>> Good afternoon, everyone.
Welcome to our February Public Health Grand Rounds on Measles:
Maintaining Disease Elimination
and Enhancing Vaccine Confidence.
My name is Dr. Tanya Telfair LeBlanc.
I'm with CDC's Office of Science.
Thank you so much for joining us today.
Public Health Grand Rounds has free continuing education
available for physicians, nurses, pharmacists,
and many other health professionals.
The course code is PHGR10.
Please see our website for additional information
on continuing education credit.
Here's our continuing education disclosure statement
for the session.
Grand Rounds is available on the web and all
of your favorite social media sites.
Please send questions to grandrounds@cdc.gov.
At the end we'll try to work your questions in
and Susan will allow a wonderful question and answer session
at the end, so send your questions.
Want to know more about today's session
and other Public Health Grand Rounds sessions?
Please visit Grand Rounds at cdc.gov/grandrounds
for information,
resources including a podcast that we call Beyond the Data
and as well as a glossary of terms for each session.
And we partner with the CDC Public Health Library
to assemble scientific articles on each topic.
The full listing is available at cdc.gov/scienceclips.
In addition to our outstanding speakers today,
I'd like to acknowledge the important contributors.
The individuals are listed here but we especially
like to recognize Miss Tiffany Smith, who was invaluable
at putting this whole thing together and worked with us
from the very beginning to the end.
She was absolutely a joy.
It is now my pleasure to introduce
to you today our Director
of the Science Office, Dr. Rebecca Bunnell.
[ Applause ]
>> Good afternoon everyone, and, and thank you so much to those
in the room and those who have joined us remotely.
I want to start by just recognizing the many CDC, state,
and local public health staff
who are currently doing critical work on coronavirus or COVID19.
I know many in the room are also helping to cover for those
who are deployed, so thank you to all of you as well.
As we are seeing in the unfolding events
as COVID19 spreads, disease importations are a constant
threat in today's interconnected world.
Measles, one of the most contagious infectious diseases,
was eliminated from the United States in 2000 thanks to decades
of robust and successful vaccination programs.
However, the global increase of measles in recent years,
in addition to increases in vaccine hesitancy,
pose a risk to US elimination,
especially when unvaccinated travelers acquire
measles abroad.
In 2019, the US saw the highest number of measles cases
in a single year since 1992,
with nearly 1300 confirmed cases.
Over 73% of these cases were linked to a breaks
in New York affecting under vaccinated communities.
Sustained transmission of almost 12 months nearly led to the loss
of our nation's measles elimination status.
Today's session of Grand Rounds will focus on measles
in the United States and the response to and lessons learned
from the outbreaks in New York in 2018 to 2019.
You'll also hear about the CDC's national strategy
for strengthening vaccine confidence
and increasing vaccination coverage to protect our nation
from vaccine-preventable diseases like measles.
The 2019 measles response in New York and in New York City
and beyond is an example of the best of Public Health.
We will need to draw on that kind of talent and that kind
of commitment as we collectively respond
to today's challenges with COVID19.
On that note, I will pass it back to, to Dr. LeBlanc
to open up our session.
Thank you again.
[ Applause ]
>> Our first speaker today is Dr. Manisha Patel
who we affectionately refer to as Moe.
She is a medical officer
and a domestic measles team lead with NCIRD.
Dr Patel?
>> Good afternoon.
So, this first presentation is going
to cover measles in the United States.
Measles is one of the most contagious
of the vaccine-preventable diseases.
In fact a single case of measles can infect 12 to 16 other people
in a, within a totally susceptible population.
It's an acute viral rash illness that classically presents
with high fever, cough, coryza,
or runny nose and conjunctivitis.
The incubation period is 10 to 14 days but rash can appear
as early as 7 days and lasts, or as late as 21 days.
And the infectious period starts four days before the rash
appears and through four days after rash onset.
And the rash typically appears on the face and the hairline
and then spreads downwards.
Measles complications are more common in younger children
and adults and can range from less severe like otitis media
to more severe complications like encephalitis and death.
Sub-acute sclerosing pan encephalitis is a rare
but fatal neurologic complication that occurs seven
to ten years after the initial measles infection
and it typically presents with these minor behavioral changes
that progress with myoclonic jerks and dementia
and eventually to death over the course of months to years.
Usually it's children who are infected when they are less
than two years of age who are at highest risk.
This is a really devastating complication.
Fortunately, the measles-mumps-rubella,
or MMR vaccine, is highly effective against measles
and it's complications.
It has a one dose vaccine effectiveness of 93%
and a two dose VE of 97%.
It has an excellent safety profile.
Common side effects such as fever and rash are usually mild
and resolve spontaneously.
Serious adverse events are extremely rare.
