Transcripts For CSPAN3 House Hearing On The Flu Vaccine Part 1 20240713

This hearing will come to order ask without objection the chair is authorized to declare recess at any time. Let me say good morning and welcome to our witnesses. Todays hearing on vaccine science and innovation. Smallpox once plague said the worlds population plaguing 300 Million People in the 20th century alone. Smallpox is the only human disease to be eradicated thanks to the development of the vaccine. Another devastating disease, polio, had just 33 cases reported worldwide in 2018 compared to 350,000 cases in 1988. Every day vaccines are saving lives especially the lives of children and other vulnerable population. Theres no such thing as healthy skepticism when it comes to vaccines. Unfortunately, there is a wellfunded, Disinformation Campaign targeting the public and weakening Public Health laws. School vaccination requirements have been common place in the u. S. For generations and exemptions were granted only for legitimate medical reasons. However, in my home state of texas, the number of unvaccinated children has spiked since 2003 when the Texas Legislature expanded the exemptions to include nonmedical reasons. The number of exemptions rose from 2003 to 57,000 last year. We are seeing this replayed across the country and innocent children are falling ill. Health officials have confirmed 21 measles cases in texas this year, and 1261 nationwide. 61 of which led to complications. I have been dedicated to the improvement of Public Health my entire career. The Science Committee may not have jurisdiction over the health and Human Service agency, but we have long had a role in supporting improved Public Health through good science. This morning we will explore the science and Innovation Challenges through the lens of influenza. For the healthiest among u the flu just lays out for several the flu just lays us out for several days. However, for the very young, the elderly and pregnant women and vulnerable groups and the flu can be deadly. The centers for Disease Control recorded an estimated 48. 8 million illnesses and 79,000 deaths during the 20172018 season and approximately 20 of those deaths were children. Influenza vaccine production began with the analysis of data many months before the beginning of the flu season. The challenge with influenza is that the viruses change constantly and by the time the flu season begins the vaccine may not fully match the circulating viruses and scientists are working to provide viable and effective, for the eggbased vaccine as well as a universal vaccine that would not require an annual update, yet another scientific challenge for influenza and many other Infectious Diseases are incomplete. Disease is incomplete data and antiquated data systems. Through modernization of data systems and data analytic tools across the federal and state levels we will be able to accelerate Vaccine Research and development for many diseases. We have two expert panels that will help us understand the full cycle from basic research to vaccine development, production and deployment and surveillance. The witnesses will also describe the role of federal agencies, state agencies and the private sector including the partnerships among all of the stakeholders. I want to extend my warm welcome to all of you this morning, and i want to thank the vice chair, dr. Berra for his leadership on this issue. I look forward to todays discussion. I might say that i have a markup in another committee so i will have to leave before we get through all of the deliberations and the the chair will recognize mr. Luca. Good morning. I would like to thank you for holing this hearing especially when were in the middle of flu season. Nearly a million individuals are hospitalized for the flu every year, including more than 48,000 children. In oklahoma since the 2019 flu season began on september 1, theres been at least one death and 73 hospitalizations from the flu. However, these numbers would be far worse if we did not have vaccines. Vaccination is by far the best flu prevention measure we can have today. Its easy to forget that a little over 100 years ago the world faced one of the deadliest pandemics in history the 1918, h1 epidemic also known as spanish flu. It killed an estimated 50 Million People worldwide including 675,000 people in the United States. Medical technology and countermeasures at the time were limited to isolation and quarantine. Influenza vaccines did not exist and antibiotics had not been fully developed yet. Advancements were made in treatment and prevention of the flu. The development of vaccines has played an Important Role in reducing and eliminating deadly disease. I can still recall my fathers stories about how late summer and fall were a terrifying time as a child because of the threat of polio during those seasons. Lucky for me, i did not have to experience this fear because of the first polio vaccine being available in 1955 and thanks to widespread vaccination, polio has been eradicated in the United States with just 33 cases reported in 2018. However, polio remains a threat in some countries with the world becoming more connected through modern transportation, it only takes one traveler with polio to bring the disease into the United States. As im sure well hear this morning from our witnesses the best way to keep the United States poliofree is to maintain high immunity through vaccination. Considerable advancements have been made in health technology, disease surveillance, medical care, medicines, drugs and vaccines and pandemic planning while significant progress has remained and gaps remain and the severe pandemic could still be with the human population, as the human population has green so has the swine, livestock and poultry populations to screen them. Birds, cattle and pigs to evolve and infect people. As a member of the House Agriculture Committee i supported the National Animal vaccine and veterinarian Counter Measures bank which was included in the last farm bill. This vaccine bank will have vaccines and other countermeasures to provide a disease outbreak. If an outbreak were to occur and we were not prepared our entire Agriculture Sector would suffer immense losses causing longterm harm of the livestock, poultry and swine production, not to mention the damage to human health. I look forward to hearing from our Witnesses Today about the current state of our stockpiles of Human Health Vaccines to provide the capacity for rapid responses to emergency situations. I particularly look forward to hearing how barta influenza vaccine infrastructure is supporting the Public Private partnerships with the capacities for potential pandemic flew events in the United States. Lastly, i would like to say how pleased i am to address modernizing flu vaccines. It recognizes that influenza as a Public Health and National Security priority with the potential to inflict harm and death. Most importantly, it establishes a National Task force for new technologies including a plan to develop flu vaccine. I would like to thank chair johnson for holding this, and i would like to thank the panel for sharing your expertise and insights this morning and i yield back the balance of my time, madam chair. Thank you very much. If there are members who wish to submit your Opening Statements your statements will be added to the record at this point. At this time i will introduce our witnesses. The first witness on the panel. Our first witness is dr. Daniel jernigan a jernigan. He is responsible for oversight and direction of a broad, Scientific Program to improve detection, prevention, treatment and response to a seasonal novel and pandemic influenza. The Influenza Division is responsible for national and global surveillance of influenza and serves as a World Health Organization collaborating center for the surveillance epidemiology and control for influenza. Dr. Jernigan entered the cdc in 19954 and is a captain of the Public Health service and was the recipient of the 2019 america gold medal. The next witness on this panel is dr. Anthony fauci. Dr. Fauci is the director of the National Institutes of allergy and Infectious Diseases, a position hes held since 1984. He oversees an Extensive Research portfolio of basic and applied research to prevent, diagnose and treat Infectious Diseases such as hiv aids, respiratory infections and diarrhea diseases, tuberculosis and malaria as well as emerging diseases such as ebola and zika. He also supports research on the plantation and immunorelated illnesses including the antiimmune disorders asthma and allergies. He has advised six president s on hiv aids and many other domestic and Global Health issues. He was one of the principal architects of the president s emergency plan for aids relief, a program that has saved millions of lives throughout the developing world. As our witnesses should know you will each have five minutes for your spoken testimony. Your written testimony will be included in the record for the hearing. When youve completed your spoken testimony we will begin with question, each member will have five minutes to question the the panel. We will start with dr. Jarnigan. Thank you very much. Good morning chairwoman johnson, Ranking Member lucas and distinguished members of the committee. I am dr. Dan jernigan at the centers for Disease Control and prevention. I want to thank you for the opportunity to report prevention of influenza. Each year, influenza causes a Significant Health burden in the United States with many millions of americans becoming ill, hundreds of thousands requiring hospitalization and tens of thousands dying. Influenza viruses are constantly changing, requiring us to update the vaccine components every year. Sometimes these changes can be sudden and significant, resulting in flu strains that can lead to devastating pandemics. Hospitalization and death can happen in any flu season and each year flu vaccination prevents millions of illnesses and thousands of severe and sometimes tragic outcomes. Influenza vaccines are very safe and they remain the single best way for people to fight the flu. Despite the significant benefit, the effectiveness of the flu vaccine and the numbers of americans being vaccinate are not optimal. We at cdc are working with nih and other federal and State Government partners to use cutting edge science to make influenza vaccines better. The broadly protected universal vaccines that dr. Fauci will talk about is the ultimate for flu prevention, however, these vaccines are still years away. In the nearer term we can save millions of americans from the flu by making incremental improvements for vaccines that can be produced by production platforms and by getting americans vaccinated each flu season. Cdc has a central role in every part of the Influenza Vaccine Development and the influenza cycle including virus tracking around the globe. Preparation of vaccine viruses. Purchasing 10 of flu vaccines used in the United States and monitoring vaccine coverage, safety and effectiveness. To improve flu vaccine, cdc has projected the cdc life cycle. Cdc has collaborated with every Public Health tomorrow p this has resulted in realtime reporting of influenza test results to cdc using cloudbased messaging. Cdc has transformed surveillance by using genomic sequencing to characterize all specimens received at cdc. This means we can identify and track viruses much more quickly and accurately leading to more timely selection of candidate vaccine viruses and earlier detection of viruses with pandemic potential. The sequencing equipment which once filled a room now fits in the palm of your hand. We now have a mobile mini lab that can be taken on the plane as a carryon and set up almost anywhere in the world including rural, resource constraint settings. Cdc has supported newer vaccines by developing candidate vaccine viruses for the cellbased vaccine and making the protein vaccine. Both of these newer vaccines have the potential to be manufactured more quickly and maybe more effective of traditional vaccines that are grown in eggs and using a technique called reverse genetics. This allows us to build a vaccine in a matter of days or weeks much faster than traditional methods making the u. S. More prepared to respond quickly to a pandemic. Cdc was the first to establish a system for the routine monitoring of the influenza effectiveness and the Vaccine Network provides critical information for manufacturers and researchers and developing enhanced vaccines by collecting more specific data about how well the vaccine works each season. Recently, we have expantded the network and are planning to conduct more studies to better evaluate vaccine effectiveness. Finally, a major component of improving vaccine impact is getting more people vaccinated. Fewer than half of adults in the u. S. Receive their influenza vaccines and despite all of our successes and our Global Leadership and influenza detection and prevention, there is still more we need to be able to do. Each of the topics i mentioned today from working with domestic Public Health partners to track and characterize viruses to developing vaccine candidates and studying vaccine effectiveness will generate more precise and timely data. I believe we can harness this to make vaccines work better. I