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tv   Public Health Officials on Measles Outbreak  CSPAN  September 23, 2019 9:08am-10:27am EDT

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structures and that's why it's harder to calculate. whatever number you see it's too low. that's one. things that we're focusing on right now, trying to get a better handle of what this actually means not only in terms of the cost of the individuals and their employers, but what it means for their families and loved ones. >> and we are going to leave this, but you can find it on-line at c-span.org, live this morning here on c-span2. we're going to be hearing from public health officials about the ungoing measles outbreak that began last fall. officials from new york city and los angeles county have been dealing with the outbreak and sharing their firsthand experiences what resources they've relied on and lessons they've learned about preventing more cases. the discussion being hosted by the american academy of pediatrics and the big cities health coalition.
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>> >> so, good morning, everybody, thank you for coming. i'm the executive director of the big cities health coalition. i want to start by saying a special thank you to representative roy allard's office for securing this for us. while i know that the congresswoman couldn't be here today. i want to thank you her for being a true champion for public health and thank the american academy of pediatrics for being such a great partner to us as we started this event, planned this event. so, the big cities health coalition was founded in 2002 and is a forum for leaders of america's largest metropolitan health departments who have changed strategies and jointly address issues to promote and protect the health and safety
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of their residents. we have nearly 30-- we have 30 members whose health department serve 62 million or one in five americans and we luckily have two of our member jurisdictions here today. so you all have bios in front of you so i'm not going to take up too much time, but i want to introduce the panel and then i'll turn it over to them. in the order in which they'll be presenting, dr. colleen kraft, the immediate past president of. aap. the doctor barbeau, commissioner of health. and the chief medical officer for the l.a. department of public health. two doctors came from los angeles and thank them for travelling so far. thank you for finding time to join us today and share your perspective. and i will now turn it over to dr. kraft. >> okay. thank you, i'm dr. colleen
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kraft, the immediate past president of the american pediatrics. we're going to measles outbreak 101, when it happened, and why immunizations for measles and other illnesses is important. the american academy of pediatrics is a nonprofit norjs with more than 67,000 peed i gos trigses, including primary care, and subspecialists and we're dedicated to the health and safety and well-being of all children, adolescents and young adults. we publish recommended childhood and adolescent immunization schedules along with acip, with the c.d.c., with the american academy of family physicians and the american college of obstetricians and gynecologists. let's go back to the history of measles in the united states. in 1963 the measles vaccine was
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licensed and in 1968 the measles vaccine began to be distributed. and measles was gone, was declared eliminated from the united states in 2000. so there was no continuous disease transmission for more than 12 months. and that was due to a highly effective vaccination program and better measles control in the united states, and in the americas. however, we have seen measles come back due to people not vaccinating their children and not getting vaccinated. so in 2010 we saw 93 cases. and in 2019 we have a whopping 1,241 cases of measles. so this disease that was gone in 2000 is back and it's back with a vengeance. if you look at the states who are reporting cases of measles in 2019, all of those red states are the red states where measles has come about.
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and we see this all over the country. so what is measles? it's an acute viral disease that's characterized by fever and cough and a rainy nose, and red eyes and store throat and then this red-brownish blotchy rash that begins on the face and spreads throughout the body. common complications include pneumonia, ear infections, croup and diarrhea. one in four people who contract measles can be hospitalized. i'm old enough to remember having measles. i had measles when i was three years old, and so did my two-year-old sister, my one-year-old brother, and the infant. and the doctor came to the house to see us, and i remember my eyes were so sore, i could hardly open them and my mother kept the shades down and the
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lights down low because there was so much eye pain with measles. i remember that distinctly. and the other thing i remember were the prayers that we said for my two-year-old sister because she got pneumonia. and we almost lost her. she was in the hospital and fortunately recovered and we looked at this disease as something really deadly that hit these four little kids at the same time, and this is very commonplace in the united states before vaccination. what we know is that 130 of the people who got measles this year in 2019 were hospitalized. and 65 of them had complications, including pneumonia, just like my little sister. and encephalitis which is brain swelling. acute encephalitis often results in permanent brain damage can occur if one out of one thousand cases. and the one to three in over
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one thousand cases in the united states. measles is back and it's just as deadly as it was back when i had it. it's extremely contagious, so if one person has measles, nine out of ten of the people they're in contact with will also get measles if they're not protected. the virus is spread easily through the air when an infected person coughs or sneezes and somebody nearby inhales those infected droplets and the important thing to know is that the measles virus is pretty hearty. it hangs in the air and can be spread for several hours after that infected person has left the room. and it could be transmitted directly from person to person as well. once a child gets the measles, exposed and infected, the first symptoms won't be there for 8 to 12 days, but those infectious children are contagious one to two days
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before they start with symptoms so you don't know they're contagious with it. and when symptoms finally emerge, three to five days they're contagious before the rash breaks out and this contagious period continues for four days after the rash appears. we know where people get measles from, and other places in the world where there has not been the same robust immune nation program, measles is commonplace and so measles becomes right away for any of our children who are not vaccinated. if they travel to other places in the world they can come back with measles and we know that people have come back from the ukraine, from israel and the philippines and majority of people who got the measles in 2019 were unvaccinated. who is at most risk for measles? it's our most vulnerable. it's our children, less than five years of age. it's adults age more than 20 years. it's pregnant women.