Children and adolescents need two doses of MMR
and most adults need only one dose
of MMR unless they have other evidence of immunity.
High-risk adults such as healthcare personnel,
post high school students
and international travelers need two doses.
Vaccination of US residents traveling abroad is really
critical and as you will see later in my talk, they account
for the majority of measles introductions
into the United States.
So two points about travel.
First, travelers twelve months of age
or older should have two documented doses
of MMR vaccine before they leave for their trip.
So, this means that you can decrease the interval
between the first and second dose to a short
as 28 days if you need to.
And then the second important point is that infants 6
to 11 months of age should receive one dose
of MMR before they travel.
This dose does not count as part of their routine recommendations
and so they will need two doses of MMR after they turn 1.
So, high vaccine effectiveness
and the excellent safety profile allowed for the rollout
of several key policy changes slash initiatives in the '80s
and '90s that increased MMR vaccine coverage
in the United States.
This includes the recommendation
of the second dose of MMR in 1989.
The implementation of the vaccine for children's program
which allowed for wider access to vaccination.
And commitment by the Pan-American Health Organization
in other countries in the region
to stop endemic measles transmission
through large-scale vaccination efforts throughout the Americas.
And all of this led to measles being eliminated
in the United States in 2000.
So, what is really key
for measles during the post elimination years
which is defined as 2001 and on is that most measle cases are
in unvaccinated persons.
And this is shown here in orange.
The other important point is that the highest incidence is
in infants who are 12 to 15 months of age.
And this is really important for providers to be aware of so
that they are vaccinating infants against measles as soon
as they turn 12 months of age.
So, I mentioned that the majority of or two-thirds
of measles importations are among US residents
in more recent years.
And the fact that these importations are occurring
in unvaccinated US travelers
who are acquiring measles infection abroad
and then developing disease and in some instances transmitting
to others when they return
to the United States really underscores the importance
of ensuring that providers are vaccinating their patients
before they travel internationally.
So, even though the US is continually getting measles
importation and there have been 747 importation from 2001
through 2019, most importation are not associated
with outbreaks.
And this has to do largely
because of the high nationwide MMR vaccination coverage
in the United States but also
because of the extraordinary efforts from state
and local health departments
who are responding rapidly to every single case.
So, the, in general the reported measles incidents has remained
less than one per million and that's shown
by the red dotted line there.
And, and this is an indicator of good measles control.
But you can see that in more recent post elimination years we
are seeing an increase in the number
of reported measles cases, particularly
in 2014, 2018, and 2019.
So why is this happening?
Well, one major contributor for the increase
in domestic measles is the increase in global measles
which tripled in 2019 and all of the
WHO of regions have reported measles cases.
But the European and African regions particularly had major
outbreaks occurring in the Ukraine and in Madagascar
which is contributing to that blue region for African region
and the red for the European region.
So, while the global measles activity remains high,
the United States will be at continued risk for measles
and these importations can land anywhere in the United States
but it is more concentrated in states
that have major ports of entry.
And then when you overlay these importations
with geographic areas that are highly dense
and have lower vaccination coverage, you're going
to have rapid spread of measles throughout a community leading
to large outbreaks.
And just as a reminder - the herd immunity threshold
for measles, which is the proportion of a population
that needs to be immune to prevent transmission, is high.
It's between 92 and 94%.
Since 2001, 158 outbreaks have been reported
in the United States but most of these outbreaks are limited
in size and duration, with 5 cases per outbreak
and the median duration of 23 days.
But you can see that in more recent years
that there are larger outbreaks that are being reported
and these shown in red are the outbreaks
that are of 50 or more cases.
And then if you look closer at those outbreaks,
the seven that I showed in red in the previous slide,
there are two points that stand out.
First, these outbreaks are occurring
in close-knit communities.
And second, these outbreaks are lasting for longer
than what we had seen when you compared it
to earlier post elimination years.
The last row shows the two outbreaks New York City
in New York State which started in 2018.
New York City and New York State were especially concerning,
not only because of the large number of outbreaks
that were reported but because of the sustained duration
of these outbreaks with transmission lasting for nine
and a half months in New York City and ten
and a half months in New York State.
And if transmission had lasted for 12 or more months,
twelve months or longer,
the United States would have lost its elimination status.
And Dr. Zucker and Dr. Barbot will talk more
about the various strategies that were implemented
in New York to control this outbreak.
So in summary, endemic measles has been eliminated
in the United States since 2000.
However, measles cases continue to occur in the US
through global importation which the majority are due
to US residents who have not been vaccinated before
their travel.
The recent epidemiology suggests larger
and more sustained outbreaks compared
to earlier post elimination years,
especially when importations
and sometimes repeated importations are landing
in undervaccinated communities.