want to close by asking you and your families to get vaccinated before the Holiday Travel begins, and i look forward to your questions. Thanks. Thank you, dr. Jernigan. Dr. Fauci . Thank you very much, madam chairwoman. Members of the committee, thank you for giving me the opportunity to testify. I am director Anthony Fauci from the, in ih and i will talk to you over the next couple of minutes over the nihs efforts to improve influenza vaccines and to develop a universal flu vaccine. As shown on this slide, although as dr. Jernigan its very important to get vaccinated because even if its not 100 effective or 50 effective, the benefit for the individual to get vaccinated and the community is profound, however, we can do better because seasonal influenza vaccines are not consistently optimally effective. In addition, we know through history that pandemics occur, but we usually are too late in our response as we were in the 2009 h1n1 and finally, we spend considerable time what i call chasing after pandemics as we had with the h5n1 and h 7 n 1 in which we made significant investments and we needed to do that, but those pandemics never occurred. This slide shows a journal, the journal of infection diseases containing a number of papers in which my colleague and i gave the introduction emphasizing the point that i just made that although influenza vaccines are good and important and should be utilized, we can do better. By doing better we need to improve the seasonal influenza vaccines which would lead to a better capability to respond to pandemic influence that which will ultimately get us to the goal that well speak about over the next minute or two and that is the development of a universal influenza vaccine. In the summer of 2017. We brought a group together to develop a plan which we published in 2018 for the Strategic Plan and the Research Agenda to mobilize scientists throughout the country and the world to develop a universal flu vaccine. So let me explain what we mean by universal flu vaccine. This is somewhat of a complicated slide, but it really does make the point. We will not get a universal flu vaccine evernight and it will be a step wise process in which we go from improvement, the broad capability of responding to a particular type of a strain, versus the ability to respond toa all strains. And notice its divided into two major groups of influenza. On the righthand part of the slide is the tip of the triangle. We make it thats highly specific that are circulating the season. However, they change. They mutate and drift. What we want to do is go to the next step is to make a vaccine that would cover all of the h 3 n 2s or all of the h1n1s and then the next step would be the one that would do all of the group 1s and the group 2s until we have a universal vaccine that essentially covers all of these. We will do that with new technologies as you are well aware. We currently have a technique of growing the virus in eggs to develop a vaccine. Although thats time, true and time hon rd, its ineffect and has many areas of going wrong. So were using new platforms as shown here on the slide such as recombinant proteins and viral vectors and nano particles and others. This is a blowup of the influenza virus and to the right is an important protein called the heem hemogluten. It has two components called the head and the stem. The head is the part of the body that the body makes an immune respon response against and it mutates often leading to the ineffectiveness and the dark blue is the stem which doesnt change much at all. So the strategy now, one of several strategies is to develop a vaccine in which you cut off that head as shown there, take the stem and put it on a nano particle which is highly immunogenic. If i can show you this. This is a 4 million times blowup of what the first universal flu vaccine would look like and these dark blue areas are the stems. We have started a phase one trial as shown here in the spring of this year and it will end at the end of this year and next year we will do a group two universal flu vaccine. So as the president said in the executive order, the purpose of what were doing is to improve little by little until we get vaccines to protect us in the most efficient way possible. Thank you. Thank you, dr. Fauci. At this point, we will begin our first rounds of questions and the chair will recognize herself for five minutes. Dr. Jernigan, there is a wellfunded disinformation campai campaign sowing confusion on the population. It has different belief systems. Innocent children are falling ill today with diseases we once thought were eradicated in the u. S. Young women are unnecessarily being put at increased risk for cancer, and these antiforces are creating a major challenge and future vaccination efforts. How big of a role does social media play in this resurgence and how can we overcome these tactics and what is cdc doing specifically to combat these efforts . Certainly at cdc we want to do everything we can to get more people vaccinated. We know that only half of americans get the vaccine. Another half still need to get vaccinated. Another one of the reasons why they dont get vaccinated for influencea is were worried about the effectiveness and improving the effectiveness of the flu vaccine will certainly get more people to be vaccinated. Your question is really around the role of the misinformation and social media participating in that. We do think that there is a lot of information out there. Parents have lots of different places that they can get information and a lot of times they dont know which of it is science based and which of it is evidence based, et cetera. At cdc our plan is to try to strengthen public trust in vaccines by trying to get people to be more confident in the vaccines and getting the information out there about how effective they are and that comes down to three things, protecting the community and helping to understand the differences in these different pockets and these different communities and what makes them have as much confidence and develop materials for those specific communities reaching out to Key Opinion Leaders in those communities. A second thing is to empower the parents and get with very young parents when they first have children or pregnant women. Get them the right information about the benefits of a vaccine and why it is so important to get vaccinated. And finally and not do it as much as possible and providing the Sciences Based and then were working to make sewer that that can be reused on multiple platforms so they can get the science based dr. Fauci, would you underscore he said what is the most important reason that people dont get vaccinated against influenza and that is the perception that it doesnt work. Ea even though it isnt 100 effective, it will prevent you from getting infected and particularly those susceptible to complications and may prevent them from being hospitalized and may ultimately save their lives and the perception that it doesnt work, we need to put that aside because everyone as dr. Jernigan said, should be vaccinated. Thank you very much. Mr. Lucas . Thank you, madam chair. The state department of health on influenced one and hospital iedzing the others. Continuing on the comment that you and dr. Fauci made, when i look at my constituents in the eye back home to stress the importance of being vaccinated, can you expand on that. Youre in a town meeting with me and youre looking my neighbors in the eye and this is rural oklahoma and youre talking about things that are to the point. Certainly, we know the burden of influenza is very high and the illnesses and deaths that occur because of influenza. There are tens of millions of cases every year and tens of thousands of deaths that occur every year and we know that with the vaccine that we have, that you can prevent thousands of deaths every year and tens of thousands of hospitalizations. Its important to get vaccinated and not just for yourself and it also helps protect the Community Around you and there are a number of benefits that the vaccine has that prevents you from getting sick and it prevents you from hospitalized with flu, and its actually like a prevention tool and its something you take every year because it can keep you from having a second heart attack so people with underlying heart conditions, it protects them as well. It protections pregnant women and their babies and getting the pregnant mother vaccinated actually helps the baby during that period of time before they can get vaccinated and theres data that it shows that its lifesaving in children and you can reduce the chance of death of influenza by 65 . There are a number of things that are important about it even if its not 100 effective and it can reduce the severity of illness if you were to get infected. Dr. Fauci, we have the veterinary stockpile which is prepared to provide farmers and ranchers against dangerous animal diseases such as influenza and swine flu within 24 hours. Could you speak to the current state of the Human Vaccine and stockpile management and what we can do to better prepare to address the potential pandemic emergencies . I would love to do that except the cdc is the one responsible for the stockpile. Not to keep passing this, actually barta is the one that manages the vaccine. So we can reassure the folks back home that youre paying attention and you and your best. Absligolutely. In terms of what we do at cdc we specialize the Avian Influenza and the swine influenza around the globe. We do that in 143 laboratories where we take that information and use it in a thing called the influenza Risk Assessment tool or the on your browser and put in irat cdc and a graph of where we have ranked these different, concerning potential pandemic viruses in that graph. With that information we work with the agency to determine which of those should be made into vaccine candidates and which of them should be made into vaccines and stockpiled and which ones should undergo trials and so with that, we have made decisions about things to put into that stockpile so that the u. S. Is prepared. Many of those vaccines say the h5n1 vaccine is in the stockpile. It may be enough to vaccinate First Responders and small risk groups. However, these viruses continue to change and so its actually very important for us to find new vaccine technologies so that the vaccine stockpile isnt something that needs to get more and more vaccines put into it and rather upstream, we have fast technologies and be able to make vaccines quickly and ultimately, once there is a universal vaccine that may be the best thing to prevent pandemic is to have that available. In my final moments before i yield back, i alluded in my Opening Statement to my fathers observation in the 40s and 50s, prior to the polio vaccine how the outbreaks kept seemingly getting worse and worse and the sheer terror that it brought in the communities in the late Summer Season and early fall. My generation was not alive for that, did not experience for that and was truly terrifying. My first farm job when i was 14 was mowing a countrem that was the family historian, and i remember asking her why in one section of the cemetery yr all these babies buried . Why are all these young women buried . She said look at the tombstones, they say 1918 and 1919, the spanish flu took them all. Took them all and brought even in rural Oklahoma Society to a grinding halt for weeks and weeks as this passed through. My generation, having not experienced all of that sometimes doesnt necessarily understand what the potential downside is and why you gentlemen and all of your colleagues work so hard and thank you, doctor, for giving us the opportunity to focus these issues and with that, i yield back. Thank you to the Ranking Member. Also to the chairwoman johnson for allowing me to be a doctor today and i think there are a couple of hearings happening on the hill and this is the most important thats taking place today, and i think thats why all of the cameras are out in longworth and thinking of dr. Fauci and dr. Jernigan, and my home district and senators and a colleague of mine and were on the front lines of trying to combat some of the disinformation that is out there, and i just want to run through a couple of quick, yes no questions. Is there any scientific risk that it leads to autism . Absolutely not. Dr. Jernigan . When i was practicing i would talk to some of my patients and they would often come back at me and say i dont want to get the flu vaccine because i had it before and it causes the flu. Dr. Fauci, is there any evidence that the flu vaccine causes the flu . The flu vaccine does not cause the flu. Dr. Jernigan. And the whole point of science is to pursue the truth and to dispel some of these myths and there are legitimate reasons for a small cohort and individuals if they have allergies to egg, et cetera, to opt out of the vaccine, but one of the most important things and measles as an example to vaccinate populations and i think its important for the public to understand that particular concept. Dr. Fauchy and jernigan. Its a very important concept not only for flu, but a recent, unfortunate experience that we had in this country in the williamsburg section is a classic example of what happens when the umbrella of immunity goes