Pediatric Grand Rounds - The Role of Measles Elimination Efforts in Building the Overall U.S. Immunization Program

Transcript

• 00:16Good afternoon, everybody.
• 00:20Good afternoon. Great to see
• 00:21everybody here.
• 00:23Why don't we get started?
• 00:24I think we have a
• 00:25great talk scheduled for today.
• 00:27I just have a few
• 00:28announcements before we get started.
• 00:29So this is just to
• 00:30announce our upcoming grand rounds,
• 00:33over the next, two weeks.
• 00:35We have, Jean Bennett coming
• 00:37next week. And then the
• 00:38following week, Carol Weitzman. Many
• 00:41of you may remember. Carol
• 00:42is a
• 00:43emeritus professor here, and developmental
• 00:46behavioral pediatrician, and she's coming
• 00:48to give the Goldstein lecture.
• 00:51Be nice to welcome Carol
• 00:52back.
• 00:54This is a reminder that,
• 00:56US News and and World
• 00:57Report voting is now open.
• 01:00So vote early and vote
• 01:02often.
• 01:04And, there's some some instructions
• 01:05there, but, basically, remember that
• 01:07you can only vote in
• 01:09your own specialty. And if
• 01:10your specialty isn't one of
• 01:12the US News and World
• 01:13Report
• 01:14specialties,
• 01:15you can't vote.
• 01:16So,
• 01:17if you feel left out,
• 01:18it's not intentional.
• 01:20It's just the way the
• 01:21voting works. But do I
• 01:22encourage you to vote and
• 01:24vote for your favorite health
• 01:25system.
• 01:28Upcoming in our pediatric educational
• 01:30learning community, Stories in MedEd
• 01:32scholarship. We have a great
• 01:34lineup of speakers. This is
• 01:36on Monday.
• 01:37So I encourage you to
• 01:38join via Zoom and hear
• 01:39some of the great things
• 01:40that are going on
• 01:42in educational scholarship.
• 01:45Today's grand rounds, there is
• 01:47no commercial support, but it
• 01:48is a special grand rounds
• 01:49when you hear about that
• 01:50in a minute.
• 01:52And this is our CME
• 01:53number. Remember, we could do,
• 01:54provide CME.
• 01:56The number is there. It'll
• 01:57be in the chat, and
• 01:58it's right there as well
• 01:59for you who are here,
• 02:02who like to read things
• 02:02on chalkboards.
• 02:05And with that, I'm gonna
• 02:06turn it over to Mike
• 02:07Capello,
• 02:09to give us to introduce
• 02:10today's talk and speaker.
• 02:17Thank you, Cliff.
• 02:19It's my, pleasure
• 02:21to introduce the Davcook Lecture,
• 02:23for today.
• 02:24Before I start, I also
• 02:25wanna extend a special welcome,
• 02:28to our students and faculty
• 02:29from the epidemiology microbial diseases
• 02:31department in the school of
• 02:33public health, my other home
• 02:34here at Yale.
• 02:36Thank you all for making
• 02:37your way,
• 02:38over to Fitkin for this,
• 02:40this wonderful lecture today. I'm
• 02:42gonna begin by talking about
• 02:44Dav Cook. So Dav was
• 02:45chair of our department of
• 02:46pediatrics from sixty four to
• 02:48seventy four. He was recruited
• 02:50here from Boston.
• 02:52And Dab was really one
• 02:53of the transformational
• 02:54figures in the department of
• 02:55pediatrics.
• 02:56Soon after he arrived, he
• 02:57was kind of mentored and,
• 02:59taken under the wing of
• 03:01this gentleman up here, Paul
• 03:02Beeson, who at the time
• 03:03was chair of the department
• 03:04of medicine. And together,
• 03:07DAB in pediatrics and Beeson
• 03:09in medicine essentially
• 03:11modernized,
• 03:12these two departments, turning them
• 03:13into real sort of academic
• 03:15powerhouses,
• 03:16creating the individual sections, recruiting,
• 03:19physician scientists and researchers
• 03:21to come into the department,
• 03:23leveraging the the sort of
• 03:25newly established,
• 03:27National Institutes of Health. Remember
• 03:29when that used to exist?
• 03:31Try trying to really build,
• 03:33the university and the medical
• 03:35school, especially,
• 03:36into a place where amazing
• 03:37research and patient care
• 03:40were happening alongside of its
• 03:42educational mission. And so Dab
• 03:44was really a very important
• 03:45person. I got to know
• 03:46him, in his retirement. He
• 03:48would occasionally come down and
• 03:49attend our weekly,
• 03:51pediatric infectious disease rounds,
• 03:53held at doctor Miller's, conference
• 03:55room. And he was really
• 03:56a delightful guy. And when
• 03:57we approached him,
• 03:59about having this lecture bear
• 04:00his name, he was really
• 04:02delighted
• 04:03in part because,
• 04:05he had always cared deeply
• 04:06about, global health and international
• 04:09child health.
• 04:10He had a significant role
• 04:11in establishing the Hill Health
• 04:13Center up the road,
• 04:14which was one of the
• 04:15first places that really provided
• 04:17this sort of three hundred
• 04:18and sixty degree holistic care
• 04:20of, children and their families.
• 04:22But also Deb's daughter Debbie
• 04:23was a Peace Corps volunteer
• 04:25in Central America. And so
• 04:26he had a particular affinity
• 04:28and appreciation
• 04:29for people who are working,
• 04:30in global health. So it's
• 04:32it's really a wonderful,
• 04:35opportunity for us each year,
• 04:36especially for the the pediatric
• 04:39students and house officers to
• 04:41hear about Dab, to understand,
• 04:43the impact that he's had
• 04:44on our department.
• 04:48Okay. So today's speaker,
• 04:50is doctor Walter Orenstein.
• 04:52He is an Emeritus professor
• 04:54of medicine,
• 04:55with appointments in pediatrics,
• 04:57epidemiology,
• 04:58as well as the Rollins
• 04:59School of Public Health, at
• 05:01Emory University.
• 05:03Doctor. Ornstein completed his pediatric
• 05:05training or his pediatric residency
• 05:07at UCSF
• 05:08and then an ID fellowship
• 05:09at UCLA. And in between,
• 05:11he served as an epidemic
• 05:13intelligence,
• 05:14service officer
• 05:15at the CDC, and that
• 05:16was really where a lot
• 05:18of his interest in vaccines,
• 05:20and vaccine implementation,
• 05:22sort of was first sparked.
• 05:24Now doctor Ornstein's had an
• 05:25illustrious career. I'm just gonna
• 05:27name a few of the
• 05:28really important leadership positions that
• 05:30he has held.
• 05:32First, he was director of
• 05:33the National Immunization Program at
• 05:35the CDC in, in Atlanta.
• 05:37He then was deputy director
• 05:39for immunization programs at the
• 05:40Bill and Melinda Gates Foundation.
• 05:42He served as director of
• 05:44the Embry program for vaccine
• 05:45policy and development,
• 05:47executive director of the Southeastern
• 05:49Center for Emerging Biological Threats,
• 05:52just to name a few
• 05:53of the dozens of important
• 05:55administrative and leadership roles that
• 05:57he has held. He's an
• 05:58elected member of the National
• 05:59Academy of Medicine and served
• 06:01as an important consultant to
• 06:03many multilateral
• 06:04organizations,
• 06:05foundations,
• 06:06government agencies,
• 06:08and the vaccine industry. He
• 06:09has really spent his entire
• 06:11career kind of focused around
• 06:12this nexus of vaccine development,
• 06:15vaccine testing,
• 06:16and vaccine implementation.
• 06:19In particular, I think what's,
• 06:21what's fascinating is as I've
• 06:23just come to know him
• 06:24a little bit better
• 06:25is, the degree to which
• 06:26he's really focused on this
• 06:28issue of reducing barriers to
• 06:31acceptance of vaccine.