These outbreaks require multidisciplinary local
responses to prevent further spread
into these vulnerable communities.
Thank you, and I would now like to introduce our next speaker,
Dr. Howard Zucker, the Commissioner
for the New York State Department of Health.
[ Applause ]
>> Thank you.
Thank you to the CDC
for convening this important Grand Rounds.
I will tell you, it was a year-long fight
against the historic measles epidemic
that public health officials in New York State
and New York City mobilized on two fronts.
So, we had the New York State Department of Health
that collaborated with the county health officials
to contain cases in the lower Hudson Valley.
And the New York City Department of Health
and Mental Hygiene tackled a similar outbreak,
a separate outbreak, primarily
in Brooklyn during the same time period.
And as New York State's Health Commissioner,
I led the department's efforts in the lower Hudson Valley
and I will address our work and progress on that front.
As a general note, all references that I make
to New York State measles cases in this presentation are those
that occurring outside of New York City.
So, I thought it would be useful to briefly look at measles
and disease prevention in New York State before this outbreak.
When the United States began tracking measles cases in 1912,
the disease killed roughly 6,000 people in the country each year.
At about the same time, New York State launched what would become
a world-class laboratory combining research,
public health, testing, and science education.
And the Wadsworth Central Laboratory initially focused
on small pox, on cholera, on typhoid, tuberculosis, tetanus,
and especially diphtheria.
In the 1890s, diphtheria alone killed 1000 people a year
in New York City.
And after developing America's first system of lab analysis
for the diagnosis of human disease,
Wadsworth became a standard bearer in public health.
And over the century, Wadsworth worked to contain
and to prevent communicable diseases like measles
which was killing up to 500 people
in the country before 1963.
The 2018-2019 measles outbreak was the largest
in New York State since the 1990s.
The graph shows that cases
in the state have held relatively steady since 1990.
And in 2013 New York City,
experienced a significant outbreak
that like our recent outbreak started
with an unvaccinated traveler
who had been infected while abroad.
The 2013 outbreak recorded 58 cases, primarily in Brooklyn.
The graph shows small spikes over this 20 year period
but nothing like what we encountered starting
in the fall of 2018.
So, let's, let's look at the details
of the outbreak at that time.
In both New York State and New York City,
the outbreaks have been concentrated among Orthodox
Jewish communities and traced to travelers returning from Israel
and the Ukraine where measles outbreaks have been prevalent.
The first case was a visiting teenager
from Israel who was unvaccinated.
And in total, we confirmed 10 imported cases
of measles including four cases from a single family.
During the outbreak, 406 cases were confirmed in Rockland,
Orange, Sullivan, and Westchester Counties
and in undervaccinated close-knit communities
like those affected, the human, the number of cases rise quickly
if you don't act fast.
And the county provides administered nearly 85,000 MMR
vaccinations before the outbreak's conclusion
on October 3rd.
The diverse geography of this outbreak was definitely a
challenge when mounting an effective response
from local partners.
The County Health Department's we worked with ranged in size
from small to large, both in terms of the populations
that they serve and the department staffing.
This presented the department with difficulties in assisting
with case investigations and monitoring,
as well as getting specimens to our public health labs.
Rockland County was truly ground zero for this outbreak.
The New York State Department of Health worked hand-in-hand
with Rockland officials for an entire year.
The last case of the outbreak occurred in Rockland County
on August 13 which was just six weeks before the deadline
in which the United States would lose its measles elimination
status, as you heard.
And Rockland officials declared the outbreak
over on September 25th.
Commissioner Rupert and our Rockland County Health
Department staff often worked 14-hour days checking on more
than a hundred people on some days.
And the county officials kept tabs
on roughly 1200 individuals known to have been exposed
to the virus and deemed susceptible to infection.
They also reviewed hundreds of thousands
of school immunization forms to check
which students had been vaccinated.
Refuah Health Center was another tremendous partner
in our measles fight.
Refuah Health's CEO Chaine Sternberg
and Chief Medical Officer Dr. Corrina Manini shared their
experiences and insights at a Grand Rounds discussion
about vaccine hesitancy that the Department hosted
at Mount Sinai Hospital in Manhattan on June 13th of 2019.
Refuah and Ms Sternberg helped connect the department
to the Rabbinical leaders in Rockland County,
leading to improved communications
and more effective promotion of vaccination.
Now, I'll run through how the department developed a
successful strategy for containing
and ending a quickly moving outbreak.
The department strategy consisted of five elements.
The department's incident management system activated
from the start of the outbreak, health care outreach
and communication, community education and outreach,
preventing spread in schools and at summer camps,
and New York state legislation.
Partnership was everything in rising
to this challenge, it really was.
It was all about partnership,
not just with County health officials
but with all the health care facilities
in the affected county.