down below a certain level because you had the community where it was somewhere between 70 and 80 . For measle, you need somewhere between 91 or 93 of the community so that when someone inevitably comes in from the outside or someone travels and brings back measles, if the community isnt protected by the herd immunity, you get the very unfortunate situation that we saw in the williamsburg section of brooklyn. What are current measles vaccination rights in america . Over 90 . So we want to keep that. Right. And measles was a disease that, for the most part we had eradicated in america and now were starting to see that and the incidents starting to pop up again. I guess, dr. Jernigan and the flu vaccine because we havent had a pandemic like the spanish flu. Can we talk a little bit about why weve been so lucky. I think with pandemic influenza this is a situation where the flu viruses are circulating in animals can mix with the flu viruses that are in humans and when they do that they share their jeans and can create a flu virus that has not been seen before and it can spread quickly throughout the community and it can cause severe illnesses and hospitalizations and the 1918 as we mentioned is one of the worst. That one probably caused 675,000 deaths in the United States. Weve had three other pandemics in the last 100 years and those were with changes in the vaccine that were not as bad. We at cdc looked at the 1918 virus and there are particular changes in that that made it severe. So theres nothing preventing from happening again and its important to maintain the vigilance and you can see the ability to have vaccine available quickly, and severe influenza. And in todays interconnected world, where people move across boundaries, having two big oceans are not necessarily protective for us. Dr. Fauci, you and i had the opportunity to Work Together around the 2014 Ebola Outbreak in west africa. Can you talk a little bit about the evolution and the development of an ebola vaccine and how thats helped us in western congo and given us the ability to better manage it . Back in the 201416 outbreak in west africa of ebola during that period of time. We together with the variety of other agencies including the cdc and other International Agencies began the testing of a vaccine called vsv which now is ultimately made by the company merck. So at that time we did phase one studies right here in the United States, and at the nih and on campus and some had done it in west africa. And we advanced to phase two and the cdc did a study in sierra leone, and ultimately it was shown in the ring vaccination study in guinea that was effective in preventing infection particularly in those, posed. That vaccine has been used in the democratic republic of the congo and 245,000 doses were in the contact ring vaccination approach, and it is very clear, and we would be in a much worse situation and as we know from the reports coming out from the cdc for ebola have gone down and down and down and were not through with it yet and weve played a major role in the explosion that we saw in west africa. Dr. Fauci and dr. Jernigan, in closing, vaccines are safe. Vaccines are effective and vaccines save lives. With that, mr. Posey . Thank you. Im grateful to the chair for holding this hearing. Flu shots can play a very Important Role in protecting the public from the flu and reducing its spread and i want to focus on a policy which should have ended years ago and flu vaccines were given to toddlers and pregnant women. In july 1999, the Public Health service with the American Academy of pediatrics and vaccine manufacturers issued a joint statement agreeing that the aerosol containing vaccines should be removed as soon as possible and at this point i have a number of documents that i would like to approve in the record by unanimous consent and theyre raising safety concerns about the aerosol which is vaccine mercury, second, outlining the miscon sengs and clearing out some misconceptions and third the 1999 joint statement of the American Academy of pediatrics and the u. S. Public Health Service calling for the immediate removal of mercury from all vaccines. In 2004 the institute of medicine recommended removing it from all vaccines administering it from women and children. In 2003, mercury was removed from vaccines in the United States. Yet a year later the cdc recommended the flu vaccine for children, six months to 31 years of age, and this thus reintroducing mercury to the childhood vaccine schedule. In 2006 california passed a law banning mercury containing flu vaccines for pregnant women and children under 3. In 2009 much to the credit of chairwoman johnson, it was banned introduced from power plants and it was even more pertinent that mercury is a neurotoxin. Even at low levels, mercury can have an Adverse Health effect particularly on women and developing fetuses. Dr. Fauci you worked with my predecessor and from october 5th, 2004 and it was removing mercury from flu vaccines, director gerberding and dr. Egan and you agreed and you stated repeatedly we are removing rapidly we are moving rapidly to thermerasolfree vaccines then you should do that. The public concerns are still there. Mercury is, in fact, a toxin newborn, and neurodevelopment and the one change is when flu vaccine became a recommended shot and manufacturers were protectioned from all liability and accountability via lawsuits. Now they have no incentive to remove mercury and the flu vaccine and each one says it has not been tested for safety and pregnant women. We should air on the and the failure to completely remove mercury and takes the backseat to saving a few bucks each shot and what steps are being taken by you as the leader in the Public Health community to move, quote, rapidly to mercuryfree vaccines, closed quote, or is it no longer a priority and when can we expect it to be completed . I dont think i can answer directly when it will be completed and in the committee and i said then and i will say it again that the optimal situation would be to have th h thymerasolfree, and that was for the peace of mind with the people with the Scientific Evidence that there is a harmful amount of this material in the vaccine does not indicate that and the issue with thymerasol and i will let dr. Jernigan comment on that with regard to the cdc is that it is in very, very few vaccines and only in multidose components and the multidose component and the balance of the rick of being a contamination of the bacteria which we know can occur if wu dont put Something Like thymerasol, with the rick of the deleterious effect which is eth ethyl mercury and clearly balances to make sure you protect the multidose vials. Dan, maybe you can amplify that a bit. Its important to note that cdc is committed to noting that the vaccines in the United States are safe. Currently, this year, its projected to be 169 million doses of influenza vaccine and we understand that only 15 of that is the thymerasol containing multidose vials and they would like to have a thyamerica erasolfree, and theyre the prefilled syringes and the singledose vials. My time has expired. Thank you. Thank you. Before i recognize you, just a quick question. Mr. Posey raised a couple of issues and maybe yes no answers. Is the flu vaccine safe for pregnant women . Yes. Yes. Absolutely. Is the flu vaccine safe for infants and children . Yes. Yes. Great. With that, id like to recognize the gentleman from california, mr. Mcnerney. The neighbor from california. Thank you, chairman. I thank the witnesses this morning. Dr. Fauci, how can computational data scientists partner better with microbiologists to accelerate the research . Well, i mean, computation alibiology is a discipline that essentially impacts on virtually all of the biological issues we do. So we can do computation alibiology when we do the sequencing of various strains of violence that come in and if you want to make a vaccine for. I think in his Opening Statement, dr. Jernigan had mentioned the fact that the culpability and the cdc and the nih to do a mass sequencing of any virus including influenza relies on computation alibiology to get to the next step in developing a vaccine. Is the symmetry pattern of this nano particle significant in any way . Yeah. Actually, what it is is the display of multiple components of that stem create the ability to engage what we call the bcell repertoire of the system so the chances of it hitting the b cells that will give you the antibody response youll want and thats a highly immunogenic approach to any vaccine is really the wave of the future and thats what were trying to do to get away from the situation of having to grow a complete virus and use that as the vaccine the way were doing in eggs. Here you use Recombinant Dna Technology and you show the immune system only that part of the virus that you want it to respond to, and you avoid all of the other distracting immune responses. So thats why the Scientific Community is so excited about those new technologies. Thank you. Dr. Jernigan, if we find ourselves in a pandemic outbreak, how quickly with existing technology can vaccines be produced to catch up with the outbreak . An example is in 2017 when there was the identification of a very bad h 7 n9 influenza virus that ended up in poultry in china that had 2,000 human cases exposed to them and we were able to receive the vaccine excuse me, the virus sequence directly from colleagues in china and with that we were able to use reverse genetics like i mentioned before to actually build the vaccine virus and the cdc has the capability to do that under Laboratory Practices and conditions like the cdc and be able to hand that vaccine virus to the manufacturers. We can do that very quickly within a matter of days to weeks. However, once we hand it off to the manufacturers, they are bound by the existing manufactun what they have. About 18 of all manufacturing right now is a non egg manufacturing rested as egg basic manufacturing which takes six months. We need things to be quick or is a National Security thing for us to respond real quickly. Thank you. Can you address the auto immune reaction to influenza vaccines and forget my pronunciation of the break . . Theres been a rare association or reactivity between some of the energetic components of the vaccine and certain tissues in the body. This is clearly not been proven yet but one of the vaccines that was available for the age one and one, flew of 2009 and there was the suggestion that one of the peptides that was associated with the vaccine and reduce the response that cross react with the substance with these big words hype a creek in which is one of the narrow peptides and narcolepsys and and has been discussed but not really definitively proven. On you exposed abroad the body to a protein and recognized as something that is similar to whats in your body makes an auto immune response. My son had a busy scary reaction to the injection. It was a seizure that was pretty scary and maybe not dangers was scared the hell out of us. Seizures is a known reaction and a number of different vaccines and that is something that is possible. It is a dangerous . No, for the most part does not have a lasting impact. Thank you. I yield back. We recognize mr. Don beyer jr. Thank you mister chairman. We appreciate the witnesses being here and sharing your expertise. So my first question, doctor jernigan begins with the testimony you membered about the many lab and the platform that was set and resource men sayings to process test virus and to send that data up to the cloud for further analysis and reaction. Could you elaborate on how this cloud based pratte form will allow Public Health officials to address the outbreaks quicker and more effectively . In largely a rule area like my fourth Congressional District in indiana . Yes, youre referring to the use of micro technologies which this right here actually is a sequencer. If you actually take this and prepare it in some little boxes that we take that fit into a carry on a plane and you prepare them and injected. Theres a way that you can do what you can do bar coding of the specimens at one time and with that you have a sequence and it just tells you that you have the influenza virus. Its indifferent settings that we actually do take it to iowa and a swine fare where we swap them for this show pigs and were able to quickly tell if they had influenza and swine flu that is circulating in that group. That data plugs into a lapped up through this little usb port. And then on the laptop it runs the information and prepares the signal that sends up to the cloud and a process called irma. Irma is a pipeline tool that takes the data and uses machine running and Artificial Intelligence to determine which of the flu viruses are in sequences and that information gets pulled down through the staff at cdc where if needed can generate the vaccine virus. This allows us to take a tool to the place where the problem is occurring, rather than try to figure out how to get viruses to the cdc. To take that one step further, you can regionalized wherever you collect your data and you can develop a vaccine specific for those areas . Its possible. The manufacturing process will let you not be able to do that. But yes, you can tailor what you know about in certain