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and it's people with a compromised immune systems who can't get the vaccine who may have cancer or hiv or other diseases where their immune system is not up to snuff. we recommend the measles vaccine be given first between 12 and 15 months of age and again at four to five years of age. and what we know is that if you get those two immunizations, there's a 97% chance that you'll develop an antibody and protection against the measles. i've changed what i've had to do in practice because we know that during an outbreak the mmr vaccine should be offered to all people exposed to the outbreak setting or anybody who doesn't have that measles immunity and we also are starting now to ask our babies and parents of babies, six to 12 months if they're going to one of these places where measles is endemic and starting
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to immunize our kids under 12 months of old if they're going to be at risk because of the highly contagious nature of measles. there's a concept called herd immunity or some people call it community immunity since we are not cattle. this is the idea that if we immunize and protect people around us then we're going to protect that one vulnerable individual who can't be vaccinated for any reason. so individuals who live in communities with high vaccination rates are effectively protected and those people who cannot get vaccine are also protected. so, it's most important for very young children in those who are immuno compromised. if you've got healthy nonvaccinated individuals and a few who are vaccinated, the most people are vaccinated that
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one child, that one immuno compromised person who can't get the vaccine is still going to be protected because most of the people around them have gotten the immunization and they are protected. so federal legislation in the vaccines act was introduced by representative dr. kim shr. >> guest:er who is a and an obstetrician. this is an awareness campaign on the importance of vaccine very much like the truth campaign for smoking. it talks about our enemy as the disease and then vaccinations are a way to pro rent that enemy from affecting all of us, especially our most vulnerable. the bill allows data to be collected to identify communities with low vaccination utilization or where vaccine mt information may be targeted. it authorizes research grants
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to better understand vaccine hesitancy, why is it that people don't want to vaccine. developing those strategies to help protect more people and vaccinate more kids. so the reminder, before that measles vaccination program started in 1963, an estimated three to four million people got measles in the united states. about 50,000 cases were reported to the c.d.c. but of these people, four to 500 a year died. 48,000, including my baby sister, were hospitalized. and a thousand developed that encephalitis or brain swelling from measles. since then, widespread use of the measles vaccine led to a greater than 99% reduction in measles cases compared with the pre vaccine era and we don't want to go back to the pre vaccine era. we still need to educate families and communities on the
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importance of vaccines. our enemy is the disease. the way we combat this enemy is by education and vaccination. thank you. [applaus [applause] >> thank you so much. so now you've learned a little about measles. i'm going to quickly set the scene about the role of health departments and the role of the different branches of government. i should have also said that we're going to hold questions until the end, but we will have time at the end for questions. so, both the health department are on the front lines of responding and preventing outbreaks. they keep communities healthy and safe or help get your communities healthier and safer. in an outbreak they investigate every case. your going to hear more about this what happened on the ground in new york city and l.a. county and they also have legal authority to quarantine emergency orders done in both cases. they look that they're
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efficiently vaccinated and provide when necessary and they also provide clear, simple accurate messaging on vaccination and work with their partners to do so. which is an important point, also. i think that the dr. barbeau will talk about. the role of the federal government. so, local health departments are on the ground. response and many or most public health issues are inherently local, but the federal government still has an important role to play. and they have resources to bear when needed. for example, they can extend the capacity of local health departments. share expertise when needed. they have the bully pulpit. the head of the c.d.c. really important people who can push out messages to a broader population that's not as localized. and then also, the federal government can provide reliable dedicated funding. so i've highlighted four funding streams here. the immunization program, the
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epidemiology and laboratory capacity or elc, which is a lot easier to say. the public health emergency preparedness funding program. and then the prevention and public health fund. and again, both dr. barbeau and the doctor will talk to you about how they've used the funding streams in talking about the epidemics or the outbreaks, rather. and this is a ten year history of c.d.c.'s immunization program. you can see in 2010, it was at 561 and today, the projected number for 2020 from the c.d.c. budget justification is 533. so we've come down over ten years despite the fact that we've had many preventible outbreaks. and also important is that this program does not just include vaccine purchase or
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infrastructure support to distribute vaccines in communities, but other activities to achieve national immunization goals and keep those high to prevent death and disability from the preventible diseases. the funding supports what's known as the 317 immunization program as well as the vaccines for children program. importantly on this graph is that the red bars shows prevention on public health funds and-- this fund is always on the chopping block on as a way to pay for other priorities. so this is just to illustrate how important it is, the fund is, for the ability of local and state health departments to do their job, protecting the public health. so as we're sitting here on capitol hill, it's important to think about what congress could do to help move the needle. it's not just about funding and there are a number of bills introduced on both sides of the capital that have key
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components to not only try to stop, but to address the next outbreak of vaccine preventible diseases and dr. kraft touched on this. the really important piece for me is that we need to support activities that focus on prevention and not just response. so thinking about surveillance of vaccine rates. we don't have good numbers about how many people are vaccinated. and many cities do and many localities do, some states do, but it varies across the country. we need more research on vaccine hesitancy. dr. kraft talked about a national campaign to increase awareness of benefits of vaccine and combat misinformation and then this new piece and i don't know when we stopped saying social media is new. i'll go with it new today. we need to assess the impact of social media in accelerating or mitigating public health crisis, anti-vaccines and things like that. if any of the programs are implemented doctors would be needed to support them so they can be carried out. now, i'll turn it over to dr.