• 06:33Certainly something that I think
• 06:34everybody in this room who
• 06:35has to interact,
• 06:36with,
• 06:37children and their parents can
• 06:38fully appreciate. It's really become,
• 06:40I think, an important,
• 06:42issue for him. I also
• 06:44wanna just let you know
• 06:45that he's not someone who
• 06:46sits around, behind a desk
• 06:47all day, but in fact,
• 06:51really has a rich history
• 06:52in, for my epi group
• 06:54here,
• 06:55field based work,
• 06:57getting amongst the people. This
• 06:58was he was part of
• 06:59the smallpox eradication programs,
• 07:02vaccine programs in India, again,
• 07:04helping to implement and ultimately
• 07:07inform,
• 07:08global policy for, smallpox eradication.
• 07:11So with that,
• 07:13there we go. I am
• 07:14gonna invite, doctor Orenstein to
• 07:16come and deliver the twentieth,
• 07:18Dav Cook Lecture.
• 07:24Yes.
• 07:28Thank you so much. And
• 07:29I think as as that,
• 07:32picture showed, I think the
• 07:33most important thing is we
• 07:35need development of a vaccine
• 07:37that will reverse the biologic
• 07:38clock.
• 07:40I'd like to be young
• 07:42and like that before jealous
• 07:44of so many people I
• 07:45see in the room.
• 07:47My goal today
• 07:49is to
• 07:50describe the importance
• 07:52of a vaccine
• 07:53delivery system.
• 07:55Vaccines
• 07:56don't give themselves,
• 07:59and vaccines
• 08:00do not save lives.
• 08:02Vaccinations
• 08:03save lives.
• 08:05And what we need
• 08:07is a way of having
• 08:09a system
• 08:10that gets vaccines
• 08:11into the bodies of the
• 08:13people for whom they're recommended.
• 08:17What it problem is that
• 08:19prevention
• 08:20is a much harder sell
• 08:22than therapy
• 08:25because with prevention, nothing happens,
• 08:27and pretty soon people don't
• 08:29realize they're getting any benefits.
• 08:32Therapy is much easier to
• 08:34sell,
• 08:35and measles
• 08:37helps us on the therapy
• 08:38side
• 08:39because it is so contagious
• 08:42and so clinically distinctive
• 08:45that it leads
• 08:48to major ways of investment
• 08:51in the public health programs.
• 08:54A colleague of mine when
• 08:55I was at CDC used
• 08:57to say, he was taught
• 08:58when he got his PhD
• 09:00that the p in public
• 09:01health was politics,
• 09:03and
• 09:04having political will
• 09:06is absolutely critical.
• 09:10This is a slide
• 09:12showing some of the vaccine
• 09:14preventable diseases,
• 09:16representative,
• 09:17twentieth century annual morbidity
• 09:21two thousand and twenty three
• 09:22cases. I wasn't able to
• 09:23get it updated and the
• 09:24percent decrease.
• 09:26The only human disease
• 09:29ever eradicated,
• 09:31smallpox
• 09:32was with a vaccine.
• 09:34And what you could see
• 09:35here is for the vast
• 09:37majority of diseases,
• 09:39greater than ninety nine percent,
• 09:42some hundred percent reductions,
• 09:45in two thousand and twenty
• 09:47three compared to before. The
• 09:48greatest miracle in vaccinology
• 09:50to me
• 09:52is Haemophilus influenzae type b.
• 09:55I was trained in pediatrics
• 09:56and pediatric infectious diseases in
• 09:59the nineteen seventies,
• 10:00and I really prided myself
• 10:02with being really good at
• 10:03doing lumbar punctures,
• 10:05spinal taps, because I saw
• 10:07so many kids to try
• 10:08and determine whether they had
• 10:10hip meningitis.
• 10:11And it's mind boggling today
• 10:13to me that there are
• 10:14people calling themselves pediatricians
• 10:17never having taken care of
• 10:19a case
• 10:20of hip meningitis.
• 10:23What has led to this?
• 10:25There is a tremendous
• 10:27partnership.
• 10:28It is not a simple
• 10:30thing.
• 10:31Academic and other researchers
• 10:34telling us
• 10:35how bad the problem is,
• 10:37what who is getting the
• 10:39disease, who is not,
• 10:41what is and what is
• 10:43not a protective immune response.
• 10:45Vaccine manufacturers
• 10:47who often at risk
• 10:49invest
• 10:50in the steps to develop
• 10:52and test the vaccine.
• 10:55Policymakers
• 10:56such as the advisory committee
• 10:57on immunization
• 10:58practices,
• 10:59the committee on infectious diseases
• 11:01of the American Academy of
• 11:03Pediatrics, and others who try
• 11:05and take this information
• 11:07and develop the best way
• 11:09to use vaccines.
• 11:11People who actually deliver vaccines,
• 11:15the deliverers,
• 11:16people who interact with the
• 11:18people for whom vaccines are
• 11:20recommended,
• 11:22third party payers,
• 11:23federal, state, and local agencies,
• 11:26political leaders, partners, and many
• 11:29others. It is not
• 11:31simple that got us to
• 11:32where we are in our
• 11:34successes.
• 11:35And this is a,
• 11:38a diagram put out by
• 11:40the Institute of Medicine, now
• 11:42the National Academy of Medicine
• 11:44in nineteen ninety nine where
• 11:46we asked them to look
• 11:47at it. The goal is
• 11:49to control and prevent infectious
• 11:51disease.
• 11:52What that means
• 11:54is remove barriers to vaccine
• 11:56access, buy the vaccines,
• 11:59have a system where we
• 12:00can get the vaccines
• 12:03into people and make them
• 12:05available,
• 12:07find out how do we
• 12:09improve
• 12:11coverage and how do we
• 12:12improve coverage rates,
• 12:15and then having surveillance
• 12:17of vaccine coverage and safety,
• 12:20and then
• 12:21all of this resting on
• 12:23a base of immunization
• 12:25finance and policies.
• 12:28So what do I want
• 12:29to cover?
• 12:31One is the concept of
• 12:33horizontal,
• 12:34vertical, and diagonal
• 12:36programs
• 12:37and
• 12:38how to use immunization
• 12:41in a diagonal approach.
• 12:43Then a little bit about
• 12:45measles and why measles can
• 12:48be so helpful
• 12:50even though it's a bad
• 12:51disease
• 12:52in triggering
• 12:53helpful responses.
• 12:56The role of science
• 12:59and politics
• 13:00in developing,
• 13:02our immunization
• 13:03program or enhancing it,
• 13:06why it can be an
• 13:07incentive for overall health system
• 13:09training,
• 13:11and can we someday actually
• 13:13eradicate measles
• 13:15as we did with smallpox?
• 13:18So my hidden agenda
• 13:20is how do we get
• 13:22recommended vaccines
• 13:24into the bodies of people
• 13:25for whom they're recommended?
• 13:27Why do we fail to
• 13:29vaccinate?
• 13:30Cost,
• 13:31is it costly for people?
• 13:33Is it convenience? They're only
• 13:35available one at a time
• 13:36when a parent is working.
• 13:39Attitudes.
• 13:40Is it people who are
• 13:41hesitant,
• 13:42who are ignorant about what
• 13:44the benefits and risks are
• 13:46of vaccination?
• 13:48And particularly, how do we
• 13:49address barriers?
• 13:51The need for political support.
• 13:55Measles as a motivator
• 13:57to improve vaccination systems.
• 13:59What we've done and what
• 14:00need we need to do
• 14:02to remove
• 14:03financial barriers
• 14:04to access
• 14:06building
• 14:08vaccine confidence.
• 14:09I'd like to say that,
• 14:10which is the solution and
• 14:12not vaccine hesitancy,
• 14:14which is the problem,
• 14:15and then nudges
• 14:17to move us forward.
• 14:19This is a very famous
• 14:21picture
• 14:22of a child
• 14:24with classical measles. You could
• 14:25see the rash there. I'm
• 14:27not gonna go with this
• 14:28more detail because I wanna
• 14:29focus on other things.