regions. I think doctor watkins will give you some of the data issues in subsequent testimony. You mention pigs and i have a background in agriculture. Any thoughts on the african swine flu . African swine fever is different than swine influenza. But, the same kinds of technology can be used in the world to have that kind of detection. Thank you. Doctor anthony s. Fauci you have any last words . The point that dr. Jernigan made in some respects im glad you brought that up because we can be confused between african swine fever and influenza thats in pigs that can reconvene with an influenza to have an epidemic. It has nothing to do with that and sometimes people get confused when they hear the word african swine fever which is completely unrelated to influenza. I appreciate that, thats part of the reason that i mentioned it. So, i thank you and i yield back. Thank you. I now recognize mr. Foster. Thank you mister chairman and thank you to our references the narrow part. The fauci can you talk about the national particle an act you bond this enamel . Its its very interesting, its the beauty of nature and its a Self Assembly ferret in particle. Its a fair written protein where you combined the jeans that express themselves as the nagano particle which symmetrically has the stem they just fit properly . I had to use the word but its almost like a miracle of the natural selection. Its just a larger proton of geometry . If i was reading her slides correctly, to stem is highly preserved but not absolutely preserved. Are you then going to need several versions of this or are there dozens of versions in terms of the stem variability . We believe that we will not need very much because even though it is not completely preserved, you dont believe that the mutations that occur in the stem have a functional relevance in making it different from one to the other. Everything weve done so far, where weve looked at the stem and we just recently completed a series of experiments, where you had body against multiple components in stem and you use those antibodies to screen the entire group of the group one which contains ten of those ages and it neutralized every one of them. Were not 100 percent sure, but if we get a series of antibodies against most double components of the stem, we can probably knockout an entire group and two major groups. Will need at least two but im not dont think will need ten. Fascinating. You mentioned this is the phase one Clinical Trials in the vaccine recharge center. For safety. Is it proven effective and out of alls . Yeah. Its all the way through safety and effective and animals . What we showed in animals is that when you injected it into the animal you got a complete array of antibodies against the whole panel of the flu. You dont challenge them with every single one because you know you will have a protective level of antibody. Fascinating, changing the subject a little bit, doctor can you say a little bit about the unique challenge of achieving high rates of immunization in immigrant populations where they very often have a lot of reticence to connect to anything official because of the demonization of immigrant communities . Relative to my earlier comments about ways to protect the community as a form of increasing vaccine confidence, certainly there are communities that dont value of the vaccine, so i think the better way to get at those groups is identify what are the factors that are leading them not to get vaccinated. In the case of immigrant communities following the 2016 election i talked to principles who were turning kids away from school who were not immunized because they were terrified that ice was going to go and get them. These are kids who are u. S. Citizens but they have someone in their family who might be undocumented. Is that something you said you monitor the rates of immunization indifferent populations, do you see in a fact . I dont know if we have that information. We do look at Immunization Coverage and we look at it by race and ethnicity but in terms of the specifics around immigrant communities, i dont have that information. If you could do a little and get back to us i would appreciate. It finally, you mentioned that it was the Meat Industry in various forms that was a major player in spreading pandemics will and viruses. In a world where you had artificial vegetable based meat, which is one that a lot of people dream about, is that something you would be intrinsically prone to have and democrats. Influenza viruses are in reservoirs, so humans are one of those reservoirs, human specific influenza that circulates among humans, the biggest reservoir is among birds and the biggest reservoir among birds is Laboratory Water fowl. Ducks, geese. Will the general kneeled. Absolutely i will yield my negative two seconds. One of the great challenges those of us in the agriculture business deal with is migratory birds to move around Central America done and canada on the u. S. They deposit little presents as they go along their flights which are subject to consumption by other forms of livestock. Thats an issue that causes us great thanks to, maybe thats just the best place to leave it. Let me read doesnt recognize mr. Gonzales. Thank you. Thank you for calling this hearing and thank you to our panel for all of your work. I am a somewhat new father with a 19 month old son. Obviously the fluids effect on children is near and dear to my heart and many hearts across this country. According to the wall street journey journal. See the siesta meathead that 118 children died in 2016 to 2018 flu seasons. Clearly this is troubling for any parent. And uncertainty more than anything. Well immunization levels in the u. S. Initiative we high gaps do exist. According to the cdc fewer than 70 of Health Care Providers receive the vaccination each year how does the cdc engage with providers to promote vaccination . Through a number of different studies the cdc has identified one way to get patients vaccinated is to make sure that the Health Care Providers are promoting the vaccine as well. If you look at the coverage among Health Care Providers it falls into different categories, the more you are at an academic hospital the more likely you are to get vaccinated. The more training the physicians have, 90 , the farther you get from a hospital the lower the training. A Long Term Care facility, those are the ones that are not getting vaccinated, we clearly want to get the message out that those folks really need to get vaccinated. Additionally, in the last decade it is predicted that fewer than 50 of americans actually get the shot. What research has been done, or are you doing, just to get a sense of why folks are not actually getting vaccinated . Trying to identify root causes here. There are periodically focus Group Testing that gets done on different groups to find out what the reasons are. The main reason that we have identified in the last few years as the effectiveness of the vaccine, people do not think its as effective as it should be and that is keeping people from getting it. Access is one of those things that may have been problem but we are dealing with, it there are more places to get vaccinated than ever. You prioritize the development of universal influential vaccines and that is a strategic goal. In your testimony you highlight one of the main challenges of the school is improving vaccine production strategies, can you tell us about plans to address this challenge and keep working towards a universal vaccine . Thank you for that question. That was the point i was trying to make, that we really need to switch into different, what i call, that scene platforms. In other, words not to require to have to decide on a strain in february and then take six and a half to seven months to get it grown and processed to be able to put it in a vaccine whereas if you do the platform, such as the narrow particle which is one of several platforms, as part of our Strategic Plan that i articulated in that document that you mentioned, its to try and develop and protect various platform so that we can get away from the burden to have to grow the virus. Thank, you i yield my remaining time. Let me recognize miss stevens. Thank you so much for this insightful panel, thank you doctor bera for bringing us here we heard a little bit today that despite strong efforts in both the public and private sector, that the universal flu vaccine remains elusive. What scientific advances do you see on the horizon to improve the flu vaccine . I believe the scientific advances will be what i was showing on one of the slides. Ultimately being able to develop a vaccine that would induce a response that would have broader coverage. I was just actually speaking to one of the scientists who made a breakthrough discovery yesterday when he visited the nih in 2009 he developed in antibody from a person who was infected with flu. And it bound very clearly to a particular component of the system antibody, which is interesting, and then he found out that not only did it neutralize the virus that the person was infected with, it neutralized all of the viruses in that particular group, which is the group, 1 10 viruses, that was the scientific breakthrough that allowed us to go to the next step in our universal flu vaccine. Its breakthroughs like that i predict over the next few years will make it easier and easier to get to the ultimate goal of the universal flu vaccine. Doctor did you have anything. The main problem in terms of the vaccine is one of the virus components. You can only put four different components in the vaccine and thats a problem child of the vaccine. So we know when you put it into eggs to manufacture, which is 80 of all manufacturing, it changes that influenza virus so that in no longer looks as much like the circulating viruses that are infecting people. So the use of the egg based manufacturing is introducing some changes that may have an effect on the effectiveness of the vaccine. So moving to other vaccines maybe quicker, it might actually make the vaccines look more like the age three and two viruses that are circulating. Can the federal government to play a role in terms of the tools that are monitoring the effect the venus and safety of our vaccines . Absolutely, i think at cdc we have a Vaccine Effectiveness Network that we manage. In that one weve been able to expand some, but expanding that much greater would allow us to get information about how the vaccine is working better or worse in certain age groups, certain parts of the country, certain types of individuals, it would give us a lot more information to know how to make the current vaccines better. In your testimony doctorate cans you mention that Public Health Data Infrastructure is a little outdated and it hinders our ability to prevent outbreaks before they occur. It hinders our ability to respond rapidly when they do occur and it also hinders our overall ability to surveillance data. Can you speak a little bit about that and what, youre both looking at me im so eager for watkins. I know watkins isnt. Here but i know one of you can talk to that and you can pay no to watkins when they arrive. I think over time there has been an improvement in the use of data and health care facilities. But the Public Health establishment has to receive information from multiple different sources and right now there is not a standardized common way that that information can come in. Plus it is hard for a state Health Department to quickly get the information they need to know if this is a case of whatever disease, do i need to intervene quickly, has this person been vaccinated, from a flu perspective we currently get real time information about influenza like illness from a number of different sources but only about half of that is realtime the other is doctors filling out forms and things. If we were able to get real time information from all of those providers regularly, we would be able to know exactly what is happening with the flu itll much more local level, more precise data, more actual data for decisionmaking. Thank you doctor jernigan. It is a race for information and data so thank you mister jernigan and i yield back the rest of my time. Thank you doctor and chairman, appreciate you and thank you to you two gentlemen for being here today and for your expert testimony. Just wanted to ask you doctor jernigan first about some of the emergency merging technologies of being note thats identified whatever pathogens that a been modernized to deliver and pardon me if you already answered a question like this but we were marked up on a different floor at the same building so i just came in. Im a dentist and my colleagues down here asked if they were vaccines to eliminate and what i be against those. I said it of course but we encourage halloween and things like that. Okay . With regard to the diagnostics, in terms of diagnostics of cdc it maintains an International Resource which is an online store front that all the Public Health departments in the United States under 43 laboratories or able to go on an order standard cdc and what they make that the glow is doing the same kind of testing for influenza so they can go through that quickly. That uses a process called pc which is a common worker ring updating of that which is a kind of pcr device