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barbeau to talk about new york city. . >> good morning, everyone. so it's my pleasure to talk to you about the response to measles in new york city. today i'm going to cover the following, i'm going to talk about the epidemiology of the outbreak and our final case count. i'm going to talk about the response being fought on two fronts, that of a communicable disease related specifically to measles and then on the second front, combatting measles misinformation. i'll talk about the fund that were used during the outbreak, lessons learned and then future challenges. so this is to kind of situate us in new york city. these are the two principal communities that were affected by the measles outbreak. here in the top circle, williamsburg and here in the lower circle, borough park and
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these are both highly populated communities. in new york city, this is kind of, as i like to say a geeky slide, but it helps to illustrate a number of things. one is that the outbreak began in the beginning of october, 2018, and that on this side of the slide you'll see that it extended until september 3rd. and even though in each of these bars represents new cases that were tallied for a particular week. generally, we don't declare an outbreak over until there have been two incubation periods. that's what this slide shows. the other thing it shows the majority of cases that were seen were in williamsburg. it also helps me to illustrate that in addressing the measles outbreak in new york city, we took a measured approach that was intended to meet the epidemiology that we're seeing at the particular time.
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we didn't jump to the most aggressive measures that we could have taken early on. so, this first phase really entailed addressing issues of transmission within schools. the second phase addressed transmission within communities, and then this third phase was when-- thank you, was when we issued our public health emergency order and we hadn't taken that kind of drastic measure in years in new york city. the last time that it was done was during the h1n1 outbreak in 2009. thankfully during that time we didn't need to enforce the summonses and violations measures we had to do in this particular outbreak. it called for immediate vaccination of people living in the four zip codes most
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affected by the measles and individuals found not to be immunized were found to be at risk for financial penalties. what we then saw overall is that our final case count, the final number of individuals that were affected were 654. you'll see from this slide that the majority of them were children one to four years of age, and that of this group, 49 ended up in the hospital, which i was listening to dr. kraft's numbers which is about a third of the individuals affected in the united states, who were hospitalized, were in new york city. additionally, 19 of these individuals required being admitted into the intensive care unit. many of them were in there because of severe pneumonia, many required oxygen therapy.
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so, and as dr. kraft was speaking, i'm a pediatrician by training as well. in my training i've been in this business for about 30 years, i've never seen a case of measles. so this was the situation for many of our providers as well. so, it's something that we thought we had seen the last of, but clearly we have not. and so, in this preventible cases you see there. the majority of them were children 12 months and older, meaning that this is the age at which most children should be immunized and these children had not been. so, that's the bulk of the preventible cases that we saw in the affected outbreak. and so-- going to go back. what we did here was, we had a very aggressive response, collaborating with our elk h had-- health care partners and delivery partners and lowered the age at which to immunize children. we actually recommended six
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months to 11 months which generally we reserved for children travelling to areas with ongoing transmission, but in this situation we wanted to do it for domestically transmitted cases. so the provider outreach you'll see there was very expensive and included both technical assistance and primarily to ensure that health care delivery sites were not sites of ongoing transmission, all the way through to ensuring that there was enough mmr on hand and distributing educational materials in english and yiddish. the bulk of individuals in this particular outbreak that were affected were members of the ultra orthodox jewish community in new york city, in those neighborhoods in new york city. so this is a slide that shows what every health public health practitioner wants to see. the measure we put in place
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were intended to increase the number of individuals that were vaccinated. so this is a slide that looks at the previous year and this year and so what we see is that typically we have a back-to-school rush. the dark line is the 2018-2019 period. the dotted line is the year before and what we saw is that at the beginning of the outbreak, when we declared it, we saw a significant spike in the number of individuals who received the mmr vaccine and then over time it dropped. we started issuing exclusion letters and working with schools more aggressively and we saw the spike there and then we had a low and then when we issued the public health emergency we saw another spike in the number of individuals who were immunized and what you see here is since august and september, the number of individuals in this school year
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getting immunized during what we call the back-to-school rush is lower than the previous year. this is a good thing. that means that families are not waiting to get immunized. that's a good thing to see. what this resulted in is over 188,000 doses of measles given during the 2018-2019 outbreak, which is over 23,000 more than the previous year in those particular neighborhoods. so it was a massive effort that was led by our department in collaboration with the health care delivery system, but that could not have happened without the engagement of our community partners. and so, what this outbreak lighted for us is that in certain situations, traditional partners are not enough. and when you-- we are up against
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misinformation, up against issues that really we have never encountered before, it was critical to engage leaders within the orthodox community, and so this community had been targeted by the anti-vaccination messages and they were targeted through robo calls, direct mailings, as well as social media. so, this was not exclusively social media, they used all available fronts to disseminate misinformation, propagate fear which ended up resulting in high numbers of individuals within this community being unvaccinated, susceptible to a disease that has significant consequences. and so we met with religious leaders as a result of this, the community took on the challenge of ensuring vaccination for folks and new
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groups started popping up. the orthodox women's is one i want to particularly highlight and these were a group of physicians who took it upon themselves to do house calls to offer vaccinations, sort of going back to, you know, polled school tactics. the importance here is talking about the consequences of vaccine hesitancy and the degree to which misinformation fear can take hold in certain communities and it's not just a phenomenon that we're seeing here in the united states. the outbreak that began in new york city actually began in israel the year before and that outbreak actually began in ukraine before that. so, this is a worldwide phenomenon just-- not just in the united states. and the common thread is the