The department worked closely with local doctors,
school administrators, rabbis, federal health officials
to contain the disease and increase public awareness
about the critical important of, importance of vaccination.
And we worked to streamline the connection
between county health departments and specimen testing
at our, our Wadsworth Lab in Albany.
I can't stress enough how crucial ongoing education
outreach was in our ability to monitor
and contain this outbreak.
We learned to be patient but firm and dealing
with communities and families.
In the late spring of 2019 the department launched a PSA video
which I discussed the safety effectiveness of vaccines
and aired in June and then again in August.
As you can imagine, schools
and summer camps were a huge focus throughout 2019.
Rockland County in particular held firm
to its vaccination requirements
in schools throughout the outbreak,
and the department provide local health departments with guidance
and informational fliers and posters to ensure
that camp administrators knew
about vaccine-preventable diseases,
about vaccination recommendations
for camp settings and medical details about measles.
We provided measles response playbooks
and immunization record templates.
We conducted an emergency preparedness exercise
for department staff.
And we provided a statewide webinar for camp operators
and camp health directors.
We were particularly proud of our preventative work
in Sullivan County, where the camp population actually surges
and it was presented a heightened risk
of transmission at that time.
Governor Cuomo signed legislation in June
to eliminate all non-medical exemptions
for childhood vaccinations, required for public private
and parochial school attendance.
And in August 2019, we heard a second PSA video reminding
parents of the new vaccine requirements ahead
of the start of the school year.
Now let's look a little bit at the data
from our epidemiology team.
Our, on our epi curve,
the colors reflect the different counties with Rockland in gray,
Orange cleverly in orange, Sullivan in yellow
and Westchester in blue.
The arrow, arrows show the importation of cases
and the last rash onset was August 19th.
The curve has two big peaks;
this could reflect the unreported cases that occurred.
Blunting the curve in the middle were the increased travel
that occurred during and before, and during the Passover holiday.
There were also two importations that occurred in April.
And here is a snapshot of vaccination rates
over the course of the outbreak.
Our base level in the state before the outbreak was 96%
of school-age children are inoculated with the MMR vaccine.
We improved our vaccination rates
in the four most affected zip codes by 11%.
This slide shows cases by age and vaccination status
in the four affected counties.
So, most cases, about 82% had not received any doses of MMR.
Among those with zero doses, 299 or 90% were children,
251 or 84% of these children were aged 1 or older eligible
for MMR under the routine recommendations.
An additional 31 or 10.4% were between the ages of 6
and 11 months, eligible for MMR in this outbreak setting.
And then 134 or 33% of the cases were between 1 and 4 years
of age and an additional 34% were
between the ages of 5 and 17 years.
The greatest public health a success in our response
to this outbreak is that no one died
from measles-associated complications
and there were no documented cases of encephalitis.
Of the 28 hospitalizations 6 children between one day of age
and 7 years were admitted to the intensive care unit
and there were two preterm births to mothers with measles
and both babies were confirmed
with congenital measles infection.
So what did we learn?
We learned a lot from this surprising long skirmish
with measles.
The case, the causes of this outbreak are
pretty straightforward.
Measles is still common in many parts of the world.
Unvaccinated people who travel internationally can be at risk.
We learned it just takes one importation for measles
to spread when residents of New York State are unvaccinated.
The World Health Organization named vaccine hesitancy as one
of the greatest threats to public health in 2019,
and that proved true in New York State.
And during this outbreak the vulnerability caused
by vaccine hesitancy, hesitancy
in the state's Orthodox communities was exploited
and made worse by the propaganda and activism
of the anti-vaccination movement.
Cultural barriers to scientific and medical communication
in the affected communities were another factor.
We didn't have a rapid-fire system in place
for persuading Yiddish-speaking communities
that vaccination was safe
and would better protect the community.
We experienced some lab testing limitations
in that it was difficult
to confirm whether IgM-positive results received
through lab reporting or measles cases
and too late for control measures.
I want to spotlight one new public health tool
that originated from this outbreak.
The department's measles watch dashboard
on New York State Health Connector provides timely
information about local, about regional
and statewide excluding New York City measles cases
and locations offering an MMR vaccination.
The watch also provides immunization exemption rates
for current and previous school years,
with school vaccine data updated annually.
And here's our prevention game plan going forward.
Vigilance, partnership, and enforcement of new legislation.
We are continually working
to vaccinate every eligible child while educating the public
that vaccination is health and the two doses of MMR
as you heard are 97% effective.
We continue to forge partnerships
at the community level, intermediaries
who can more effectively reach families.
And as we are always reaching out to parents
with communications like this back-to-school flyer
about the new vaccination law.