which is Game Changing in the ability to with the sequencing so cdc has established some centers in the public crowds where they do all those testings and the antiviral resistance and which could be a pandemic for a virus that is turning. Thank you very much as very fascinating. What are the main hurdles that stand in the way of the development of a universal influenza virus and Something Like that and how are you working on doctor jernigan . Ill ask you one in the second. All let doctor fauci talk about the different hurdles out there but for us, the influence of iris is able to evade human immunity so you can get influenza every year and the task at hand is a very difficult one in the virus itself and the body itself is to have longlasting immunity so were something at the body itself is not looking at. Doctor fauci if you could elaborate as well then . Theres one hurdle that i think is really serious even if we get a universal vaccine that will induce a response against the wide range of influenza and that is the phenomenon that is really interesting and its called imprinting. What it is is that your body tends to make a response against the first influenza or the first energy and that was exposed when you were a youngster. So even later on in life, when you get exposed to that organism that micro organism from an evolutionary standpoint that was a good thing. Because i mean your immune system is primed so that if you see that micro again youll have a really good response. That is great for Something Like measles or lumps or inaudible which doesnt change or stays the same. With influenza it works against you. So that what you will do is that if im in h1n1 person. In the sense that i was born at a time when h1n1 was around. So my immune system is primed to make a response against h1n1. So, if i get exposed to an age three and two or get vaccinated with that and even a response, my body it will revert to wanting to make a response to h1n1. Its referred to as original inaudible so the real problem is how you get around that. So you can vaccinate someone and overcome that tendency to make a response against something that you originally were exposed to. Thats the important obstacle. That was the question i was saving for you because you mostly answered because thats why measles were part of the vaccines i have a 97 effectiveness where influenza is only 10 . That was a very bad year. 60 right . 40 to 60 . Thats the biggest hurdle we have. You hit the nail on the head exactly. Thank you very much and i yield back. Let me recognize mr. Sean casten. Frank you both very much. Im intrigued by this universal idea and please humor me as a biology nerd. Paul in a follow on fosters question. So the fact that the stem has been so preserved how confident are you that thats because there is something fundamentally the budget just cant change that protein versus the fact that statistically adage ends were on the surface so as we start developing and going after the stem are you confident that this ten will go into Something Else . It couldve all under the ideological pressure from from the standpoint of conserved components we call them apart ills, when something is concerned throughout evolution it is usually because it is critical for those critical things to survive and a new form of protein. It is something about that stem that is absolutely critical to the function of the virus. We think its not going to change but we better be careful. We dont want to make an assumption that it will turn out to be wrong. Have to studies have a long enough duration and something ideological . We havent done it for a decade and weve showed that over a period of time and we keep acceding and animal and having a response against him and years later they will evolve. We havent proving that yet so obviously its that kind of thing. What if anything can we do to accelerate this side of the room to accelerate a development of these universal vaccines . Is the time to have to trials at this point or Something Else that you need . What it is that we have done very good support from congress with doing the kind of work that were doing and the vaccine with our law last appropriation we set aside that was poor to stimulate the research and we are very appreciative of congress for what you already are doing. I wanna pivot and this is im going to take a chance here because i get the sense doctor fauci you and i may share essential humor. Do you know you call alternative medicine networks . Medicine. I raise that cars were in a moment where this is rise in scientific slip thinking from denial to the new yorker last week and the rise and people that think that where the stars were where they were born have an impact on their future. As you think about the concerns to public caliph. Theres ones that have concerns with the Anti Vaccine Movement that are choosing not to take proven medicine. There is a separate risk of people that are choosing to take bogus medicine. Which of those maybe im phrasing this wrong, are those comparable concerns that would be enough to combat both . I think they are comparable. Theres danger in both of those. You brought up two very important points there. There is an obvious concern on people that are anti science and dont want to believe the clear cut science facts. There is a danger to actually having effects of assuming that the epic could see that the veins that are bogus and we have several years ago established a first a center in our institution for alternative medicine to be able to look at some of these things that society and people in community have convinced worked for what they do and do not work. Were doing something about trying to put some scientific rigor into some of these things that could potentially be bogus. So thats what were trying to do on that and. On the anti science and the only thing we can do is to continue to do what doctor Daniel Jernigan and his colleagues at the cdc is to continue to try to get out the message in the evidence based proof of what works. There is nothing like evidence to be able to convince someone that something works and you have to keep coming in with evidence over and over again. So are we doing enough to keep bogus science off the shelf, when i go to walmart and i look down the flu vaccine, the flu medicine, theres some homeopathy up there as well. I dont think the average person knows the, difference should we be doing more to make sure i think as a society we should be, im not sure there is much that we at the nih or cdc can do. But clearly there is stuff out there that really doesnt do anything except potentially harm people. Thank you, i yield back my time. Let me recognize mr. Murphy. Thank you mister chairman, i just want to say thank you actually, professionally, to both of you gentlemen, i followed your career since the early eighties you made such a fantastic landmark discoveries with hiv, and put forward today something its manageable, thank you for mark immunity and i want to go back to what my colleague pointed out the anti scientific i think thats a major problem i saw last week the people are now starting back from the flat earth agenda i want to go back to the Anti Vaccine Movement in our country what its run for countries at risk where do you see that going in risk certainly i think there are pockets where individuals are talking with one another, some schools where folks are hearing from each other rather than looking at the science bases. Those pockets can lead to more children not getting vaccinated for school to get into school. I think its important for us to recognize the people get their information in different ways now. So for us to be minimal on how it is we get the science based information, the evidence based information to those folks. Identify what their needs are and provide them the information that they need. But in till you address those specific groups, i think with information that is valid to them, i think its actually going to be very difficult. Thank you, one other issue i would like us to revisit is ebola. I dont think people in the United States really understood the gravity of what would have happened if that had gotten into lagos or any of the other places in the future. So i was wondering if you could talk a little bit more about the vaccine of ebola, doesnt mutate on the level that the other ones do, and can you, just for edification, just to explain to folks the f effectively the raid of the ebola virus versus the hiv virus, for example. I know there are a multitude of scale more effective but i think an example would be helpful. It will la, unlike influenza which drifts and mutates, is pretty stable, its in our in a virus so theres always mutations but they are not always functionally relevant. So if you do a sequence of ebola in a strain in west africa which was wool is iea. There is different types of ebola but within a bullseye year which is the one we are dealing right now it hasnt been a problem where its mutated the point of being functioning relevant. So you can measure point mutations but they dont change anything about, it i think the question you asked is what is the relationship with the vaccine . The relationship with the vaccine is that the vaccine has worked and any change in the virus has not had any impact on the vaccine so it looks pretty good, so as i mentioned a little bit earlier in the testimony, we have now distributed over 250,000 vaccinations in the outbreak. The second part of the question is the issue of how its transmitted. In an untreated, unvaccinated arena, such as whats going on in the drc right now. That is the mortality of that is about 67, 70 , it is transmitted only by direct contact with a contaminated bodily fluid. That was really important. So somebody gets ebola and they are incubating it, and they have a fever but they are not having diary, other not having bleeding or vomiting. That person is really quite non contagious. And that is the reason why there wasnt a concern of people back when the patients in texas got infected, there was a concern that those two nurses were infecting people, and they were not. Where is when you get Something Like influenza, influenza is transmitted by the respiratory route. There is a window of when you are actually not very sick, when you can actually transmit it because you are shutting virus for a period of time before you get sick, there really is a rather substantial difference in transmits ability, it is tough to get infected with ebola unless you have direct contact with a really sick person. Where is you can get influence on an elevator when a person sneezes. Theres a big difference. Thank you. We will yield back the remainder of my time. Thank you, for yielding. I would like to add one more document. It clearly indicates that while these vaccinations are safe for most people, there are some for whom its not safe, the Vaccine Injury Trust Fund has played out over four billion dollars which they did not mention, 46 of those were for influenza based vaccinations. So i didnt want to ruin the love in here, but i think we should not be cavalier about those for whom its inappropriate. And that we do try to identify who it might not be appropriate to receive those shots for Public Safety and the future. Thank you very much. Let me recognize miss thank you for reminding us we could get flu in elevators. Which we are reminded of all time. Im glad i got my flu. Shot thank you to the witnesses for being here. Willingly reflect over what happened last century we made such an astounding success developing vaccines to eradicate pernicious diseases in the United States. We have essentially eliminated polio, smallpox, diphtheria and the rest of the world, largely defeated those, the World Health Organization estimates the vaccines to prevent these 10 Million Deaths between 2010 and 2015. That is pretty remarkable. But in this hearing today we are acknowledging today that there is a great deal of work to do. Especially with influenza, one of the most pervasive Infectious Diseases globally. Yet despite all the efforts, we are still struggling to effectively protect or respond to those annual epidemics because of the rapidly changing nature of the flu as you both discussed. The good news is our witnesses indicated, this is exciting Cutting Edge Research thats being conducted throughout the country to develop new approaches, thank you doctor foul see it for bringing your model. Thank you doctor john again for bringing your mobile lab, a lot of that work is federally funded or supported which is as why im glad were having this hearing. Some of that Innovative Research is happening at the Science University in portland. Are working on a novel method of long term flew investigation that inserts pathogens into see envy to struggle or trigger spots. I dont understand what that means and im hoping youd be willing to explain. It are you familiar with this approach and can you explain how it functionally difference from the one you spoke to in your testimony or more traditional efforts as well as comment on the importance of pursuing varied methods in search of a breakthrough . So the person youre refusing to his named doctor lewis picker and he has established a vaccine platform which uses a highly immune agenda virus and what that platform is called is