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prop puagation of gear and lies there is is pamphlet that was distributed which was filled with, really, inflammatory conspiracy-based theories about the dangers of vaccine and how it was much safer to get measles than it was to get the vaccination. so when we were fronted-- confronted by peach, we made pie. and so this is a communications material that we put together in collaboration with our partners and took each point that peach made and refuted that with actual scientific basis and this was distributed throughout the community, not only by ourselves, but by our partners and it was clear that there were many opportunities
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to do both large scale educational efforts as well as sort of the equivalent of the old school tupperware parties where there were small gatherings of families, to really have time to understand, the underlying science behind the safety and efficacy of vaccines. as part of that effort of combatting the measles on the second front of combatting misinformation, we put out a lot of educational materials and emphasized the importance of spreading the truth, not measles, the importance of getting vaccinated, having materials in yesterdayish as well as in english. we also had materials in spanish and chinese and then i think, i'm particularly, you know, this particular graphic, i think, does a very good job at conveying what the doctor was talking about in terms of
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herd immunity and that with one infected individuals there are others in the light gray who are unable to get vaccinated and are at risk for illness. so by the numbers, at the end of the day there were over 547 staffs deployed for this. the person hours spent. 20,000 new yorkers were tracked down to confirm exposure and immunity status and 2400 individuals have a more indepth investigation to determine that vaccination status and whether or not they actually did have measles and it cost us $6 million to address something that's incredibly preventible. and so these dollars were primarily, and let me just walk you through. this top line is top total dollars. you'll see that the bulk of dollars that were used to
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address this were city dollars. the next level was state dollars. you'll see that this was after we declared the public health emergency and that the lower line are federal dollars and even though that is a much smaller curve, it's a very important curve because this is where we have the capacity to do our laboratory testing, this is where we have the capacity to do our disease surveillance. we would not have been able to mount the robust and aggressive response that we did were it not for these funds. i think the other important thing to note is it that this line also includes emergency preparedness dollars and so, i don't want to lose sight of the fact that often times i think the public thinks that this is, you know, this is like jiffy pop, right? there's a lot of training and preparation and systems that
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need to be put in place in order to ensure that we protect and promote the health of new yorkers. so those funds are critical for us. and so i want to just end on-- or actually i have one more slide after this. the lessons learned. i think this was a lesson for the entire country on not taking public health victories for granted. that even though the united states has, you know, been declared measles-free since 2000, this is a clear example of how because of international transmission, we now have measles reintroduced into our population and it's critical for us to redouble our efforts on ensuring that families have appropriate and accurate information that we have individuals within a number of different communities be the health care provider community,
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be it the religious communities, armed with information that they can share with their neighbors and be trusted messengers about the importance of-- and the safety of vaccinations and also ongoing public health campaigns regarding the importance of the vaccinations, clearly not just as measles, but of all vaccinations. and then the importance of having more granular surveillance because in new york city, we have a 99% immunization coverage for children that are school age, but what this outbreak showed us was that there are pockets where there are high number of individuals who are susceptible to this virus and so having more resources to do that granular surveillance is key for us. and then, leveraging community relationships to build new alliances, not just for this particular outbreak, but for
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public health emergencies moving forward. what we clearly have learned through this experience is that the partnerships that we have put in place will also help us for emergency preparedness or, you know, man made as well as natural disasters in the future. and so the challenges for us remain with vaccine hesitancy. given we did a health opinion poll recently in new york city and 21% of the-- or adults who had children between the age of birth and 17 years of age. 17%, excuse me, 21% of them, let me say that correctly, 21% of the adults who had kids, zero to 17 reported that they had delayed or refused vaccinations so that's a very concerning statistic in light of the fact that we have
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ongoing international transmission, in light of the fact that we've got transmission in other parts of the country and it really gives us the urgency to continue the efforts that we've put in place, and so as i mentioned, the future challenges also include continued education to spread misinformation. in this case it was the ultra orthodox community, but in other parts of the country it's been other communities with this information. i don't want to in any way, shape or form indicate that it has anything to do with religion. this has to do with misinformation taking hold and not having enough credible messengers to counter it. and it's the need for funding to sustain these educational efforts and response efforts. so thank you very much. [applaus
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[applause] >> good morning, i'm from los angeles county. do want to thank representative roy allard for helping to set this up and krissy juliani. it's a pleasure to be here with dr. kraft and dr. barbot. haven't had to make any pie, but we're keeping our communiti communities, and how we address the challenges and how to help going forward keeping all of our communities safe. i have a few things i'm going to cover. i want to make sure you know a little about los angeles county, but i also want to talk about three measles outbreaks we've experienced in the last five years and i also want to
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highlight two bills recently passed by the california legislature to protect our residents go ens-- against this disease and finally successes. los angeles county is far and away, more than 10 million residents the largest county in the united states. covering more than 4,000 square miles, which is a very big area, having 88 incorporated cities, including los angeles, which is a little over 14s, 4 million and six cities over 100,000 and a city were over 200 languages are spoken, you can imagine that communicable diseases can be a challenge when they occur. and we see measles as a serious thread to our residents. we're addressing this as strongly as we can. as of today, our department has been successful at containing three measles outbreaks in the
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last five years. this has not been easy and it's been very costly. the first was the well-publicized disneyland associated outbreak in which a single individual infected about 40 other persons late in december of 2014 which resulted in about 148 cases which occurred in many counties throughout the state of california, about a half dozen other states and also, affected people who lived in canada and in mexico. this is that nerdy epidemic curve slide that's so frequently referred to, but shows the distribution of cases over time. you can see on the left side of the slide, there's a cluster of about 12 blue cases, these were the first wave of cases that suddenly in early january we found we had in los angeles county. and you can see that this outbreak extended over three additional waves into march of that year.