We are using what we learned to protect the efficiency
of the department's incident management system should another
outbreak occur and the threat
for vaccine-preventable diseases is always present
and the department is not letting down its guard.
We will remain vigilant in protecting all New Yorkers
from measles and other dangerous,
dangerous vaccine-preventable diseases.
And finally, I want to recognize these individuals
in the Department of Health, the affected counties,
and the CDC who helped us weather the storm
and develop better protocols for handling any future outbreaks
of communicable diseases across the state.
It was an incredible tour de force and we all worked together
to achieve our goals and I want to thank you for the opportunity
to speak with you today about our experience.
Thank you.
[ Applause ]
>> Good afternoon.
So, it's my pleasure to speak with you all
about New York City's experience
with the 2018-2019 measles outbreak.
And I think it's fitting to sort of take Howard's last statement
to begin our statement in terms of the collaboration
between city and state as well
as our federal partners was really what made this response
what it was.
So as an overview, I'll talk
about the epidemiology of what we saw.
I'll talk about the two-fold response
that we undertook in New York City.
And then end with lessons learned and future challenges.
So to begin, as Dr. Zucker mentioned,
the New York City outbreak was centered primarily
in the ultra-orthodox community.
And these two red circles highlight the neighborhoods
where the outbreak was most concentrated.
The top one, Williamsburg, and the bottom one, Borough Park.
These two neighborhoods each have roughly
about 200,000 children and as was mentioned,
the first case had a rash onset of September 30th
and was a child who returned from Israel.
So, it wouldn't be a public health talk
if it there wasn't an epicurve.
So this here is a representation
of the outbreak highlighting the neighborhoods
that were most affected.
And so Williamsburg is I guess the rust color, yellow,
Borough Park, and then the smaller slices
that you see there paint the full picture.
But really, the, the punchline here is
that those two neighborhoods were the main sources
of ongoing outbreak.
And so this overlay here is a representation
of the phased approach that we took
at containing the measles virus.
And phase one was one where we focused primarily on schools
that had children documented to have had measles.
And working with those schools, requiring the exclusion
of non vaccinated children or children who were exempted
who were known contacts of children who had measles.
And so this was started in October of 2018
and you'll see there that in Borough Park over the course
of about two months, it started to turn the tide.
But what we were seeing is increasing numbers
in Williamsburg as well.
And so phase two then, we moved from excluding children
in schools known to have exposures to excluding children
in communities known to have exposures.
And so this took us to over a hundred schools and programs
that needed to have ongoing audits.
Because what we found was that many of these schools had little
or no technology with which to track immunization compliance.
So this was a very labor-intensive component
of our response.
And in total as I mentioned there were 101 schools
and childcare facilities that were ordered
to exclude unvaccinated students.
Excuse me.
Forty-one of them had summonses.
We actually had two twelve programs until we could work
with them to come into compliance in terms
of effectively excluding children who were unimmunized.
And then the response culminated if you will with a declaration
of a public health emergency that I will talk more
about in a few minutes.
And then the last date of onset for the rash was 7/15.
So in total, transmission occurred over a nine
and a half month period but the response itself was roughly
11 months.
And so in terms of the epi of the outbreak, you'll see here
that the vast majority of children were in the 1
to 4 year age group and that most of them in the greater
than 12 month period were preventable cases.
What we saw was a mixture of children
that had no measles vaccinations to those
that had actually just one dose.
And so for us it was a combination
of both vaccine refusal as well as vaccine hesitancy.
And then in terms of the complications as a result
of the outbreak as Dr. Zucker mentioned, the, the lede here is
that thankfully there were no deaths due to measles
and no cases of encephalitis but we did have 8%
who required hospitalizations and our age range there was
from 3 months to 66 years of age requiring hospitalizations,
20 ICU admissions, most, most of whom required O2
but none needing intubation.
And so for us, why did this outbreak occur?
And you know, the punchline here is
that there was low herd immunity and a densely populated,
relatively closed community with large, young households.
And the existing coverage was low
and vaccinations were delayed
until school enrollment as I mentioned.
And particularly in the Williamsburg area,
it's a very interesting neighborhood
because though we have a large concentration
of ultra-orthodox community members,
we also have a fairly large
and ever-growing population of hipsters.
So you know, it's, you know,
it's it really is quite emblematic of New York City.
And so we, and so it was is especially interesting
to see transmission really pretty much primarily limited
to the ultra-Orthodox community.
And you know, that impart was due to the increasing
in religious exemptions that we were seeing.
Citywide we went from 0.5% to 1.5% you'll see there
from 2012 to 2018 school years.
And in some of the schools and the communities
that were affected we saw religious exemptions
as high as 28%.
And so this made ongoing transmission pretty effective.
And so our efforts at quelling the outbreak really focused
almost exclusively on working with schools, daycares,
and community members affiliated with them.