• 14:31But
• 14:32there is a differential diagnosis,
• 14:34but it is much more
• 14:35clinically distinctive than COVID
• 14:38or, for example, influenza,
• 14:40where we have a great
• 14:41deal of difficulty in making
• 14:44the public understand
• 14:46what the disease is and
• 14:47what it is not.
• 14:49Whoops. And this is just,
• 14:51a from Krugman's,
• 14:54infectious disease
• 14:55textbook was from nineteen eighty
• 14:57five
• 14:58showing what measles was like,
• 15:01starting with,
• 15:02rash on the first,
• 15:04few days and then how,
• 15:06it comes over time.
• 15:08The incubation period for measles
• 15:11is about ten to fourteen
• 15:13days,
• 15:15and
• 15:16it starts with a prodrome
• 15:18of,
• 15:19fever, cough, choriza,
• 15:21and or conjunctivitis.
• 15:24And
• 15:25spread occurs be generally before
• 15:28they have a rash,
• 15:29before they look like they,
• 15:31and, basically, they just look
• 15:32like they have a common
• 15:34cold.
• 15:35And very often, if you
• 15:36come down with measles, you
• 15:37may not know who gave
• 15:38it to you because it
• 15:39was,
• 15:40again, somebody who had a
• 15:43a a cold like illness.
• 15:47And
• 15:48the other issue is measles
• 15:50is not a trivial infection.
• 15:52And these are data from
• 15:54the United States published in
• 15:56Plotkin's vaccine,
• 15:57but
• 15:58ear infections is one of
• 16:00the most common complications
• 16:02about seven to nine percent
• 16:04of infections.
• 16:06Pneumonia,
• 16:07one to six percent. This
• 16:08is
• 16:09probably the chief cause of
• 16:11death when measles cause death
• 16:13causes death,
• 16:14and it does it in
• 16:15two ways. One
• 16:17is actual viral pneumonia,
• 16:19a giant cell pneumonia, hep
• 16:21pneumonia.
• 16:22That's the measles virus.
• 16:24Or secondary infections,
• 16:26bacterial infections,
• 16:28most common being
• 16:30mucococcide,
• 16:32but, Hib and many other
• 16:34bacterial causes.
• 16:36And then diarrhea and dehydration
• 16:39is also a common cause,
• 16:40particularly in low and middle
• 16:42income countries.
• 16:43And then
• 16:44one of the sad parts
• 16:46is post infectious
• 16:47encephalitis,
• 16:49about one to four per
• 16:50thousand and two thousand,
• 16:52which is often associated with
• 16:55residual brain damage,
• 16:57subacute sclerosing panencephalitis,
• 17:00which can occur
• 17:02five to ten years or
• 17:03more after initial infection,
• 17:05which is universally fatal,
• 17:08and then death,
• 17:10about one to three deaths
• 17:11per thousand cases.
• 17:13In the developing world, it's
• 17:15much more severe with a
• 17:16much higher death rate.
• 17:19Diarrhea
• 17:20is more severe. Vitamin a
• 17:22deficiency
• 17:23is also a problem
• 17:24and leads to blindness
• 17:27and substantial numbers of deaths
• 17:29and then neurological
• 17:31complications.
• 17:34So
• 17:35what about community
• 17:37protection?
• 17:39And what you have, it
• 17:41measles is a person to
• 17:42person spread disease.
• 17:45So you have a transmitting
• 17:46case.
• 17:48And in a place where
• 17:49there's poor vaccine coverage
• 17:51or poor immunity,
• 17:53that case can infect people
• 17:55and then set up generations
• 17:58of
• 17:59further infection.
• 18:01And the red is the
• 18:02cases
• 18:03and the blues are the
• 18:04immunes.
• 18:07When you have high coverage
• 18:09in a population,
• 18:11the likelihood a transmitting case
• 18:13will come in contact
• 18:15is markedly reduced,
• 18:17and so you can get
• 18:19rid of measles without having
• 18:20to have a hundred percent
• 18:22immunity.
• 18:23This is often called herd
• 18:25immunity.
• 18:26I prefer the term community
• 18:28protection
• 18:29or community
• 18:30meeting immunity.
• 18:31And that's why it's in
• 18:33our interest,
• 18:35not only to get individuals
• 18:37vaccinated,
• 18:38but when individuals get vaccinated,
• 18:40they're not only
• 18:42helping themselves,
• 18:43but they're helping their community.
• 18:45For example,
• 18:47for measles,
• 18:48people who who are indirectly
• 18:50protected, people are people who
• 18:52have legitimate medical contraindications
• 18:55and can't get vaccinated,
• 18:57people who have compromised immune
• 18:59systems, who can't make a
• 19:00protective immune response,
• 19:02And even measles, which is
• 19:04highly effective, two doses
• 19:06in the US under the
• 19:07immunization
• 19:08schedule
• 19:09is about ninety seven percent
• 19:10effective. It's three percent ineffective.
• 19:13How are they protected?
• 19:15They're protected if they're not
• 19:16exposed.
• 19:17And so
• 19:18community benefit is very important
• 19:21because the anti vaxxers
• 19:23are now using it's my
• 19:25body or my child's body.
• 19:27I can make my own
• 19:28decision
• 19:29and have been arguing against
• 19:31mandates
• 19:32based on that. And mandates
• 19:34not only protect
• 19:36the individual, but they protect
• 19:38our community.
• 19:40So what are our successes
• 19:42and challenges?
• 19:44One, herd immunity from measles
• 19:46is
• 19:48difficult to establish. It
• 19:50is the most contagious
• 19:53of the vaccine preventable diseases.
• 19:56And so one needs a
• 19:58very high level
• 20:00to get there.
• 20:01Now we have reduced measles
• 20:04cases
• 20:05by ninety nine percent since
• 20:07the introduction of the first
• 20:08vaccines
• 20:09into the US in nineteen
• 20:11sixty three.
• 20:12And in two thousand,
• 20:14we declared
• 20:16the US had eliminated
• 20:18measles. What does that mean?
• 20:20It means
• 20:21that there was no sustained
• 20:23transmission
• 20:24of measles
• 20:26for over a year
• 20:29since two thousand.
• 20:31We have had multiple
• 20:33introductions
• 20:34and cases,
• 20:35but fortunately,
• 20:36we've been able to stop
• 20:39those cases from spreading
• 20:41because we've had high enough
• 20:43immunity.
• 20:44But we are in the
• 20:45presence of a resurgence
• 20:47now, and my big fear
• 20:49is a return to measles
• 20:51becoming endemic.
• 20:54So, again, the miss risk
• 20:57of measles outbreaks increases exponentially
• 21:00with declining,
• 21:01vaccination.
• 21:03And
• 21:04there is a global resurgence,
• 21:06particularly with the rise of
• 21:08anti vaccine movements
• 21:11and social media and others
• 21:13and our political some of
• 21:15our political leaders being anti
• 21:17vaccine
• 21:18and the COVID pandemic.
• 21:21And then the public health
• 21:22implication
• 21:24is
• 21:25we need to implement
• 21:27rates to mitigate risks,
• 21:29but can we get the
• 21:31resources
• 21:33to do that? Will we
• 21:34need
• 21:35more
• 21:36evidence of the need for
• 21:38it with more and bigger
• 21:40resurgences
• 21:41and deaths
• 21:42with the first death this
• 21:43year
• 21:44in,
• 21:45ten years from measles,
• 21:47or can we prevent outbreaks?
• 21:51So, again,
• 21:53what makes measles a characteristic
• 21:55for overall immunization
• 21:57programs?
• 21:58As I said, it's the
• 21:59most contagious and most infectious
• 22:02of the vaccine preventable diseases.
• 22:06While there is a differential
• 22:07diagnosis,
• 22:09there is a fairly distinct
• 22:11clinical syndrome compared to, as
• 22:14I said earlier,
• 22:15influenza,
• 22:16COVID, and other syndromes.
