really understand what were doing and hopefully that will bring us together in unity and theres agreement that we do want to prevent these diseases. Weve got to learn more about the voice, what people are thinking and what they have to say and so that were in the dialogue with them. Ill add to that that Public Health almost on a daily basis has to balance Civil Liberties with civic accountability, and that the powers that we have date back to jacobson versus massachusetts and small poks. And since that time its been clear that the needs and the urgency of the Broader Community really super seed that of the individual in certain cases when theres a risk to human life. So i wouldnt necessarily characterize it as coercive. I think its part of our responsibility as Public Health authorities to make that sort of judgment on an ongoing basis, balancing, as i said, Civil Liberties and civil accountability. And finally, its that interaction between Public Health and our practicing physicians and practitioners thats so important, because when the child cant go to school because they dont have their vaccines, they come to me and we start to talk about what it is you should be doing and what are our fears and what can we do to make you feel comfortable with this whole process. So thats the interaction between our practitioners and our Public Health system thats so important. Thank you. I think thats a great note to end on. Thank you to the panel and thank you all for being here. Really appreciate it. And we have some contact info. [ applause ] this evening, a look at how campaign 2020 is shaping up with charlie cook, founder of the cook political report. Hell talk with liberal Radio Host Bill press in a conversation hosted by the hill center in washington, d. C. Cspan will take you there live or you can listen in live with the radio app. Late nights were featuring American History tv programs as a preview of whats available every weekend on cspan 3. American history tv was in the classroom as the university of arkansas professor gave a lecture on the Environmental Impact of the California Gold rush. You can see that tonight at 8 00 eastern here on cspan 3 and enjoy history every weekend on cspan 3. The Supreme Court justices return for the new term next week, the first monday in october, with the Court Hearing cases on employment discrimination based on sexual orientation, the trump administrations winding down of daca, and state funding for religious education. Listen to significant Supreme Court oral arguments on our website, cspan. Org and watch on cspan. The mother of eric garner who died five years ago during an arrest where a new York City Police officer used a choke hold, went before a House Committee to talk about policing practices. She was joined at the Judiciary Committee witness table by the reverend al sharpton and former professional tennis player, james blake, along with Law Enforcement officials. They answered questions on ways to improve policing