So what made it complex in addition to the cultural issues
that we were challenged with is
that there were multiple exposures.
Over the course of the outbreak, we investigated roughly 2000,
about 2,200 people suspected of having measles and then
over 20,000 exposures with roughly
over 100 chains of transmission.
And so what made it challenging was that oftentimes of the,
as the outbreak grew, people were more and more reluctant
to share the names of potential exposure individuals.
And so that made, as Dr. Zucker alluded to,
community partnerships that much more vital and central
to this outbreak in terms of leaning heavily
on our trusted messengers
to get information out to the community.
And so as I mentioned earlier, vaccine hesitancy fueled
by vaccine misinformation cloaked
in religious terms was one of the main things
that we were struggling against.
And then the other thing that we found
in our community was there were lots of folks
who were having measles party,
parties which made school containment efforts
that much more challenging as well.
And so our response strategies focused
on clinical school day care.
There were significant legal components to our efforts.
And then the communication aspects of this.
And similar to our colleagues at the state,
we had activation of our agency.
We had a divisional activation that started in early November
but then we had a broader agency-wide activation just
before we issued the public health emergency and that was
at the last week of March.
And so for the clinical, there were multiple fronts on this
and that ranged from provider education all the way
through to technical assistance to try and reduce the number
of healthcare site related exposures.
Additionally, in terms of the school response of this,
there were hundreds of school audits that were done
over the course of this outbreak and tremendous number
of hours spent providing technical assistance to schools
so that children could be appropriately excluded.
And so here the public health emergency was declared
on April 9th and the last time the New York City Health
Department had used the public health emergency powers was back
in 1901 to compel people to be vaccinated against the smallpox.
We have used that power previously during
for example H1N1 but it was more to compel practices
to report adults being immunized,
not compelling people to be immunized.
And the Public Health order was limited to individuals living
in the four ZIP codes most affected by the outbreak.
Many of them, let me back up.
There were 232 potential violations
that we ended up issuing.
Thankfully, more than half
of those were canceled before they were filed
because individuals were able to have proof of immunity
or documentation that they indeed were vaccinated during
the period.
And 35 of them were adjudicated through our oath system,
the city's hearing system,
and there's only one pending hearing.
And thankfully no one has of yet had to pay any fines
because really, the purpose of this was not
to penalize individuals but to raise the urgency
of needing to be vaccinated.
And this was the first time in any of our ICS activations
where we actually had to have a whole arm
for the legal components of this.
We of course were sued I think about a week
after the order was issued.
And the motion for an injunction was denied and the judge
on this was I think fairly poetic.
I'm just going to quote one line from his decision where he said,
"A pivotal question posed
for this court's determination is whether respondent
commissioner had a rational, non pretextual basis
for declaring a public health emergency
and issuing the attendant orders challenged herein.
The evidence in this regard is largely uncontroverted."
And then he goes on to say,
"A firemen need not obtain the informed consent
of the owner before extinguishing a housefire.
Vaccination is known
to extinguish the fire of contagion."
I think he must have been a public health practitioner
in a previous life.
And so communication,
communication was really critical here we leverage the
power of our religious leaders in the Orthodox community
and what we saw was that there were new community-based groups
that sprouted in response to this.
And the Jewish Orthodox Women's Medical Association was really
pivotal in this response.
They actually went door-to-door
in Williamsburg engaging families
on the importance of being vaccinated.
And similarly we put them together
with the Visiting Nurses Association
and offered immunizations in the home, because we realized
that over the course of this, though we did all we could
to minimize stigma around this there was a lot
of stigma I think I'm both ends of the spectrum.
Folks wanting to hold the firm to their beliefs in terms
of vaccines not being right for their children
and on the other end, members of the community trying
to publicly shame folks for their beliefs.
And we tried to, you know, play the middle ground
and so offering vaccinations in our, in people's homes was a way
for us to accomplish the public health mission while allowing
community members to have their, their voice.
And information dissemination.
There was I would say an outright war between us
and the anti-vaxx community.
They would do robo calls, we would double match them.
They would do direct mailings, we would double match them.
There were, we did over 3,000 mailings.
We had multiple rounds of robo calls to the point
where people were calling City Hall
and saying please have them stop.
And so it was in an our area,
it was a group called Parents Educating and Advocating
for Children's Health, otherwise known as PEACH,
that were really the main drivers
of misinformation cloaked in religious ideology.
And so when we were up against PEACH, we ended up making pie.
And so this was a educational brochure that we did
in collaboration with community members where we went point
by point on whatever PEACH put out to refute
and give community members the data.
And we found this to be a very effective tool.
And as you can probably see there,
it has no Health Department markings on it and we did
that intentionally because we wanted community members
to use this as their own.