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we have a total of 28 cases in total. this massive outbreak consumed many resource hours of public health work, including, as dr. bar dbot mentioned, you had to interview the people we contacted and many we had to test. nl we had to restrict their movement if they were incubating it they wouldn't infect others. in total over 2200 contacts we had to interview for this process. officially, due to herd i am community or community immunity, the outbreak ended in 2015. two years after that outbreak almost to the day, we had another outbreak, which was somewhat different. and i do want you to understand there are different kinds of outbreaks that can occur. so the disneyland was a massive exposure that affected 40 people that were suddenly affected and traveled other
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parts of the state and country whereas this one was one individual similar to new york who is coming back into a group that was unvaccinated. here a single unvaccinated person, part of a closed largely unvaccinated people. and spread through children causing a total of 18 cases in our county and six cases in other nearby jurisdictions. of note, the closed social group, despite a lot of outreach was unwilling to cooperate with our investigation and refused vaccination. this slide gives you the information that we're tracking on a daily or regular basis to see how well our efforts are going. this is our final summary dashboard of this outbreak and displays the amount of work that we perform to prevent further spread.
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shown in the case timeline which is at the bottom. cases were spread out again over four waves and similar to the disneyland outbreak, even though the number of cases in the county was lower, it was only 18. we had identified more than 2200 contacts again, about a thousand of these were in health care facilities alone, and again, we had to identify, interview and restrict their movements. more than 50 persons here, fortunately, we were able to identify early and we provided them either mmr or immune glob ulin to report their illness. this has been 2019, an extraordinary year for measles outbreak in los angeles county. these are two different from the prior episodes and others have described the driving factor behind this has been the explosive outbreaks of measles occurring in other parts of the world leading to a total of 19 persons who picked up this
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infection somewhere else in the world and during this year then came into los angeles county. 11 of these were temporary nonresident visitors, los angeles county is a very popular forest designation. we had a traveler from new zealand who recently came in and saw a bunch of sites and exposed a lot of people, so this has been a common occurrence for this year. eight of the cases occurred among residents and two of these residents spread the infection to eight others. in total, we've investigated about 4,000 contacts this year from these 27 cases. we've placed hundreds of people either in quarantine or restricted their movements. many people are unfamiliar with some of the work we do in public health. so when suddenly they find out they can't go back to school. they can't go back to work and in some case we even restrict them to their homes and this can be disruptive to people's
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lives. i think you heard in the news how we had to quarantine students and cal state and we had the reports and again, this was very disruptive. what have we learned from this outbreak? i hope you can appreciate that each of these was very different. so measles can affect an individual community in very dinner ways. and yes, that disneyland outbreak which was an explosive point outsource outbreak sort of a worse case scenario and eventually herd immunity prevailed and that outbreak was over. second at least in my professional view, the rain reason they did end was due primarily to the prevailing level of herd immunity in our communities. eventually those final cases, while they may have had contacts with other people almost all of those contacts were immune due to vaccination, and that is what afforded these outbreaks.
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third, i can't stress how costly and challenging it is. and our response to these outbreaks has really grown and i feel we're very competent in this area, but unless you work in a public health department and have appreciation for the different kinds of activities that are required, it's difficult to describe the complexity and organizational efforts that are needed. and fourth, i do want to mention that the increase, the level of herding immunity is what we really need. so now i want to touch briefly on a couple of bills that were passed recently by the california state legislature. i think you've heard about these. the disneyland outbreak brought to public attention the fact that more than a few public schools had high levels of nonvaccination, in some schools more than 25% or even more than 40% of students were not vaccinated, owing largely to parents claiming personal belief exemptions so that their
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children could avoid the mandatory vaccinations such as mmr to protect against measles. in response, senator richard hand, a physician, introduced senate bill 277 which eliminated personal and religious belief exceptions and allowing only medical exemptions as a reason for exclusion from the mandatory vaccination requirements. this slide is a little busy. but the table shows our data from prior to sb 277 in the red area and the green area is the result for the post 277 era. so, you can see a couple of lines one highlightled and completed the vaccination and you can see on the left in 2014, 2015, this rate was only 86% of our students. and we have over 100,000
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children entering kindergarten or first grade this year. you can see by the end after sb 277 on the right and you can see in 2018 and 2019, the up-to-date rate is about 95% which is very fantastic from my point of view. and i want to highlight in the second to last row of data down there, you can see something called pme stands for permanent medical exemption, you can see before sb 277, these were at the rate we would expect, about 1 per 1,000 or 1%. and after the law went into effect the medical exemption increased seven fold up to .7% last year. this is somewhat concerning for the state not for los angeles county and just over 95%, and you can see that the
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private schools shown in green consistently for the average. in this statewide data and major concern was the statewide increase in the last three years of the medical exemption rate to statewide about .8%.: and what came to attention is the small number of. and local health officers in the medical board to interrupt the exemptions, so in response to the address described as the moneyization of exemptions by a small number of exemptions,
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they had senate bill 276 which required a physician to state the specific medical reason for the exemption, and certificate that an actual medical examination had been performed. the law requires that the california department of public health review all medical exemptions from schools where the overall medical exemption rate is-- or the vaccination rate is less than 95% and also to review all exemptions from any physician who has submitted five or more of the exemptions within a year. though highly contested, this was recently signed into law by governor newsome. let me briefly describe our challenges and successes. >> we've been successful in l.a. county and with the recent legislation our children are increasingly protected, but the
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worldwide outbreak continues and in our county we have nearly 1 1/2 million persons who remain unimmunized against in disease. and even the traveler even if they don't infect somebody else, costs us abouted 30,000 to investigate and each contact we have to reassess their community costs on average between 500 and in some cases up to $1,000 to investigate and respond to. given more than the 8,000, we've easily spent, 3, 4, 5 million dollars just responding to what is less than 100 cases of measles occurring in our county. we need to find ways to strengthen our adult vaccination and we need your appreciation and support building trust around the safety and efficacy of vaccinations.