• 22:18Virtually all infections
• 22:21are clinically
• 22:22apparent. It's not like you
• 22:24have a symptomatic
• 22:25infection
• 22:26such as the great majority
• 22:28of polio infections are.
• 22:30We have good diagnostic tests,
• 22:34IGM
• 22:35serum
• 22:35or,
• 22:38PCR
• 22:39from, particularly nasal,
• 22:41swab specimens,
• 22:43and
• 22:43it's episodic in nature.
• 22:46And what happens is
• 22:48when it goes down after
• 22:49an outbreak, people get accustomed
• 22:51to very low. And so
• 22:53when it resurges,
• 22:55it's often easier to get
• 22:57the political will because the
• 22:59low level has become the
• 23:00politically accepted.
• 23:02And it does have a
• 23:04number of complications,
• 23:06including hospitalizations
• 23:08and deaths.
• 23:11What you can see here
• 23:14is the basic reproduction
• 23:16number for a number of
• 23:17the vaccine
• 23:18preventable diseases.
• 23:20The basic reproduction
• 23:21number is the average number
• 23:24of of secondary cases
• 23:26that would
• 23:28occur if an infectious case
• 23:30came into a population
• 23:32that was a hundred percent
• 23:34susceptible.
• 23:35The herd immunity threshold is
• 23:37calculated as r naught minus
• 23:39one over r naught. So
• 23:41for example,
• 23:42if you have an r
• 23:43naught of four,
• 23:45then four minus one is
• 23:46three over four.
• 23:48The herd immunity threshold there
• 23:50would be seventy five percent.
• 23:53Because at seventy five percent,
• 23:55the average transmitting case would
• 23:57transmit to only one person
• 23:58because the other three people
• 24:00are immune. If you went
• 24:01above seventy five percent, it'd
• 24:03be one.
• 24:04And what you could see
• 24:05here is with measles,
• 24:07look at that herd immunity
• 24:09threshold,
• 24:10ninety two to ninety four
• 24:12percent.
• 24:13It is an indicator
• 24:15disease
• 24:16because you have to achieve
• 24:18such high immunization.
• 24:21And, again,
• 24:22what we're seeing now,
• 24:24particularly with the COVID pandemic,
• 24:27but also vaccine hesitancy.
• 24:29In two thousand nineteen, before
• 24:31the COVID nineteen
• 24:33pandemic,
• 24:34measles was listed
• 24:36as one of the
• 24:37ten great public health challenges
• 24:40by the World Health Organization.
• 24:41Not measles, but vaccine hesitancy,
• 24:43I should say. And what
• 24:44you can see here
• 24:46is the number of cases
• 24:48around the world
• 24:50reported in the last six
• 24:52months.
• 24:53And you could see here
• 24:55countries, particularly
• 24:56in Europe,
• 24:57Africa, and Asia,
• 24:59who've had huge
• 25:01returns
• 25:02of measles
• 25:03in that period.
• 25:04And one of the big
• 25:06issues with measles
• 25:08is it helps us in
• 25:10supporting
• 25:11global efforts.
• 25:12Because when we support global
• 25:15efforts, we are not only
• 25:17helping those countries,
• 25:18but we're helping ourselves
• 25:20by reducing
• 25:22importations.
• 25:23All of the measles we
• 25:24see in the US comes
• 25:26from international importations,
• 25:29either from US travelers
• 25:31who are not immune and
• 25:32bring it back
• 25:33or from other people in
• 25:35these countries who come and
• 25:37visit the US.
• 25:40And this just shows some
• 25:42of the problems we're seeing
• 25:44in meeting,
• 25:46the,
• 25:47immunization
• 25:48agenda
• 25:49and how many countries
• 25:51were nowhere near
• 25:52meeting goals
• 25:53for two thousand and thirty
• 25:55with regard
• 25:56to measles.
• 25:59So, again,
• 26:01measles was declared eliminated in
• 26:03the US,
• 26:04and
• 26:06it has been,
• 26:07documented as being sustained. I
• 26:09participate
• 26:10in the National Sustainability
• 26:12Committee, the NSC, which is
• 26:14a US committee,
• 26:16and we just recertified
• 26:18that while we're seeing a
• 26:19measles resurgence,
• 26:20we have not seen
• 26:22a sustained,
• 26:25evidence for over a year.
• 26:27And, again,
• 26:28this is just a WHO
• 26:30definition
• 26:31of at least twelve months,
• 26:34lack of sustained transmission. But
• 26:36we've seen some bad news
• 26:38in the last few years.
• 26:39Brazil,
• 26:40for example, is is is
• 26:42now endemic. It it has
• 26:43sustained transmission, and other countries
• 26:46in the world have lost
• 26:48their elimination status. And this
• 26:50just shows you in the
• 26:51US
• 26:52how things were.
• 26:54And what you can see
• 26:55here, this starts in nineteen
• 26:56eighty five.
• 26:58We had a big, big
• 26:59resurgence of measles there.
• 27:02We had in that period
• 27:04over fifty five thousand cases,
• 27:06over eleven thousand hospitalizations,
• 27:09and more than a hundred
• 27:11deaths.
• 27:12And that led to a
• 27:13presidential initiative. I'll go over
• 27:15more,
• 27:16in nineteen ninety three. We
• 27:18got to a sustained elimination,
• 27:20but we've had returns.
• 27:23We had a big resurgence
• 27:24in two thousand and nineteen
• 27:26and almost lost our effort.
• 27:27And what you could see
• 27:29here is two thousand twenty
• 27:31four and just the first
• 27:32few months of two thousand
• 27:34twenty five, we've seen a
• 27:36big resurgence of measles.
• 27:40And these are just some
• 27:41of the problems,
• 27:42the Texas area, particularly West
• 27:45Texas and the Mennonite
• 27:46population,
• 27:47but that spilled over into
• 27:49New Mexico.
• 27:51CDC has talked about the
• 27:52concerns about the global measles
• 27:54resurgence,
• 27:56and the need for us
• 27:57to invest in global efforts.
• 27:59We've had the first death
• 28:01in ten years.
• 28:03And, again,
• 28:05this keeps ongoing
• 28:07because,
• 28:08as I said, vaccines don't
• 28:10save lives.
• 28:11Vaccinations save lives, and we
• 28:13need to work to get
• 28:14it out.
• 28:15Now
• 28:16we have a vertical program
• 28:18is one that focuses
• 28:20only on doing
• 28:21one disease, for example.
• 28:23So, for example,
• 28:26smallpox, where we got rid
• 28:28of it, we really focused
• 28:30primarily vertical.
• 28:31The hell with the rest
• 28:32of the things.
• 28:34A horizontal
• 28:35is when we build platforms.
• 28:37So, for example, in the
• 28:39US, well, child care, the
• 28:40wealth child visits.
• 28:42A diagonal
• 28:43is where we use
• 28:45a vertical program
• 28:47to build
• 28:48other things. And that's where
• 28:50measles
• 28:51became helpful because it got
• 28:53us vaccination
• 28:54mandates.
• 28:55We do vaccination mandates, not
• 28:57measles,
• 28:58but other
• 29:00vaccines.
• 29:00It got us mandates
• 29:02for immunization.
• 29:04We don't mandate only measles.
• 29:07And it brought us
• 29:08strength in our overall
• 29:11advisory community
• 29:12practices,
• 29:13and so measles has played
• 29:15a diagonal role.
• 29:17The initial strategy for measles
• 29:20eradication, and that's not the
• 29:22correct term, that was the
• 29:23term used
• 29:24because eradication
• 29:26is zero forever.
• 29:29Elimination
• 29:31is getting rid of disease
• 29:33or getting to a certain
• 29:35level and sustaining it,
• 29:37but
• 29:38it can return
• 29:40easily.