And then these are some of the media materials
that we put together in Yiddish as well
as English for the community.
And here, this is like my favorite curve because the,
the solid line are MMR vaccine uptake
in Williamsburg during the outbreak.
The dotted line is Williamsburg the year before.
And you'll see there that we had fairly significant uptake
when we first declare the outbreak in October
and that we also saw another spike with the emergency order.
But if you look all the way to the end of the slide
in September, you'll see
that the back-to-school rush was actually lower
than the previous years.
And so that was I think the ultimate sign to demonstrate
that the community had adopted the messages we were trying
to convey and immunize their children in a timely way, way.
And over the course of this,
there were 188,635 MMR doses administered
which is citywide 23,000 more than the year before
and in Williamsburg specifically,
there were roughly an additional 4500.
It was a Herculean effort on the part of our staff.
We have amazing staff.
At the end of the day, it was $8.4 million of unbudgeted cost
and there were at the peak 261 staff working
on this at the same time.
So, lessons learned.
We can't take public health victories for granted,
and the importance really for us was the need
for more granular surveillance and immunization coverage.
It wasn't enough to be monitoring immunization uptake
at the community level.
We had to really get granular at the school level and account
for schools that had relatively little no technology
to do that tracking.
And then leveraging community relationships to build new.
We had actually on staff members of the Orthodox community
because we had had previous experience
where that was really critical for the work that we do.
And so this then gave us the opportunity to build
on those partnerships and build new ones
for subsequent outbreaks.
And the challenge here are going forward is
that with the vaccine hesitancy, you know,
the need for ongoing resources to educate community members,
I think, you know, hand-in-hand with not taking victories
for granted, it means that this year after year will need
to be a significant investment on our part to ensure
that we don't have any backsliding
on community immunization rates
and school-based immunization rates in light of the fact
that the measles outbreak is an international issue
that continues.
And so we being an international city need to make sure
that we are always on alert for that.
And then thankfully we, New York State was able
to join California, Maine, Mississippi, and West Virginia,
states that I never thought I'd put in the same sentence
in terms of having religious exemption removed.
And we then, our Board of Health
in New York City then also requires us
to now review all medical exemptions for vaccinations
in all schools, both private as well as non, excuse me,
public as well as non-public schools.
And so that will require a significant amount
of investments on our part to make sure
that we don't see what happened in California in terms
of seeing an uptake on medically,
medical exemptions for vaccinations.
And so it, these are folks in various parts of our agency
that played a pivotal role in the response and I want
to give a special shout-out to Dr. Jane Zucker
who really has been a hero in this for many,
many, many, many hours.
So, thank you.
[ Applause ]
>> Good afternoon.
I am going to wrap the session up by talking
about CDC's vaccinate with strategy, strategy.
First I want to start
by thanking Doctors Patel, Zucker, and Barbot.
Thank you Dr. Zucker and Barbot specifically for coming
down here, given all of the other things that we have going
on at state and local health departments right now.
But also not only for sharing your stories today but also
for sharing everything you've learned
with us over the past year.
As you'll see, it really informed our vaccinate
with confidence strategy.
Learning through all of this with you as well
as multiple other health departments
that have faced measles outbreaks
in the last couple of years.
So I'm going to start by sharing some good news with you.
Nearly 99% of US children have received some vaccines
by the age of 2 and over 94%
of kindergarteners have received both doses of MMR.
But while these data demonstrate the strength
of the US immunization program,
it also masks some vulnerabilities.
For example, by the age of 24 months only 90% of infants
in the US have received one dose of MMR.
In some states, that number is just 85 to 89%.
While we know that most of these children are caught
up by the safety net
of school-aged vaccination requirements,
toddlers are being left unprotected from measles during
at a time when they're most at risk for severe complications.
Additionally, national and state data masks local pockets
of under vaccinations that exists across the country.
In these communities, there is no blanket of protection
from measles outbreaks once there is an introduction.
As you guys have clearly heard, we know that each
of these communities is unique
with distinct factors affecting vaccination coverage.
These communities may be close-knit or isolated
or distrust government.
Access may also be an important issue
in some of these communities.
Localized misinformation about vaccine and safety
and effectiveness and a lack of understanding
about the potential consequences of the diseases present,
prevented by vaccines frequently contribute as well.
Myths have always been a part of the vaccine landscape
but rapid dissemination and sophistication of misinformation
in this current environment per dense,
presents new challenges we need to address.
Misinformation is eroding confidence in vaccines
and putting our immunization program
and thus children's health at risk.
The outbreaks of measles you heard
about this morning make it clear that educating the public
about the importance of vaccines is not enough.
We need new investments, innovative
and culturally competent interventions targeting local
and virtual communities.