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a life long public health professional i've grateful for the legislative efforts that have supported our cause to protect against vaccine preventible diseases and i also want to highlight the indispensability the others have mentioned, the public health emergency preparedness funding which out, with the local health departments, we have many beyond the measles outbreaks and these funds are critical for our efforts to protect the public health. and i want to emphasize, the appreciation that l.a. county has for the prevention fund and vaccination efforts that have been funded in the county and in particular, the 317 immunization program which has given us thousands of doses on a very timely basis to protect
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our residents which otherwise we wouldn't have had the money and it would have taken a long time to find those vaccine doses and abort these outbreaks. so with that, i want to say thanks for your time and attention and i think we'll look forward to your questions. thank you. [applaus [applause] >> okay. i don't know about the rest of you, but i'm exhausted just hearing about what these folks have been doing for the past year. i was telling somebody that we were doing this briefing and they said, why are you doing a measles briefing? isn't it over? i said yes, people finally have time to tell us what happened. and thank you, i really appreciate it. so important to hear the public health story, the local public health story from people on the ground. so with that, we do have time for questions. and have a microphone.
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if anybody has a question i would love for you to identify yourself, also, so that we know who is asking what. pass it down. and you all need to-- ... >> we have one of the most robust immunization registries in the country, and all providers that receive the funds are required to report into that. and so during this outbreak we
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were able to do a lot of geocoding to determine baseline immunization rates. in the beginning it was something like 83%, and then post effort immunization rates and we bumped those up to roughly 93% in the affected communities. the really understanding that our efforts were targeted in the right -- basically, we were efficient, effective, and make best use of our resources. where we then found challenges, and jeff and i were talking about this earlier, is in terms of having ready access to adult immunization information. and the fact that right now we encourage adults to have their information entered into the vaccine registry. it's a very small percentage.
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we worked with our health information exchanges to try and get that information, but we see that moving forward it's going to be a focus of attention in order to maximize the number of adults who have read access to the vaccine information. as many of us, myself included, have no idea where our immunization record are. in our lifetime have probably gotten them from a combination of the health department, your private provider, and who knows, a travel clinic. so we want to ensure that we have replicated a system that is as robust and detailed as what we have four children, for adults. >> what's the most challenging part of getting the adult data, the consent? >> part of it is getting providers to ask on a regular basis if adults are willing to have their information entered into the vaccine registry. we find that once they are
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asked, that the vast majority said yes, our health and hospital systems, this routinely we are working with other health systems to increase that frequency. >> i'd like to add a couple of comments. first, in california we don't have a state law like new york does that requires that vaccines be reported. so we are even further behind. we do have the california immunization registry so all the federally funded vaccines have to get reported into that. but as of today many of the electronic health records don't speak with the immunization registry. so like, for example, in my department where we recently stood up electronic health record a year and ethical, despite a lot of effort, we still get data from the immunization registry come into hours so i can see that the patient, and unsympathetic clinic, has actually been immunized. we've got a long way to go on
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this. having access to the vaccine information would allow us to see where outbreaks could happen. so as we have talked with our colleagues in new york, looking at l.a. county thinking what is it in the county what might have these highly unvaccinated groups works we have school data which is helpful and and you can see it was primarily one year old are very young children. but in l.a. county we have similar between 1 million, 1.4 million people who haven't been vaccinated based on some population studies i really don't know where it is concentrated. so short of having that i don't have a focus. the other thing i will say is information systems are so vital, how we run thinks inside the department. when we first had the measles outbreak resulting from disneyland, we sort of struggle to put together complicated information on a timely basis so i could know where people were and make sure within two or three days people that needed to
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be quarantined, it was happening. when you've got hundreds of cases, hundreds of nurses all of the county doing things. to pull the information together, was very challenging. but now the fight has been so helpful, we've been able to find i.t. things, we quickly stand up dashboards and within a a coupe days we can track our response efforts and really be precise in where we're doing our work. it's really been very helpful. >> so while the moving the microphone, there are only a handful of big cities, locals that directly get the funding. you hearing from two of them and it's really critical. you are also hearing from two of the largest health departments and wealth resource department in the country and these of the challenges that they happy with that heightened capacity compared to others. >> arthur allen from politico. i had a couple of questions. i just wonder if you could
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elaborate a bit on the data because you have my school records. so can't, doesn't that help you identify pockets of susceptibles? >> i'll start. yes, we do. and as i mentioned, our public school system has above a 99% immunization rate. and so in this particular outbreak, the outbreak was contained to nonpublic school kids who were below the age of school enrollment -- >> private schools, you don't get data from private schools? >> no, it's the state that oversees them. but again because of the fact that we have requirements for entering immunization information into the vaccine registry, we do have all of that vaccine information for every
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child in new york city. but we don't have is the resources to do sort of the more granular analysis to look for those smaller pockets. that was one of the lessons learned in this outbreak, and we are looking into doing more of that. >> the other question i had was about hesitancy. i just wondered if you come through this experience, if you i think on a national level a lot of people, there's a lot of doubt about really how to communicate with parents and if you feel like the experience of this outbreak gave you information that's solid and scalable, or you know, a variety of -- >> i can start but i think that might be something dr. kraft can address. i think what i'll say is that i