a vector platform so he takes a virus that we know and have experience with, he inserts the virus a jean of a particular protein that he wants to, make he has done it with tuberculosis, he has done it with hiv, and he is doing it with other pathogens. So what happens is that if you wanted to make a vaccine which he is trying to do, against hiv, he takes the gene that codes for the outer protein of the hiv, called the envelope, he sticks it into thes any in jackson first injured animal he hasnt done within the human yet of course there were some safety there that is not above nine virus it gets big scrutiny from the fda, but in the animals its been very effective, he injects it into the animals it starts to replicate and it starts pumping out this protein which is the age ivy protein and he has created in the animals, at, least a pretty good hiv vaccine. Fascinating. When i was mentoring was that the Science University Gene Therapy Institute in oregon. So, also, i want to ask about doctor jernigan and the flu site website. Since 2013, the cdc has efforts to protect data analytics. How is that working . And the public facing website . What are you learning from that . This is a network where we have 25 different academic models wear these individuals that used difference sources of information of social media, weather and all sorts of information and provide some input each week and they have to tell us what they think is going to happen in terms of the peak this week isnt going to get a good start and its a way theyre trying to get them not whats happening with the flu now but will were going to do with that support so we have a pandemic and use that information but during regular seasons, that information can be quite helpful and the patient clinton when they know to increase the amount of staff for the hospital and need to have the beds in the icu and even for pharmacies to know. Some places run out of flew back scene. Countries are used to determine which influenza virus are recommended for inclusion in the end fallback seen. Look how many are collaborating in so many countries and what could be done to improve the International Disease surveillance to be better prepared . And the United States we have very good view of whats happening with influenza of the thousands of hours as that are characterized with three other laboratories and we see viruses for them but there are spots where we dont know whats going on the more we can get improved surveillance and the surveillance in that setting and what helps that country and helps the rest of us to know whats going on with pandemics and if they are showing up with those vaccines. My time is expired i yield back. Let me recognize missed jennifer wexton. Thank you both for joining us today. On october the cdc i stakes about maternal vaccinations. I was surprised to see that only one in three pregnant women received both flew and wolfing cough because women with the flu are most likely to be hospitalized if theyre pregnant and 70 of wolfing cough there is death for their children for their kids of under two years of age. Vaccination through pregnancy through hot of spittle is a shun and looping cough vaccination for the hospitalization. It is 91 . I think we can agree that the vaccinations are a critical part of prenatal care for mothers. I understand that dr. Jernigan you, mentioned there just a way that half of adults are the United States get their flu shot because they have a perception that flew backseat is not effective. I know youve already talked about misconceptions and false information out there. How can we be more effectively communicate the benefits of vaccine . With regard to pregnant women i think its a current occurring about half are getting vaccinated for a flu. That is a real Success Story in the last several years. Weve seen it rise to the level and we need to do more with the other vaccines for pregnant women. If you look at who is getting vaccinated only half of americans, you can see that theyre happening among the old and the very young. So trying to get it with people that are late and their teens from 18 to 49 is the group that were looking to get up to it increase vaccinations. Were targeting efforts and using social media and others. Just get them used to getting a vaccine every year . As like an annual thing . You have the vaccine every year plus these are people that they themselves have a lot of Preventative Health care of getting that group in is a challenge. Im glad you brought up social media because weve seen a lot of how social media can impact the lives in a good way or bad way. One of the issues with social media is that information spreads so quickly in the violent nature of it. We communicate in a bottle without external sources and point with something is just plain false or when something is true and has peer review in all of that. It is something that weve seen across committees another context as well here and were talking about lives that are at stake and earlier this year the American Academy of pediatrics had ceos of major social media platforms with Google Facebook pinterest and had the harm of children from a black vaccines that are spread across our sights and you have already spoken to other testimony about the misinformation and how it spreads. This is for both witnesses, do you think these platforms are doing enough given that lives are on the line plea . I think people access their information and multiple different ways and making sure that we have our scientific based evidence in the format thats going to be reused in that setting and i dont know if you want to talk about this . I agree. We can do more and can do better. I think the platforms that we have now to get the message out are having some positive effects and its clearly a challenge thats not going to go away and its not going to be a problem to solve and its over and we have to keep at it over and over again. Thank you so much and i yield back. In closing, two other questions that come up repeatedly. Folks will say its almost the end of november and i made it this far and i dont need a flu shot this year. Is that correct . A recommendation from them is that you get your vaccine if possible by the end of october and as long as the of influenza viruses circulating that it is not too late to get vaccinated. Her goal is to get people vaccinated prior to the season starts and theres two weeks of time before they allow their immune systems to get exposed. Clearly, we recommend you continue to get vaccinated now. So most of america is watching this and not another hearing. laughs it is not too late . It is not too late to get vaccinated. Another question that comes up is nasal flu vaccine versus flu shot. Any recommendations . Cdc does not have any preference over another. There are personal preferences but with regard to the live into new waited influenza there is no preference and there are all listed with each other. Great. Once again i want to thank both of you for your service to this country and service to medicine and for those watching at home a flu shots are safe and vaccines are safe and effective and they do save lives and thank you and we will recess for a few moments and allow the second panel to get seated. Thank you. Thank you. Welcome back. At this time, id like to introduce our second panel of witnesses. The first witness in the panel is doctor Sharon Watkins. Doctor watkins is a director for they burrow a the criminologist for the department. Shes also the president of the council of state of territorial epidemiologist she is the oversight of the division of Infectious Disease and environmental health. Doctor watkins has led key surveillance in efforts including those who have zika, health care infections and dr. Watkins has over 40 reviewed publications in 20 years of experience a Public Health and thank you for being here doctor watkins. Our second witness is dr. Robyn robinson. She is Vice President of affairs for the Care Incorporated and for wound healing. He served as the first director of the biomedical advance Research Development or coren i and Deputy Assistant secretary for a response from 2008 to 2016. He also served as the influenza and Disease Program from 2004 to 2008. Doctor robinson was the recipient of the department of defense award in 2008. The hhs distinguished a finalist for the service of america meddled 2009. Thank you for being here doctor robinson. As our witnesses should note, nil each have five minutes for your testimony it, written testimony will be included in the record for the hearing. When you have completed youre spoken testimony with questions each member will have a five minutes to question the panel. It will start with doctor watkins. Doctor ami bera and members of the committee, thank you for the privilege to appear before you today, im doctor Sharon Watkins and president of the council of state and territorial epidemiology and the genealogy is for the department of health. See as tee is an organization of states and territories recommending the meteorologist and we work every day and partnership would cdc to detect and respond influenza outbreaks and get an understanding of potential changes in the virus and deliver lifesaving vaccines. I have witnesses devastating impact of a seasonal influenza and the two dozen line h1n1 era measles and any other walk vaccine diseases and Public Health threats require efficient and timely responses with a network of Health Agencies at all levels of government in coordination with Health Care Providers. Response to outbreaks happen at the local level. Data on the age group affected of vaccination vaccination status and pregnancy status and whether the outbreak is in his school or Long Term Care facility. For example, they all need to be identified so we know where to respond and what is needed. Unfortunately, this Public Health network is choked by antiquated data systems that rely on obsolete and sluggish data sharing efforts. Faxes and phone calls are still in widespread use and the system is in dire need of security and lack of interoperability, reporting consistency and data standards with errors and quality and timeless and communication. I have stood before communities and crisis who are justifiably bewildered and anger that Public Health cannot pass this disease data or access it faster. How is it that you can simply log in to a portal and get a medical test results in a matter of minutes and new who are charged with protecting Public Health dont have access to todays health. Its shocked people to learn that i do not have coverage connecting hospital im urgency departments with Public Health surveillance systems. About 40 of all each visits are not submitted to the Health Department. Leaving us flatfooted and identifying and responding to the fear flu infections among pregnant women, children and the elderly. We are now entering flu season and are challenged by the current outbreak of lung illness associated with ecigarettes. Public health is urgently decisive ring facts among the records to distinguish ecigarettes cases from the flu cases. This information arrives in different times two different channels. Tried to decipher a denim one in my written testimony. Its a four page sample of 350page facts of medical record received by the Pennsylvania Department of health on one of our ecigarette cases. Providers already have our data shared and collected full of Electronic Health records that cannot rapidly share this Public Health and have no way to receive electronically. They are still filed on paper in some states and only 63 of all deaths divots are submitted to cste within ten days. Regrettably, most pediatric deaths occur occur in unvaccinated ways and it takes weeks to uncover it and the flu deaths or vaccination industry has communication to stay who have answers to these questions. See as tea and our partners with Public Health laboratory are more than 90 other institutions. Believe the time is now to step up and take coordinated approach to building 24 century public data super highway. This super highway will collect health data from Health Care Providers and report automatically to Health Departments. They will lead to other key data including birth and death black oops and industries that share the data slim leslie with cste. The technology is here but we need our resources which is why the proposed funding of 100 Million Dollars in the labor health and Services Appropriation bill to support data at the cste is urgently needed. During the ongoing deliberation, cste they hope you consider the modernized electronic Public Health it is system and public data Health Scientists to strengthen Public Health beth prevention revaccination. We recognize this effort must be funded with new money rather than cut underfunded Public Health. Without federal support, the modernization will retain and they will suffer. We look forward to working with you and i thank you for the opportunity to testify before you today. Thank you. Doctor robinson. Good morning. Good morning acting chairman and lucas and the members of the committee. Thank you for speaking today and on behalf of dr. Robinson, the former director at asper and in the influence of vaccines and four years ago, and for seasonal influence and what we could do to remedy this flu vaccine. This