Vaccinate With Confidence is CDC's strategic framework
for strengthening vaccine confidence
and preventing outbreaks of vaccine-preventable diseases.
The strategy has three pillars.
The first is to protect communities.
A measles outbreak should not be the signal that a community is
at risk for undervaccination.
We need to protect children by increasing vaccination coverage
in these communities before the outbreaks occur.
The second pillar is empowering families to be confident
in their decision to vaccinate
by strengthening the provider-parent conversation.
All parents want to do what's best for their child
and we know providers are providing strong
recommendations, but that's not enough with this environment
of misinformation and all of the various sources of information
that parents are getting.
We know that it can be challenging to address all
of a parent's questions when a baby is due for vaccines.
Finally, we need to stop the myths.
We need to build a network of local and trusted,
trusted messengers to amplify accurate information
about vaccines to parents who are grappling
with understanding misinformation and myths.
So, how are we going to do all of this?
I'm actually going to slit, skip the next couple of slides
and get to my final messages so that we have a couple of minutes
to answer questions from all of you.
So here's what CDC is doing.
Over the next year, we're leveraging diverse data sources
and finding protecting communities at risk losing,
using local data such as IISs.
We're hoping to expand resources for working with communities
and support our healthcare partners to build
and foster a culture of immunization
and throughout the entire healthcare practice.
We want to provide technical assistance
to our immunization partners and engage new partners
who can reach parents and soon-to-be parents
in many different settings.
But we mostly want to continue to rely
on our public health partners working in state
and local health departments and organizations who are
on the front lines of this efforts every day.
Partnerships are key to increasing vaccine confidence.
We need continued investments, new ideas and approaches,
and we need to build an evidence base
for successful interventions.
As we ramp up this effort, what can you do to help?
One of my favorite jobs outside
of work is being a trusted information source for vaccines
for parents in my children's school and community.
The next time a patient, parent, friend, co-worker
or relative shares misinformation about vaccines,
I challenge you to stop, listen, and share information
to help them understand
that vaccines are safe and save lives.
As was made clear by these recent measles outbreaks
in New York State and New York City,
the most effective vaccines don't work at all
when they're sitting on a shelf.
Thank you for your attention and I want
to leave these last few minutes for, to answer your questions.
So I'll turn it over to you, Susan.
[ Applause ]
>> Thanks.
I want to remind our online viewers you can send your
questions to grandrounds@cdc.gov.
One question from Trisha.
Is there any risk of viral spread
from a fresh freshly vaccinated child to a parent
with primary immunodeficiency?
>> I can take that question.
So, there have been no cases of vaccine transmission
which is genotype A. Certainly
with immunocompromised hosts we always worry about that
because their immune system's not able
to fully contain the virus but there's been no evidence
or case reports of that.
>> We'll go ahead with another question.
Do, specific to a bar chart that was showing
that most measles cases come,
where among unvaccinated though some were vaccinated,
do vaccinated groups discussed include only persons
with up-to-date vaccinations or do people
with out-of-date vaccinations contribute
to that vaccinated group?
>> I will try to answer that question.
So when we classify, when our team classifies measles cases
as unvaccinated or vaccinated or unknown vaccination status,
its if you're up-to-date.
So measles being out of date, we don't have recommendations.
For example, like an adult dose of MMR.
Most adults just need one dose of MMR
or if they have other evidence of immunity.
>> Are there any questions from the audience?
Are there more questions online?
>> Sure, from Lisa.
This is via Facebook.
Hundreds of thousands
of students' health forms were examined for vaccinations.
Does that research activity violate HIPAA?
>> I don't view it as a violation
of HIPAA, first of all.
That's usually, it is important to look at the,
the records of those who are in the, in the schools
and usually the schools themselves were the ones
who were doing the evaluation of that.
>> I want to remind we had several questions
about coronavirus online and I would like to refer people
to our website for the most current information
which is cdc.gov slash coronavirus.
That's, you will find the most current information
available there.
>> Can we take one question from the audience before we close?
>> Yes.
>> I'll talk loud.
I had a question about the health system, I mean the
school system that, didn't have the proper technology.
Was there any like consequences for those schools or you guys
working with States to try to help them get up to par?
Was there any, anything to help that gap?
>> So yes, we are working with the schools to have them be able
to access technology that will make tracking immunizations
in the future much easier and more efficient.
>> And that tracker that I mentioned
in that slide would be one of the ways to help on that.
>> We want to thank our speakers so much
for a wonderful presentation offering today.
Let's give them a round of applause.
You learn so much.
And on behalf of the Office of Science and CDC,
I want to thank you for attending both in-person
and online and look forward to upcoming presentations in March,
April, and May with equally exciting topics.
So, this brings our session to a close.
Thank you so much.