• 29:41And
• 29:42in nineteen sixty seven,
• 29:45there was an effort to
• 29:46get rid of measles with
• 29:48a four strategy,
• 29:50routine immunization,
• 29:52immunization
• 29:53on school entry,
• 29:55surveillance,
• 29:56and epidemic
• 29:58control.
• 30:00What led to this?
• 30:04One
• 30:05is the measles vaccine
• 30:07was the first new vaccine
• 30:10licensed
• 30:11since the establishment
• 30:12of the three seventeen
• 30:14grant program.
• 30:16The three seventeen
• 30:17grant program
• 30:19was a federal grant given
• 30:22to state and local health
• 30:24departments
• 30:25to help them with their
• 30:26immunization
• 30:28infrastructure
• 30:29and delivery.
• 30:30The law was sound I
• 30:32signed into effect
• 30:34by John f Kennedy,
• 30:36RFK Junior's uncle,
• 30:40and has played a major
• 30:42effort
• 30:43in
• 30:43sustaining our immunization
• 30:45program.
• 30:48It was
• 30:49a desire to build a
• 30:51vigorous program. And, again, this
• 30:53was not worldwide
• 30:55eradication of measles. It was
• 30:57how do we improve
• 30:58measles
• 30:59in the US.
• 31:01What was the,
• 31:04impact of the program?
• 31:06There was a ninety percent
• 31:08reduction in measles cases
• 31:10from over five hundred thousand
• 31:12in the pre vaccine era
• 31:14to about twenty two thousand
• 31:16in nineteen sixty eight.
• 31:19Now
• 31:20the five hundred thousand
• 31:22is probably a gross
• 31:24underestimate
• 31:25underestimate
• 31:26of the number of measles.
• 31:28There was a birth cohort
• 31:30of about four to five
• 31:31million, and virtually
• 31:33everybody
• 31:34was infected.
• 31:36And so
• 31:37only about ten percent of
• 31:39cases were actually reported.
• 31:42So,
• 31:43again,
• 31:44there was a big
• 31:46impact.
• 31:47But what happened
• 31:49is people said, oh, great.
• 31:51Measles is gone.
• 31:53And at that time, people
• 31:55were very concerned about rubella.
• 31:57There was a massive outbreak
• 31:59of rubella and congenital
• 32:01rubella in the early sixties,
• 32:04about twenty thousand cases
• 32:06of congenital
• 32:07defects.
• 32:08We had a a rubella
• 32:10vaccine that became available
• 32:12in nineteen sixty nine,
• 32:14and all of the funding
• 32:16was redirected to rubella.
• 32:19And so what happened
• 32:21is
• 32:22we then
• 32:23had another
• 32:25measles
• 32:26resurgence
• 32:27because
• 32:28each year,
• 32:29children are born and they're
• 32:31not born immune to measles.
• 32:34You need to continue an
• 32:36ongoing
• 32:37immunization
• 32:37program.
• 32:39It came down
• 32:40a bit
• 32:41in the early seventies,
• 32:44and then
• 32:45it
• 32:46again resurged
• 32:47again in the early in
• 32:49in the mid seventies.
• 32:51And this led to a
• 32:52presidential
• 32:53initiative, the first one by
• 32:55president Carter.
• 32:58And what was
• 33:00accumulating knowledge? What led to
• 33:02that?
• 33:03Smallpox
• 33:04was being eradicated
• 33:07with an outbreak
• 33:09control
• 33:09strategy. In other words,
• 33:11the initial strategy was mass
• 33:13vaccination,
• 33:14but what they found was
• 33:16far more effective
• 33:18effective
• 33:19was to get
• 33:21a surveillance system in place
• 33:23to detect cases,
• 33:25make some estimate of who
• 33:27those cases
• 33:28might have exposed the primary
• 33:30contacts,
• 33:31and then make some guesstimate
• 33:34of
• 33:35who
• 33:36might be exposed
• 33:37if those
• 33:39primary contacts
• 33:40got infected, the secondary ring.
• 33:42So it was ring vaccination,
• 33:44and it worked very well.
• 33:46It got rid of smallpox.
• 33:47So my mentors
• 33:49who mentored me when I
• 33:50was with smallpox, which is
• 33:52a picture you saw,
• 33:53said, let's try that with
• 33:55measles.
• 33:57And demonstrating measles could be
• 33:59eliminated from the US could
• 34:01set the stage for worldwide
• 34:02eradication.
• 34:04There could be
• 34:05school laws. For example, there's
• 34:07a very famous study in
• 34:08Texarkana,
• 34:09Texas,
• 34:10where Arkansas had a school
• 34:12mandate, Texas did not, and
• 34:14had measles outbreaks
• 34:16and much, much lower in
• 34:17Arkansas
• 34:18than in, than in,
• 34:20Texas.
• 34:22The need for a continuous
• 34:24source of funding.
• 34:26Surveillance
• 34:26was critical. Our goal is
• 34:28not immunization.
• 34:29Our goal is disease reduction
• 34:31or elimination,
• 34:32and we needed to fund
• 34:33that. And political leadership
• 34:36was critical for success.
• 34:41But the issue is
• 34:43smallpox wasn't measles.
• 34:46One, there was a clinically
• 34:47distinctive illness. Measles had a
• 34:49much larger differential diagnosis. I
• 34:51could teach a non physician
• 34:53to make a diagnosis of
• 34:54smallpox. It was that,
• 34:57there, it had a much
• 34:58lower r naught than measles.
• 35:01The herd immunity threshold was
• 35:02lower.
• 35:05Spread prior to the rash
• 35:06was very rare with smallpox,
• 35:08whereas
• 35:09the biggest spread for measles
• 35:11is in the prodromal period
• 35:12where
• 35:13children or others are not
• 35:15feeling that great. Smallpox
• 35:17was almost a hundred percent
• 35:19effective.
• 35:20Measles vaccine
• 35:21was about ninety three percent
• 35:23effective
• 35:24in the right age group.
• 35:25And
• 35:26with smallpox, I could tell
• 35:27who was protected and who
• 35:29was not because they had
• 35:30a big reaction, whereas the
• 35:32measles
• 35:33didn't know that.
• 35:36And this is a study
• 35:37that I did,
• 35:39when I was
• 35:42just after I finished my
• 35:44EIS
• 35:45at CDC
• 35:46showing how measles was spreading
• 35:49and how you couldn't predict
• 35:50it. It was church contact,
• 35:52it was music lessons,
• 35:54there was sharing comments, facilities,
• 35:57school
• 35:57buses,
• 35:59preschool neighbors,
• 36:02etcetera.
• 36:04Surveillance and containment
• 36:05didn't work,
• 36:07but
• 36:08good science
• 36:10was trumped by good luck.
• 36:12I'll tell you good luck
• 36:13after
• 36:14after good better than good
• 36:15science.
• 36:16And good luck
• 36:17led to the political will
• 36:19to get a presidential initiative.
• 36:22And what really
• 36:23did it
• 36:24is in nineteen seventy seven,
• 36:27we had an outbreak of
• 36:29measles
• 36:30in
• 36:31Los Angeles County.
• 36:33And what we did
• 36:35with
• 36:36I when I was at
• 36:37CDC is we forced
• 36:39all the state and local
• 36:41health departments
• 36:42to take on the measles
• 36:44outbreak control effort.
• 36:47And it causes
• 36:48caused a lot of frustration
• 36:51because it wasn't successful.
• 36:53And Shirley Fannin, who is
• 36:54head of commute communicable diseases
• 36:57in Los Angeles County,
• 36:59found the measles outbreak in
• 37:00mid January.
• 37:01There were deaths. There were
• 37:03encephalitis cases, a lot of
• 37:04hospitalizations.
• 37:06And she was very frustrated
• 37:09because she offered vaccines,
• 37:11and people didn't get it.
• 37:13Then the vaccine hesitancy was
• 37:14not so much safety problems,
• 37:17but, what's the big deal
• 37:18with measles? We had it
• 37:20as kids.