has returned each year and despite our medicine cabinet and new influenza vaccines are the four strain of influenza vaccines and the antivirals ive been there since 2015. We saw the chief issue with the vaccines. Our domestic capacity produced the vaccine that has quadrupled since thousand five, thanks to our news sell that covers our ability and influenza vaccine and has peak affects. And those over the four years ive never cross the finish line. I wish to address pour vaccine effectiveness and production and elusiveness of vaccines. Ive seen effectiveness and near vaccines that are dependent on this election that can illicit long lasting strong protective force through the influenza violet drivers sometimes. The influenza vaccine will elicit strong and lasting that is currently circulating and drifted strains to the need for seasonal influenza and serve as a vaccine for epidemic means. The story of universal influenza is long and willful for the past four years, multiple ways of innovation had universal influenza vaccines. One of the earliest and most expensive working in the 19 eighties and nineties focuses on the vaccine of the influenza but the vaccine candidates were inaudible . They target the two protein that were developed and allergenic as well. They had to discoveries in which doctor fauci mentioned earlier and the anti bodies were discovered in 2011 and specific to the stem portion of the protein and neutralized widely to first influenza virus was discovered and led to the new development of hemoglobin mechanics that are undergoing presently. Another discovery which we heard this year was the antibodies to conserve on the protein which is done targeting for many years. These antibodies are neutralized by the to first influence. This discovery it will likely initiate another wave of vaccines that will include this specific protein in the next generation of flu vaccine candidates. On the issue of more rapid production of those vaccines of the new Synthetic Technology which might expedite the facts of production. They do not require the adaptation of the viral facts scene and the self in placed influenza vaccine in the vaccine production that is production above seasonal influenza went in a measure occurs from the influenza viruses and these flat vaccines. Its time for 600 million doses of influenza vaccine of six months to three months and become available before in a week. At the added value its a faster and easier way with those vaccines. Those vaccines are encapsulated with doctor fauci and what he stated. In these properties and the ability of trans determinately there is a view for the self administered catch. These discoveries will make it of the influenza vaccines of 2020 and the funding and authorities of the fta and see the sea as Industry Partners and of yesterday and today. With the wisdom, generosity and support that have carry us this far. Help us finish the journey. Thank you. Thank you doctor robinson. Well begin our first round of questions. The chair recognizes himself for five minutes. Doctor robinson, thank you for your service at barbuda and we met with another organization that had a chance with is giuseppe and a organization but the International Community together and we had vaccines for urgent disease and can you elaborate a little bit more on that and one of the biggest points for me is that they dont participate point and on your opinion on whether the u. S. Should participate and if you an elaborate on that. Can you turn your microphone on . Sorry. Thank you for the question. I always smile because my former deputy was Richard Hatch and hes the current ceo and should the u. S. Participate and the activities of these Infectious Diseases and the answer is that we already are and when this occurred and 2014 and a reality in 2017. The nih and more specifically they had investments in Infectious Disease and vaccines which is an ebola and others at thats part of our contribution or we continue the u. S. Governments efforts at least in specific areas. We do support what they do and in many places we have contracts and grants and projects that we are working on but the duplication of what theyre doing. If we play off of that for a moment and the interest in some of the threats. If we look at the urging diseases and some of those a pandemic threats, what is our capacity within the private sector to ramp up if we see an emerging pathogen and quickly identify it in a potential vaccine to mitigate from your perspective . So, i will give it in the context of where we started my Public Service in 2004 which would take months and years to be able to respond to a new passage. My first assignment was on the age five influenza virus. And since that time, we had a test in 2013 with the emergence of age seven and new viruses. We had to produce those vaccines and we brought them closer to three months. There was a specific reason why. We heard from dr. Fauci and doctor jernigan we, had to sequence of that virus immediately into action and it was april fools day of 2015 then within weeks to have distributing to the vaccine manufacturers but also from the common proxy. By the summer, we had those vaccines in clint trials. At the time, we were able to do that and the issues that we were talking about and even expedite that and our goal is to have anti vaccine produced but are available with the 12 weeks. Doctor watkins, in a prior life i was at the Sacramento County in health work and it makes me chuckle because we would get information fast and most of the public wouldnt believe in this day in age that a lot of Public Health records and information was the fact that you talk about interoperable and collecting data. Creating big data sets. Can you elaborate a little bit more on what that will allow you to do in terms of more rapidly identify potential outbreaks and why its more robust medical record and electronic Public Health record. Sure. When i think about medical delivery in the Health Care System today, it is amazing be advances that have been made. And has been left behind a little bit. We are dealing with faxes and are dealing with phone calls and spreadsheets and impact our ability to quickly respond to the situation. If records were able to be quickly linked to our disease reporting system. If were able to get electronic case proponents and see data as is coming in and digest that we would be able to respond much faster. Much of what we do in the emerging threats that we have today is scratch our heads and are struggling with the data sharing and the Data Management of so much big data. Public health needs to have our system renewed and reinvested and see as tea has released this book in conjunction and a lot of stakeholders stories and why Public Health and the time is now to invest money in the systems. The chair now recognizes the Ranking Member for five minutes. In your testimony you highlight the Clinical Trials that are stone that are stockpiled and remain highly effective after ten years of storage. How does the work with the industry improved shelf life and style vaccines of the pandemic emergency . Thank you for the question sir. We started in 2005 buildings are stockpile with the epidemic influenza and will treat those individuals that are highly vulnerable and high risk and the workforce to introduce the severe pandemic. Around 27 million and that was for all the different trends that are from the age five and one virus and that we described a moment ago to the age seven and nine. Through the process with the fda and nih we have twice a year ago these trends one which are available in 2015, its a question that came up in the numbers here and as a vaccine that you had stockpiled in these companies . Is a still good . The answer was we know the essays look really good but we said that is not enough. We went and did a critical study using age five and one virus vaccine against that one that had been made ten years before and the results of that has been published and shows that they were equal and they were still highly energetic and they could be used without to protect those individuals. Thank you doctor. Doctor watkins you suggested deep Artificial Intelligence that could be a useful tool to identify outbreaks early but can you elaborate further on how this technology could be realized . Sure. Thank you for that question. Public health does have a lot of data and its not interconnected and i think that the ability to look at birth and death certificates an immunization rates and calling that with census tract information and information on poverty and Integration Status and all of those other data sets help us better understand the community level. What are the hesitations and what are the limitations to vaccination our access to health care or the language barriers. When were able to use all of the data that google has at their hands and we dont. I think that were better able to target where efforts should go. As an example, during the Opioid Crisis we and other states ive been looking at vulnerabilities and where are the deaths happening. Where are babies being born and where our rates of hepatitis increasing and where does that overlay with poverty and those are big data is in the state to really look at the vulnerabilities. We could be doing that with that technology and interconnection. Thank you doctor i yield back. We recognize dr. Murphy. Thank you mister chairman. Thank you guys for coming in this afternoon and we appreciate your expertise. What i want to have is for dr. Watkins i was looking through some of the copies that you have and having experience in the explosion of the political records of my own practice and set the challenges for it. If you could wave a magic wand, there is a way to pull data out of these reports and quantify it, what would look like . My eye preface it by saying we have so many different medical records in our country, most of which dont talk to one another. Unless we have literally a single system, im not sure what this would look like. I am interested in your thoughts about the reality of this because i think the purpose altogether is a great one. But the devil is in the detail. What is a look . Like thank you for that question. I would also refer you to this report that has been done and we can get you a copy of that. But, what we are talking about is modernizing systems we have so our Laboratory Systems is its ability to transmit data between us and the provider and cdc and handles those genetic results and needs to be modernized and more interoperable. Death and birth certificate needs to be more rapid. We should be having paper records of these important documents. Our immunization registry should be interconnected with our other disease reports. Our electronic disease Collection System should be able to know if youve gotten influenza and a death certificate comes in i should have to wait weeks, i should be able to see that within realtime. So, looking at being able to bring those in and its easy that theyre doing a lot of work on the case records and modernizing all of these systems. What were talking about is bringing all states to a better level. Some states are really far behind in some states are behind in some things but not in others. When i think about a pandemic in this issue, we do not want Public Health to be the wink weak link in the chain. We want help to protect your family, my family and the Publics Health with the same tools by private medicine has in the same speed. Thats were talking about. Thank you for the question. Its a daunting task and i think its a good idea and it does add an entirely additional level of data entry but that is what we do. Wed like to get out of the data entry. I have some analogies for you if i may and to me im sure we all have private positions and Health Care Providers. They are not sharing information on you and are not blocking your test results in a spreadsheet. We are working in a modern world with modern technology. Public health is the front line for epidemics and should be working at the same speed. Its like building a space probe and forgetting to put in the advanced communication and data sharing aspect. I feel like in this modernization of health care and were talking about vaccine intervention, were thinking about we need to think about modernization and public data share so that we can be the front line a Public Health and not be the wheat chain. Thank you. I agree that its not cancerous and not other things. Just one other quick question, i wonder if you could speak that we talked a little bit about the vaccines that come primarily from eggs versus the cell based. Can you speak to really why do you believe that the technology is taken up or are we making Good Progress to move moving away from these various vaccines . Because of the efforts we have we actually made a paradigm shift to what yearn again said today and how are we going to move in having greater adoptions but we dont have some of the problems. We really have to realize that the influenza vaccine in the commodity that is driven and the way we were able to move was interacting with the private partnerships which has to be revived and continue with the new discoveries to make it worthwhile for them to have a product so we can have the in base vaccine business. There is promising progress the