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was on a panel with the number of individuals talking about the new york city measles experience. one of the individuals on the panel was a nurse who was a doing on the ground work with families and talking directly with them about sort of what the issues were. and one of the things that sort of surfaced was that many families didn't feel like they had the time with their pediatricians are with their healthcare providers to really go in depth in terms of addressing the questions and the concerns and the myths they had heard about the immunizations. and so then resorted to going elsewhere for that information. and i think what we have been working on is working with our provider community in terms of
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streamlining information. we reached out to the aap as well. but i think on the other end it's realizing that it's as important to ensure that with credible messengers within the community so that we create pockets of correct information, and that can be sustainable whether it's for the measles or whether it's for other issues. and that's what some of these new groups have popped up happily taught us. >> -- have really taught us. >> apel forget the common enemy is the disease. back in 2000 when we didn't see measles around anymore, people didn't worry so much about the disease and they don't have the same memories that i did as a child about measles. so when people came in and talked about myths with the vaccine, they were much more focused on the vaccine that on the disease. and sadly, we are seeing disease back again.
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it's an opportunity for us to talk about the common enemy. >> are you doing anything like, do you have any of the parents of kids who were hospitalized have become, you are trying to enlist as -- because as you say, there's always these compelling story from parents who claim their kids got sick after the got the vaccine. we know that's not true but it makes a huge impact. so do you have, , i mean, that's always a problem success of vaccination. so have you, anyway. >> so we have families within the affected communities that have agreed to be part of public service announcements, talking about the importance of vaccinations for them. that really goes to the issue of having credible messengers. that includes utilizing all channels of media to get that information out, and those have
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gone out on social media as well as on billboards and kiosks all over the community. >> this also supports the need for the vaccines act that we discussed here that's been put forward by representative schreier and burgess, that we need that public education campaign. we need that child who had the disease in the paris who talk about why their child should be vaccinated and wide your child should be vaccinated. >> other questions? okay. well, i'll take the prerogative to ask the question. if you could do one thing moving for out of all these lessons, whether it's you or a policymaker, what is the one thing you would do first to start to sort of turn the trend on these outbreaks or increase vaccines? and i didn't prep them for
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this. >> i'll take the first stab. i'm very happy with the legislative in california there were all interest in protecting our children and to do think the laws we now have on the books put us in a good position to safeguarding the children going forward. but i think if i do wish that could be fulfilled for l.a. county, i wish i really had the date on the vaccine prevalent in the county because i have lots of kids that are later in school, that one of those outbreaks primarily affected older children, and understand which community. because we have a lot of immigrant communities were folks at coming and i don't really know their vaccination status. if i had the information we would be doing outreach today better understand our vulnerability in trying to protect the when i would add is wanting to have information on adult vaccination because
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because though the outbreak was primarily concentrated in the pediatric population, a lot of the number engines of people we have to investigate what adult the didn't remember the vaccination status. and so that wasted a lot of time and that ate up a lot of resources that could of been put to better use. >> and i think finally, really requiring that were kids are and what the catholic schools,, preschools, that these children be protected against the diseases, focusing of the diseases on our common enemy. it's been affected and we need to spread that two more states in the country. >> great. and i was one of those adult was asking dr. barbot if i should get -- sheela and i said i'm serious. i ran into at a meeting, like okay. i think there's another question in the back. >> taylor pin with a national
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governors association. so you have any recommendations for governors on what they should focus on when thinking about how to prevent or to reduce the occurrence of outbreak? >> yes. >> i mean, first is to understand the facts. you've heard a lot of good information today. if there's a a way we can get e best information about the effectiveness of vaccine, we can understand the toll, the gaps in his vaccinations are having on the health of children and others in our community today. and also understand some of the efforts that are really going on against vaccination and how they're promoting information as incorrect would be very helpful. that's just establishing a a baseline of the facts. and i think the on that it would be good for governors to understand where maybe this been really good successes in other
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states, because a lot of lessons have been learned very well but jurisdictions that it had these outbreaks, because i would say if they haven't had that experience they are vulnerable. so to appreciate what's happened elsewhere to bring those experts with the lessons that have been learned, perhaps get some quick technical assistance from places that have expertise to kansas the risk in their state and give a couple of pointers on hey, if we don't have information system, we don't have strong vaccination infrastructure, if you don't have good channels to reach families and others at risk you can identify quick steps to shore protection interstate. >> what i would add to that is two things. one is since the great recession of 2009 there's been a systemic disinvestment in public health infrastructure and i think it's critically important that governors look at their budgets nca much is being allocated to public health. it's always been a small