• 37:21And what happened is she
• 37:22got so frustrated
• 37:24that she
• 37:26said, if you don't get
• 37:27vaccinated,
• 37:29I am going to throw
• 37:30you out of school.
• 37:32Many of the kids were
• 37:33vaccinated,
• 37:34but they hadn't get their
• 37:35records there. She held clinics
• 37:37in the school. She made
• 37:38it easier.
• 37:40But of the four one
• 37:41point four million students,
• 37:43about fifty thousand didn't have
• 37:45evidence, and she excluded fifty
• 37:48thousand kids from school. And
• 37:50it worked. She got rid
• 37:51of measles.
• 37:52And this became
• 37:54the strategy we used for
• 37:56outbreak control.
• 37:57But it didn't take long
• 37:58to realize
• 37:59we should be in the
• 38:00business of preventing outbreaks, not
• 38:03controlling them, and that led
• 38:05to the no shots, no
• 38:06school mandates.
• 38:09And this just shows you
• 38:11we didn't have a national
• 38:12mandate, even though that would
• 38:14have made the most sense.
• 38:16But because we had state
• 38:17mandates, we could convince other
• 38:20states to do it. And
• 38:21this was some data in
• 38:22six states that had laws
• 38:25and,
• 38:26other states that didn't. And
• 38:27what you could see here
• 38:28as they enforce their laws,
• 38:30look at this difference from
• 38:31measles. And I remember when
• 38:33I was director of the
• 38:34US immunization program
• 38:36testifying before the Florida Florida
• 38:38legislature
• 38:39showing them the benefits of
• 38:41vaccines this way.
• 38:43Another
• 38:44big issue
• 38:46is political,
• 38:48leadership.
• 38:49And there were two women
• 38:51who made a big difference.
• 38:53One was Betty Bumpers, who
• 38:55was the wife
• 38:56of senator Dale Bumpers,
• 38:59who
• 39:00was governor of Arkansas and
• 39:01then later senator,
• 39:03and then Rosalynn Carter, who
• 39:05was first lady of Georgia
• 39:07and then became first lady
• 39:09of the United States.
• 39:11And
• 39:12they
• 39:13formed a group called every
• 39:14child by two,
• 39:16now renamed vaccinate your family,
• 39:19that politically advocated. And
• 39:21secretary California
• 39:23was the director, I forgot
• 39:25I think it was, at
• 39:26that time, health education and
• 39:27welfare
• 39:29of supporting immunization.
• 39:31And I remember
• 39:32going,
• 39:34to
• 39:35efforts, and there was a
• 39:36goal of attaining ninety percent
• 39:39immunization
• 39:39coverage,
• 39:40establish a permanent system to
• 39:43vaccinate,
• 39:44and focus on the enforcement
• 39:46and activation
• 39:47of comprehensive,
• 39:50schools. But what happened?
• 39:52This shows you what happened.
• 39:54We began the effort
• 39:57in, the nineteen sixties, and
• 39:59this shows you the cases
• 40:00reported in the solid line.
• 40:02We had dollars up,
• 40:04cases down.
• 40:06Cases down, dollars down. Now
• 40:08all this was switched to
• 40:09rubella.
• 40:10Dollars down, cases up. Cases
• 40:13up, dollars
• 40:14up.
• 40:15Dollars up, cases down.
• 40:17Cases
• 40:18dollars down, cases up. And
• 40:20then recognition
• 40:21that we needed to have
• 40:23a consistent
• 40:25source of funding.
• 40:29The other thing we were
• 40:30learning about measles
• 40:32is it wasn't a uniform
• 40:34pattern.
• 40:35We had two types of
• 40:36outbreaks.
• 40:37Preschool
• 40:38outbreaks
• 40:40where
• 40:40the biggest problem
• 40:42was not was lack of
• 40:44vaccination.
• 40:45And we learned
• 40:46a lot of that
• 40:48was problems with access.
• 40:50The parents couldn't afford the
• 40:52vaccines,
• 40:53the,
• 40:54inconvenience
• 40:55of the vaccines.
• 40:57And school age children
• 41:00where the big problem
• 41:02was often
• 41:03first dose failures,
• 41:05that the immunity level achieved
• 41:07in school age children with
• 41:08a single dose
• 41:10was not
• 41:12high enough to meet a
• 41:13to herd immunity threshold,
• 41:15because, again, in those settings,
• 41:17there were much more contacts
• 41:18and much more spread.
• 41:21The other thing that became
• 41:23important was politics.
• 41:25And the Children's Defense Fund
• 41:29was an organization
• 41:30dedicated
• 41:32to trying
• 41:34to improve the health of
• 41:35young children, particularly poor children.
• 41:38And they were looking for
• 41:39ways of measuring
• 41:41access
• 41:42of poor children
• 41:45to immunize to health care.
• 41:46And what is recommended for
• 41:49all children repeatedly,
• 41:50immunization.
• 41:52So immunization
• 41:53coverage
• 41:54was looked at as one
• 41:55of the top areas. And
• 41:57we had an immunization coverage
• 41:59system called the US Immunization
• 42:02Survey,
• 42:03which we didn't feel was
• 42:04accurate. It gave us low
• 42:06levels of country. It was
• 42:07often coverage. It was often
• 42:09based on parental history.
• 42:12And then we got a
• 42:13front page article in The
• 42:14New York Times saying we're
• 42:16at big risk of measles
• 42:17outbreaks.
• 42:18And my gut reaction
• 42:20was
• 42:22I need to write to
• 42:23The New York Times telling
• 42:24them they're using false data,
• 42:27faulty data, and we're not
• 42:28at risk.
• 42:30And the best advice I
• 42:31ever got in my career
• 42:32was from my chief administrator
• 42:34who said if you don't
• 42:35if you do anything, you
• 42:36don't tick off the Children's
• 42:38Defense Fund.
• 42:40And little did I know
• 42:42is Hillary Clinton was on
• 42:43the board of the Children's
• 42:45Defense Fund.
• 42:46So
• 42:47we invited them to
• 42:49the,
• 42:51effort. We developed a coalition
• 42:53with them, and we became
• 42:55allies.
• 42:57It turned out they were
• 42:58right, and I was wrong.
• 43:00We had a big resurgence
• 43:02of measles with over fifty
• 43:03five thousand cases,
• 43:05over a hundred deaths, over
• 43:07eleven thousand hospitalizations.
• 43:10And we had unvaccinated
• 43:12preschoolers,
• 43:13and we had vaccinated
• 43:15older children, including college students.
• 43:19And one of the things
• 43:20I did
• 43:21the most important things I
• 43:22didn't require
• 43:24my career was staff
• 43:26the,
• 43:27a national vaccine advisory committee
• 43:30for a paper that it
• 43:32was called the measles white
• 43:33paper.
• 43:34And this had ten factors
• 43:37that the primary cause was
• 43:39a failure to vaccinate young
• 43:40preschool children.
• 43:42Opportunities
• 43:43for vaccination were missed in
• 43:45physicians' offices
• 43:46and clinics for two reasons.
• 43:48One,
• 43:49the children's parents might not
• 43:51have been able to afford
• 43:52the vaccine, so they were
• 43:53sent to public clinics, and
• 43:55they weren't vaccinated.
• 43:57Or some pediatricians were using
• 44:00invalid contraindications
• 44:02not to vaccinate and missing
• 44:04opportunities.
• 44:06Another public program, a food
• 44:08program, the women's infants and
• 44:10children program,
• 44:12again, they weren't taking advantage
• 44:14of their opportunities.
• 44:16And, again,
• 44:17see, as I mentioned, the
• 44:19children were being referred out
• 44:20of,
• 44:21the program.
• 44:23So
• 44:23there were several recommendations,
• 44:25provide funds through the three
• 44:28seventeen program
• 44:30to not only purchase vaccines,
• 44:32but enhance the delivery infrastructure
• 44:35and eliminate by legislation
• 44:37what was called under insurance,
• 44:39which later was eliminated
• 44:41with the Obama administration.