companies that are solely a egg based and that are actually license now and our developing new influenza vaccines. We need to expedite that with the continued efforts and the good form from before. I have one followup. Do you think that the difference of doing that is regulatory or is it the economies of the cost . Its not regulatory. The industry that im now part of will say that we dont want to do that and not getting a new vaccine from the ftc f but thats they no more course and the real problem is why spend money that we dont have to . Thats the reality. Thank you very much, a yield back. We want to recognize mr. Cohen. Thank you mister chair. Doctor robinson, you touched on it in the first panel the whole social media conspiracy ferries about vaccination is causing autism. How much of an effect does this have on people getting vaccinated . How much in effect of people not getting vaccinated does it have on Public Health . So, theres two parts that question in the first part is what was the anti vaccine groups for autism . We fought this battle during the last decade and will say that from great extent that battle has been one. Scientific data was shown that there was no link between vaccination and autism. The second part let me ask you a followup on that. You say its been one, ill answer that because we have a new wave of anti vaccination and im very concerned about this. Because, they dont have as their true agenda vaccination they could care less of whether it works or doesnt work. Because they have a hidden agenda of things of anarchy and other things and the tactics were using the ones that are cyber terrorists in the past several years and again, the root of the vaccination. For instance, our friend Robert Kennedy junior is a major antivaxxer and is not for anarchy. I think his issue was thinking mercury as a preservative is that correct . That is one of the platforms. Has there been studies to show that that is wrong . What was said by doctor fauci earlier is the hoofs a big that is in some pristine and you made a point it ever in 2008 with the influenza vaccines to remove the manufacturers who did this without being mandated to do so and there are single dose of syringe is and are primarily given to children and to pregnant people and as they said in their testimony that cdc as an influence to minimize that and are working and are not the kind i mr. Kennedy. Doctor watkins do you have any perspective on this at all . Thank you. Public health is clearly worried about these sentiments that we need to do a better job and communicating the efficacy of the vaccine and the benefits it does to prevent tendencies and lessons the severity and complications. But typically for those that prevent death and hospitalisation. Public health thinks a lot about the fact where to people get their Health Information and how do they communicate with each other. We need to do a better job of producing and convincing messages that are shared on different platforms. How many people do we know that use the figure and die annually of the flu . I dont have that figure in my head but we can do that for you. Doctor robertson, you have a clue . At the low and 10,000 and at the opera and 48,000. Those people more than likely than not get the flu vaccine and someone might not have gotten the flu vaccine in a particular way and more likely that wouldve been reduced greatly and not inoculated . Thats correct. Thank you. Im a big proponent of vaccination. My father was a pediatrician, he had vaccines and a 1954, he gave the vaccine to second grade students at the test trials. He had someone those in a second grade and he gave it to him. I was in kindergarten any right at home to give to me. He had second thoughts because there was outside of his charge and within two months i got polio. Back to scenes are good and i yield back. Well open it up to additional questions from the members and also i recognize myself. In my interest doctor watkins, weve been having conversations with Companies Like google and i know google has been doing some work and identifying a particular search that may pop up that may allow us to say, people are searching the term fever and etc to try and quickly go in to a country in africa. Are you familiar with those trials . Have they been successful . Unsuccessful . Those crowds sourcing tools which has a gi symptoms but we have not been using them in those restitutions as they might have. What we are interested in because we are a system that is using case based systems. If youre sick we are counting new as an individual. Weve expanded into ways to identify Emergency Department visits and gaining a lot of information that way. So, i cant say whether the google has been validated for the rePublic Health methods of the crowd sourcing but i can say looking at a burden seat departments and weve seen a spike which has been incredibly effective, not just in identifying the uptick of flu but in many other diseases including being able to identify clusters. Doctor robinson would you like to add . Nothing, watkins to set it. As you are looking at Global Health and the preparedness to continue to work with these technologies because part of the rapidly responding and getting ahead is quickly saying, lets get up and lets see if we cant mitigate that at the source. Is that correct . Absolutely. With all due respect to the Public Health it is under sourced and under resourced. So, our ability to pat go between that is contingent on us being to rely on this. To Public Health Information Systems speak across to life . Though, not unfairly. Thats not because of the regulatory issues as congress. Im under resourcing. Its both. Ohio doesnt have the jurisdiction that john smith in pennsylvania has with influenza. It is my jurisdiction. But we can do a better job of sharing not data across Straight Lines and we need to share that information and we do so securely. For example, in my state, philadelphia is one of the difference terms than the status. It doesnt really matter. We wrote the really work hard and they want to see statewide data and we have to work with philadelphia to harmonize it. It is inefficient. As a Public Health expert let me ask another question about vaccination rates. Let me put it when i was a child, i got a lot of my vaccines at school. Im an internist by nutrition but its occurred to me that for efficiency sake, especially for multi dose of vaccines. Youve got to cap the body and the kids are going there. But the overhead if you had School Based Nurses that are able to go into those schools. It would be more effective, more efficient and i just be curious for your perspective doctor watkins if thats something we made a mistake and moving away from . We certainly do to school based vaccinations and we do use that venue. I think School Based Nurses are a resource that is shrinking. So not all schools have access to that. I think blue big schools into other kinds of issues is always a goal of Public Health and i think that weve done it broader in that footprint. There is probably concerns about liability to move this away from that but just from a pure cost perspective and an ethics perspective, doesnt investment in Public Health nurses and School Based Nurses overhead etc with the efficiency particularly with multi dose vaccines. You lose a lot of kids and our later for that second vaccine and i believe you could rapidly use the number of children that are getting vaccinated. If we were to utilize tools like that. I would ask one last question with regard to measles etc. Id be curious from your perspective, as a Public Health professional how pennsylvania and others around the country are trying to address the periodic outbreaks. Sure. Were exhausted all just be honest. I was at a conference with new york and i cant even imagine what theyve had to go through to be able to address those cases and in pennsylvania i think we are at 17 cases but what we dont realize is that for every case hundreds of people are likely exposed. If its been in close contact, and if you were infectious with measles right now everyone in this room and everyone for the two hours after you have left it would have been exposed. Public Health Notifies you and we track you down when we can. We assessed youre an unity and make sure that not only are you taking care of but everyone is not exposed who is notified and perfectly treated. You are not and if you cant you can get there in time you may be quarantined. There is a lot of steps i go into measles and its an enormous resource and its been difficult for any of us who have had the case of measles. Doctor watkins thank you for your work and all those Public Health professionals. If you have any additional questions. Thank you mister chairman. Thank you guys for coming down and allows some questions because were looking at this in one level of the problems that you face and challenges by all means but my question is, what have you done in the state of pennsylvania to talk to the other counties because the Public Health department in North Carolina run by counties. What have you done on the state level to develop interconnectivity and on a corollary, ive done a lot of work with the Opioid Epidemic and we have people on North Carolina and going into virginia. So we were close by with our state neighbors to develop a system that somebody in virginia could know if they have prescriptions. Its the same thing and its state interconnectivity and the push down a process where we look at the hole in whats going on with that information. This tends to be localized. What have you done on the state level, . Let me just say that pennsylvania is structured differently the North Carolina. We have ten county and municipal jurisdictions so, they are on our same system of surveillance so we are able to share that. What happens is that our lab reports come in and our decision comes into the state Health Office and we push it to the jurisdiction. Or to the district office. Mostly, if youre home rule system and if youre in pittsburgh for example they have seen the records but we do collect it all with the same data system and philadelphia is able to have their own and differences some. We work with them, from a disease perspective and we heard that all the time and from an i. T. Perspective, we try to harmonize what we do. We are always working with our neighbors with appetite estate outbreaks or measles or sharing of and patients dont have a borders. You can be hospitalized in new jersey and go into a Long Term Care facility in pennsylvania and that happens all the time. We keep touch but we could do it better and faster and without loss of information or misinformation if we were better electronically suited. Let me just follow up then. Are you not electronically suited indifferent counties and why would you not appeal to your state rather than the federal government to make that happen . What im talking about is the sharing of a laboratory information, surveillance and that is happening at the state level. It is not an easy connection and to invest money in a long time. For example, our organization record is a collective to our surveillance record and were speaking from cste. But i could be answering for many states. I dont know if your organization record and North Carolina is connected to your disease from any state. That is the kind of things that would help us get data and respond faster. In the measles exposure situation, who is been immunized . That is a hard question, it shouldnt be but it is. We have resorted to actually going to high schools, are Old High School to store records because the physician had gone out of practice Public Health is a make it work kind of system and we do what we need to do. We are getting further and further behind. One other quick question. Just for mr. Robinson. And the success that weve seen with several vaccines against the hpv virus. Here i am a physician try to put myself out a business, where do you see us as far as other witness vaccines then ive seen that for 15 years. I just dont see the door being knocked down. Can you speak to that briefly and what you experience and thought . 20 years ago, we actually worked on the Prostate Cancer vaccine and what is driven this vaccine has been supplanted by the antibodies that have been developed with Great Success over the last 15 years. So that is somewhat moving in the fact seen programs to companies to a lesser degree. Some of those vaccines were extremely promising as we and others were evaluating those at the clinic. I would suspect that once we reach the peak of the antibody oncology purpose that we will see a resurgence of vaccines for different types of cancer. Were probably going to be in the next decade in fact. Thank you. Great. Before we bring this to close. I want to thank both of our witnesses for testifying before the committee today. The record will remain open for two weeks for additional statements and any additional questions. Anything we may ask of the witnesses and the witnesses are excused. Youre going to resume so that everyone can get over to the alcohol as soon as possible. I should note that as this is being filmed that it is not purchased with Government Funds but by the Catholic University so you know its open bar. We are really honored to close out the day with one of my