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percentage as compared to healthcare delivery systems in other sectors, but i think this is a wake-up call for all of us to ensure that we have a robust public health infrastructure that can respond to what i like to call brushfires, like measles as well as other simmering epidemics like the opioid epidemic. the second thing is that it would ask governors to really show leadership in courage in terms of ensuring that we have more states that are only allowing medical exemptions for vaccinations. i think that that is the best and most important way to ensure that all of our children and all of our communities are protected against vaccine preventable illnesses, both now and in the future. >> i would just add to that and
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say, to keep on the message that it's the disease is our enemy and the disease taking the life and the health of our children. >> any last bastions? -- questions? >> just was wondering if the experience you had in california with protests, if that gives you any pause? i mean, is there a way to study what the impact of these, adding more coercion -- and it don't mean that in a negative way but did adding more of the course of approach to vaccination, whether that has any come if there's any risk, low back -- i'm not using the right word, but response that makes the public less
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trusting in the vaccination enterprise? >> i think that's a really for the study. in looking back over the measles outbreaks that we've had, you know, with the disneyland outbreak, public health was not in the communication space for those who oppose vaccinations were at the time but i was very happy to see a lot of of the groups stood up as the boys, parents included, to start to speak positively about vaccinations. and you're absolutely right. as we use our legal authority,, whether their state laws require vaccination, are we use our local authority to quarantine people, so what is so forth, it's extremely important we always explain that to people because it is seen as a very course of approach at sometimes. but we've got to go beyond that and constantly stay in communication with folks so that we are hearing what their concerns are and where addressing those with accurate
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information. because after all, these decisions about authority and which we -- which with would be as a society rest with the public. it really does. our role as a public health organization is prevention. to the link we can with the authority we are given, but only at the will of the people and our legislators in terms of defining how far we can go that way. but we need at that constant dialogue with people, with our residents, with parrots, i don't involve so they really understand what we doing and hopefully that will bring us together in unity and agreement that we do to prevent these diseases but we've got to learn more about the voices, what people are saying and what had to say so we're in that dialogue with them. >> i'll add to that, that public health almost on a daily basis has to balance civil liberties with civic accountability. and that the powers that we have date back to jacobsen versus massachusetts and smallpox.
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and that since that time it's been clear that the needs and urgency of the broader community really supersede that of the individual in certain cases when there's a a risk to human life. and so i wouldn't necessarily characterize it as coercive. i think it's part of our responsibility of public authorities to make that sort of judgment on an ongoing basis, balancing as i said civil liberties and civic accountability. >> and finally it's the interaction between public health and our practicing physicians and practitioners that so important because when the child go to school because they don't have the vaccines, then they come to me and we start to talk about what it is you should be doing and what are your fears, what can we do to make you feel comfortable with this whole process. so that's the interaction between our practitioners at a
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public health system that so important. >> thank you. i think that's a great note to end on. thank you to the panel. thank you all for being here. really appreciate it. we had some contact info. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations]
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[inaudible conversations] [inaudible conversations] [inaudible conversations]
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[inaudible conversations] [inaudible conversations] >> climate change activists shut down several roads in washington, d.c. this morning. cq roll call showing protesters with their banner across the street by mount vernon square that is is not a busy business intersection. a fox news producer sent this
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out as protesters continue to block the intersection at 16th and a street northwest. from a d.c. examiner reporter pictures of protesters chaining themselves to a boat in the middle of anomic busy is intersection. we heard from climate change activists last week as a test that before lawmakers pick you can watch the hearing in last weeks rally outside the u.s. capital at c-span.org. to find that they do type climate change in the search bar at the top of our home page. president trump is in new york city from beatings at the united nations. he will be speaking about religious freedom during the global call to purchase religious freedom event and vice president pence is expected to attend. you can watch it live at 11:30 a.m. eastern on c-span. as congress begins its week, the center plans to take up the house passed short-term spending bill that would fund the federal government for seven weeks through november 21 and avert a
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possible shutdown at the end of this month. senators will continue working on executive nominations when they see another vote on the joint resolution to come at the present emergency vaccination on the southern border. the house will debate banking policies for state authorized canada's gross and distribute. also members will consider immigration legislation. that would bar the separation of family members and would limit the length of detention and another measure dealing, setting standards on medical treatment of people caught crossing the border illegally. you can watch the senate live on c-span2 when the gavel in today and the house in tomorrow live on c-span. >> tonight on the committee can one of the nation's top telecom market analysts on the future of television, video, media and internet industries. >> you will see the live tv model only survive for sports and news and almost everything else will move toward on-demand
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models, and content live entertainment content or streamed real-time entertainment is to young people a kind of competent oxime or to begin with, , the idea there is a time of day for a particular show is sort of an odd concept for anything other than a sporting event. >> tonight at 8 p.m. on c-span2. >> british prime minister boris johnson's decision to suspend parliament is being challenged in british court. activists gina miller filed a a lawsuit saying the prime minister went beyond his authority by suspending parliament until mid-october, two weeks before the uk is scheduled to leave the european union. attorneys in the case presented closing statements that uk supreme court in the case miller v. prime m minister.

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