• 44:44That is, there were people
• 44:46with insurance who had insurance
• 44:47but didn't cover immunization,
• 44:50develop coalitions.
• 44:52When I was at CDC,
• 44:55what I used
• 44:56to work with is the
• 44:57American Academy of Pediatrics.
• 45:00I couldn't go to Congress,
• 45:01but they could.
• 45:03And so
• 45:04coalitions were very important.
• 45:06Issue standards of immunization
• 45:08practices
• 45:11developed work with inter agencies,
• 45:13such as the women and
• 45:14the interest of children.
• 45:16Government should reach out to
• 45:18medical societies
• 45:20to work with them,
• 45:21measure coverage,
• 45:23explore ways to do it,
• 45:25and support
• 45:26implementation
• 45:27science research.
• 45:30And this led to the
• 45:32childhood initiative
• 45:34in the,
• 45:35Clinton administration,
• 45:36and the goal was to
• 45:38implement
• 45:39immunization action plans.
• 45:41We implemented national immunization
• 45:43surveys in all fifty states
• 45:46in ex in one methodology
• 45:48so we could compare states.
• 45:50We set up these elimination
• 45:52goals, and we focused on
• 45:54fixing financial efforts. And one
• 45:56of the things we did
• 45:57is establish the vaccines for
• 45:59children program,
• 46:01which was
• 46:03provided to poor children free
• 46:05vaccines
• 46:06in their provider's office.
• 46:08It led to a good
• 46:10coalition between public health and
• 46:12private providers.
• 46:15It provided free vaccines
• 46:17for uninsured
• 46:18children, for children on Medicaid,
• 46:21for,
• 46:23American Indian and Alaska Natives,
• 46:25and for children who had
• 46:26insurance but whose insurance didn't
• 46:28cover immunization at the time.
• 46:30If they went to a
• 46:31federally qualified health center, they
• 46:33could get
• 46:34free vaccines.
• 46:36And it really
• 46:37built this effort.
• 46:38And so this just shows
• 46:40in the thirty years of
• 46:42it, about five hundred and
• 46:44eight million illnesses were prevented,
• 46:46about one point one million
• 46:48deaths, and it's at a
• 46:50savings
• 46:51two point seven trillion dollars.
• 46:54The key features of the
• 46:56vaccines for children program is
• 46:58it was entitlement.
• 46:59It covers
• 47:00about
• 47:02half of children zero to
• 47:03eighteen.
• 47:04These are the eligibility,
• 47:07criteria.
• 47:09The other thing it did
• 47:10is it put in a
• 47:11committee
• 47:13the ability to make appropriations.
• 47:15A committee of experts, the
• 47:17ACIP,
• 47:18if they voted a vaccine
• 47:20into the ACIP,
• 47:21it had to be covered.
• 47:24And you didn't have to
• 47:25seek additional appropriations.
• 47:27And it built a public
• 47:29private partnership
• 47:30because public health would support
• 47:33free vaccines to private providers.
• 47:36They would have a relationship
• 47:37to enhance
• 47:39their delivery.
• 47:41And the other issue is,
• 47:43again,
• 47:44we have to remember what
• 47:46I said earlier.
• 47:48We have an obligation to
• 47:50protect society.
• 47:52And with vaccination
• 47:54for the vast majority of
• 47:55diseases,
• 47:57getting vaccinated
• 47:58prevents
• 47:59transmission of disease
• 48:01and protects people who can't
• 48:03be vaccinated
• 48:05or people who are vaccinated
• 48:07but do not make a
• 48:09protective immune response.
• 48:12So what was diagonal
• 48:14about it? One is school
• 48:16mandates impacted
• 48:18other vaccines.
• 48:20Immunization
• 48:21financing was for all recommended
• 48:24vaccines.
• 48:25We measured coverage of all
• 48:27vaccines.
• 48:29We needed a constant source
• 48:31of funding.
• 48:32And, again, therapy was easier
• 48:33to sell than innovation.
• 48:36And it led to enactment
• 48:37enforcement of school and daycare
• 48:40laws,
• 48:41not just measles. It led
• 48:42to financing
• 48:43to remove costs as a
• 48:44barrier.
• 48:45It led to the national
• 48:47immunization
• 48:47survey measuring coverage of all
• 48:49vaccines
• 48:50at two presidential
• 48:52initiatives.
• 48:53And, again, it can
• 48:55be integrated with overall immunization
• 48:57program,
• 48:58and planning
• 48:59on the global side,
• 49:01a school entry check for
• 49:03applied vaccines,
• 49:05the planning of of mass
• 49:07campaigns or supplemental immunization
• 49:09activities.
• 49:11And it can address negative
• 49:13impacts and Pablo
• 49:15efforts. And then again, one
• 49:16of the biggest things we're
• 49:18hearing now is vaccine hesitancy.
• 49:21The SAGE
• 49:22strategic advising group of experts
• 49:23of the World Health Organization
• 49:25on immunization
• 49:27is vaccine
• 49:29refusal has become a big
• 49:31problem,
• 49:31and it's influenced by a
• 49:33variety of factors. And this
• 49:34just shows
• 49:36data
• 49:37on the increase
• 49:38in vaccine hesitancy
• 49:41that has
• 49:42happened
• 49:43afterwards. And as I said,
• 49:44in two thousand nineteen, vaccine
• 49:46hesitancy
• 49:47was one of the top
• 49:48ten
• 49:49global challenges to health.
• 49:52And this just shows you
• 49:53problems. And in red,
• 49:56is,
• 49:58is the
• 49:59the problems of of,
• 50:02negative
• 50:03confidence
• 50:04in vaccine,
• 50:06problems. And, again,
• 50:09just real problems
• 50:11in it. And some cases,
• 50:12pro increase confidence,
• 50:14but the negative
• 50:16is the problem. And this
• 50:17just shows you some of
• 50:19the people,
• 50:20looking by age
• 50:22at various countries around the
• 50:23world.
• 50:24And,
• 50:25the blue dots
• 50:27are
• 50:28for persons under thirty
• 50:30five. The red dots, I
• 50:31mean,
• 50:32are, over thirty five,
• 50:36and the blue dots are
• 50:37under thirty five. And you
• 50:38can see here in the
• 50:39vast majority of countries,
• 50:41young people
• 50:42are less convinced.
• 50:44Young people,
• 50:46haven't seen these diseases,
• 50:48are a problem, and that's
• 50:50why prevention
• 50:51isn't a difficult sell and
• 50:53why we need to find
• 50:54ways of doing it. And
• 50:56this is just,
• 50:58a slide
• 50:59that can let you know
• 51:01what the status is of
• 51:02vaccine hesitancy and confidence is.
• 51:04It's w w w dot
• 51:06vaccine confidence
• 51:08dot org.
• 51:09So critical issues for immunization
• 51:11program
• 51:12success is understanding
• 51:14the immunology
• 51:15of the disease, what are
• 51:17the transmitted, who's are effective,
• 51:19should a universal immunization program
• 51:21be implemented,
• 51:23knowledge of the effectiveness and
• 51:25safety in populations for whom
• 51:26vaccine is recommended,
• 51:28having a surveillance
• 51:29system
• 51:30in place to determine cases
• 51:33if the result of vaccine
• 51:34failure or failure to vaccinate.
• 51:37We used to, in the
• 51:38US, call them preventable cases.
• 51:40A preventable one was should
• 51:41have been vaccinated but wasn't,
• 51:43and a non preventable
• 51:45was someone who was a
• 51:46vaccine failure,
• 51:48someone who wasn't eligible for
• 51:49vaccination,
• 51:51etcetera.
• 51:52And if failure to vaccinate,
• 51:53what is the reason? Vaccine
• 51:55hesitancy,
• 51:56problems with access,
• 51:58not recommended for vaccination by
• 52:00the National Immunization Technical Advisory
• 52:02Group.
• 52:04And having an ongoing monitoring
• 52:06program in place to answering
• 52:08questions not answered when a
• 52:10vaccine is first approved.
• 52:12Vaccine effectiveness
• 52:13and observational
• 52:14studies when randomized placebo controlled
• 52:17trials are not ethical or
• 52:19feasible.
• 52:20Vaccine safety evaluation
• 52:22to look for rare events
• 52:23and determine
• 52:24if such events are causally
• 52:26related or coincidentally
• 52:28related and having a strong
• 52:30communication
• 52:30system
• 52:31to deliver the right messages
• 52:33by the right messengers
• 52:35to the right communications
• 52:37channels.
• 52:38Thank you very much.
• 52:47I I'd be happy if
• 52:48there's time to take questions.
• 52:49Time for some questions. Ginny.
• 52:52So there's a lot of
• 52:53focus on the the for
• 52:55me being grateful for me
• 52:56as well as being this
• 52:57ninety five percent and the
• 52:58idea that if you have
• 52:59at least ninety five percent
• 53:00covered,
• 53:01you'd say. I'm wondering,
• 53:03to what extent that may
• 53:04be counterproductive
• 53:05just based on the fact
• 53:06that's based on a single
• 53:07estimate or not that is
• 53:09quite old,
• 53:10single homogeneous with the
• 53:13the fact that, for example,
• 53:14in schools,
• 53:15you're likely having higher mixed
• 53:17data and higher transmission.
• 53:19So we're just taking to
• 53:20account that even if you
• 53:20reset, you'll get
• 53:22phase transmission
• 53:23that out.
• 53:25Do you think it's the
• 53:26messaging? I well, it's useful
• 53:28to have that full. Should
• 53:29the messaging be changed to
• 53:32we really vaccinating everybody in
• 53:33the
• 53:34cell phone.
• 53:35Oh,
• 53:36well, I I
• 53:37hit both on here. I
• 53:39think the
• 53:40the issue
• 53:42reviews that that I have
• 53:44found helpful in talking with
• 53:45politicians
• 53:47is
• 53:48we need to get high
• 53:49levels
• 53:50and we need to have
• 53:51a system to achieve high
• 53:52levels.
• 53:53And measles
• 53:55is an indicator of disease
• 53:57for that. I agree completely
• 53:59with you. The big issue
• 54:01is
• 54:02not getting to herd immunity
• 54:03threshold. It's getting rid of
• 54:05measles. And I think part
• 54:06of the problem
• 54:08is when the now it's
• 54:10called the it was called
• 54:11the expanded program immunization
• 54:14is now fifty years old.
• 54:15It was started in nineteen
• 54:16seventy four.
• 54:18It is now called the
• 54:19essential program on immunization,
• 54:21but
• 54:23it measured coverage
• 54:24and not disease incidence.
• 54:27And what I have found
• 54:28with politicians
• 54:29and others
• 54:30is disease incidents
• 54:32is more
• 54:34easier to
• 54:36persuade people. And as I
• 54:37showed you, it was the
• 54:39resurgences
• 54:41that got us the political
• 54:42support.
• 54:44But I think
• 54:45it is important
• 54:47to have models
• 54:49to help us and to
• 54:50particularly
• 54:51help policymakers
• 54:53to know what the right
• 54:54strategies
• 54:55are.
• 54:56And so I think we
• 54:58need both.
• 54:59And
• 55:00the other thing we need
• 55:02is investment in the implementation
• 55:04science.
• 55:06What is the right message?
• 55:07How do I deliver?
• 55:10One of the most famous
• 55:11studies
• 55:12done on vaccine hesitancy was
• 55:14done by Brian
• 55:16who was at Dartmouth at
• 55:18the time
• 55:19working with people who were
• 55:20hesitant about giving measles vaccine
• 55:23to their children.
• 55:25And what he found is
• 55:26just correcting the numbers
• 55:29backfired,
• 55:30and then he had more
• 55:31hesitant.
• 55:32How do we teach our
• 55:34trainees
• 55:36to talk with hesitant parents?
• 55:39For example,
• 55:40it's ridiculous.
• 55:42They have to say a
• 55:43parent who's hesitant. It's like,
• 55:45you're in need.
• 55:46Vaccines are much better. That's
• 55:48not gonna work. It's gonna
• 55:50push the parent parent away.
• 55:52On the other hand, you
• 55:53say, you know, you have
• 55:54every right
• 55:56to be concerned about your
• 55:58parent. I'm glad you brought
• 55:59this question up. Let me
• 56:01tell you what the facts
• 56:02are. I get my own
• 56:03shoulder vaccinated or whatever. It's
• 56:05called motivational
• 56:06interviewing. It's one way to
• 56:09overcome that. And so I
• 56:11think what is often hard
• 56:13is to invest in that
• 56:14implementation
• 56:15science.
• 56:16And it is a science,
• 56:19and it is not as
• 56:20simple
• 56:21as what one
• 56:22normally thinks
• 56:24you can do.
• 56:25And and
• 56:27as I said, vaccines don't
• 56:28save lives. Vaccinations
• 56:30save lives.
• 56:32How do we
• 56:33invest on that? And one
• 56:35of the things to me
• 56:36that's very important
• 56:38is
• 56:39the primary health care provider.
• 56:42Because
• 56:43if a parent
• 56:45doesn't trust their parent health
• 56:46primary health care provider, they
• 56:48wouldn't bring
• 56:49their child to that primary
• 56:51health care provider.
• 56:53But primary health care providers
• 56:55are often overwhelmed. They don't
• 56:57have time
• 56:58to sit, spend
• 56:59with a parent.
• 57:01There are reimbursement
• 57:03codes
• 57:04for
• 57:06counseling
• 57:07when vaccines are not given.
• 57:09I don't know how many
• 57:10insurers
• 57:11get them. We need to
• 57:13study that,
• 57:14and we also need to
• 57:15see whether it makes a
• 57:17difference. I remember
• 57:18this came up at the
• 57:20National Vaccine Advisory
• 57:22Committee many years ago when
• 57:23I was chair, and
• 57:26there was real concern
• 57:28that vaccine counseling curves would
• 57:30be abused
• 57:32and that providers would just
• 57:35get reimbursed when they didn't
• 57:37take any time to do
• 57:38anything to get the vaccine.
• 57:40Yeah. And they asked or
• 57:42show me the data makes
• 57:44a difference.
• 57:44So I think that will
• 57:46be a very important implementation
• 57:48science
• 57:49is
• 57:50when you reimburse
• 57:51for counseling,
• 57:52does immunization
• 57:54improve in that area? I
• 57:56mean, one of the things
• 57:58that we did do research
• 58:00on that played a big
• 58:01role
• 58:02in children is something we
• 58:03call a fix or repair.
• 58:06A was to go to
• 58:07an individual practice and assess
• 58:09the immunization
• 58:10coverage.
• 58:12F was feedback to the
• 58:14provider how well and not
• 58:15well they were doing.
• 58:17I was incentives
• 58:19to make changes if they
• 58:20needed it. And x was
• 58:22exchange of information
• 58:24to tell them what the
• 58:25more successful practices were doing
• 58:28so that they can up,
• 58:30update it.
• 58:31The acronym has been changed
• 58:32now. It's called iQuIP now,
• 58:34immunization
• 58:35quality improvement program.
• 58:37I'm an oldie. I prefer
• 58:39AFIX.
• 58:40But the but the issue
• 58:41is, again, that was implementation
• 58:44science, and that was led
• 58:46by actually the state of
• 58:47Georgia.
• 58:48And then we made it
• 58:49part of our presidential initiatives
• 58:51in building relationships. And that's
• 58:53what VFC
• 58:54really helped because we were
• 58:56giving vaccines to private providers,
• 58:59and,
• 59:00yes, we, established these relationships.
• 59:03So So in the interest
• 59:04of time, it's just about
• 59:05one o'clock. I wanna thank
• 59:07you, doctor Wertz team, for
• 59:07really