So, good morning, everybody, thank you for coming. Im the executive director of the big Cities Health coalition. I want to start by saying a special thank you to representative roy allards office for securing this for us. While i know that the congresswoman couldnt be here today. I want to thank you her for being a true champion for Public Health and thank the American Academy of pediatrics for being such a great partner to us as we started this event, planned this event. So, the big Cities Health coalition was founded in 2002 and is a forum for leaders of americas largest metropolitan Health Departments who have changed strategies and jointly address issues to promote and protect the health and safety of their residents. We have nearly 30 we have 30 members whose Health Department serve 62 million or one in five americans and we luckily have two of our member jurisdictions here today. So you all have bios in front of you so im not going to take up too much time, but i want to introduce the panel and then ill turn it over to them. In the order in which theyll be presenting, dr. Colleen kraft, the immediate past president of. Aap. The doctor barbeau, commissioner of health. And the chief medical officer for the l. A. Department of Public Health. Two doctors came from los angeles and thank them for travelling so far. Thank you for finding time to join us today and share your perspective. And i will now turn it over to dr. Kraft. Okay. Thank you, im dr. Colleen kraft, the immediate past president of the american pediatrics. Were going to Measles Outbreak 101, when it happened, and why immunizations for measles and other illnesses is important. The American Academy of pediatrics is a nonprofit norjs with more than 67,000 peed i gos trigses, including primary care, and subspecialists and were dedicated to the health and safety and wellbeing of all children, adolescents and young adults. We publish recommended childhood and adolescent immunization schedules along with acip, with the c. D. C. , with the American Academy of Family Physicians and the American College of obstetricians and gynecologists. Lets go back to the history of measles in the United States. In 1963 the measles vaccine was licensed and in 1968 the measles vaccine began to be distributed. And measles was gone, was declared eliminated from the United States in 2000. So there was no continuous disease transmission for more than 12 months. And that was due to a highly effective Vaccination Program and better measles control in the United States, and in the americas. However, we have seen measles come back due to people not vaccinating their children and not getting vaccinated. So in 2010 we saw 93 cases. And in 2019 we have a whopping 1,241 cases of measles. So this disease that was gone in 2000 is back and its back with a vengeance. If you look at the states who are reporting cases of measles in 2019, all of those red states are the red states where measles has come about. And we see this all over the country. So what is measles . Its an acute viral disease thats characterized by fever and cough and a rainy nose, and red eyes and store throat and then this redbrownish blotchy rash that begins on the face and spreads throughout the body. Common complications include pneumonia, ear infections, croup and diarrhea. One in four people who contract measles can be hospitalized. Im old enough to remember having measles. I had measles when i was three years old, and so did my twoyearold sister, my oneyearold brother, and the infant. And the doctor came to the house to see us, and i remember my eyes were so sore, i could hardly open them and my mother kept the shades down and the lights down low because there was so much eye pain with measles. I remember that distinctly. And the other thing i remember were the prayers that we said for my twoyearold sister because she got pneumonia. And we almost lost her. She was in the hospital and fortunately recovered and we looked at this disease as something really deadly that hit these four little kids at the same time, and this is very commonplace in the United States before vaccination. What we know is that 130 of the people who got measles this year in 2019 were hospitalized. And 65 of them had complications, including pneumonia, just like my little sister. And encephalitis which is brain swelling. Acute encephalitis often results in permanent brain damage can occur if one out of one thousand cases. And the one to three in over one thousand cases in the United States. Measles is back and its just as deadly as it was back when i had it. Its extremely contagious, so if one person has measles, nine out of ten of the people theyre in contact with will also get measles if theyre not protected. The virus is spread easily through the air when an infected person coughs or sneezes and somebody nearby inhales those infected droplets and the important thing to know is that the measles virus is pretty hearty. It hangs in the air and can be spread for several hours after that infected person has left the room. And it could be transmitted directly from person to person as well. Once a child gets the measles, exposed and infected, the first symptoms wont be there for 8 to 12 days, but those infectious children are contagious one to two days before they start with symptoms so you dont know theyre contagious with it. And when symptoms finally emerge, three to five days theyre contagious before the rash breaks out and this contagious period continues for four days after the rash appears. We know where people get measles from, and other places in the world where there has not been the same robust immune nation program, measles is commonplace and so measles becomes right away for any of our children who are not vaccinated. If they travel to other places in the world they can come back with measles and we know that people have come back from the ukraine, from israel and the philippines and majority of people who got the measles in 2019 were unvaccinated. Who is at most risk for measles . Its our most vulnerable. Its our children, less than five years of age. Its adults age more than 20 years. Its pregnant women. And its people with a compromised immune systems who cant get the vaccine who may have cancer or hiv or other diseases where their immune system is not up to snuff. We recommend the measles vaccine be given first between 12 and 15 months of age and again at four to five years of age. And what we know is that if you get those two immunizations, theres a 97 chance that youll develop an antibody and protection against the measles. Ive changed what ive had to do in practice because we know that during an outbreak the mmr vaccine should be offered to all people exposed to the outbreak setting or anybody who doesnt have that measles immunity and we also are starting now to ask our babies and parents of babies, six to 12 months if theyre going to one of these places where measles is endemic and starting to immunize our kids under 12 months of old if theyre going to be at risk because of the highly contagious nature of measles. Theres a concept called herd immunity or some people call it Community Immunity since we are not cattle. This is the idea that if we immunize and protect people around us then were going to protect that one vulnerable individual who cant be vaccinated for any reason. So individuals who live in communities with high vaccination rates are effectively protected and those people who cannot get vaccine are also protected. So, its most important for very Young Children in those who are immuno compromised. If youve got healthy nonvaccinated individuals and a few who are vaccinated, the most people are vaccinated that one child, that one immuno compromised person who cant get the vaccine is still going to be protected because most of the people around them have gotten the immunization and they are protected. So federal legislation in the vaccines act was introduced by representative dr. Kim shr. Guest er who is a and an obstetrician. This is an Awareness Campaign on the importance of vaccine very much like the Truth Campaign for smoking. It talks about our enemy as the disease and then vaccinations are a way to pro rent that enemy from affecting all of us, especially our most vulnerable. The bill allows data to be collected to identify communities with low vaccination utilization or where vaccine mt information may be targeted. It authorizes Research Grants to better understand Vaccine Hesitancy, why is it that people dont want to vaccine. Developing those strategies to help protect more people and vaccinate more kids. So the reminder, before that measles Vaccination Program started in 1963, an estimated three to four Million People got measles in the United States. About 50,000 cases were reported to the c. D. C. But of these people, four to 500 a year died. 48,000, including my baby sister, were hospitalized. And a thousand developed that encephalitis or brain swelling from measles. Since then, widespread use of the measles vaccine led to a greater than 99 reduction in measles cases compared with the pre vaccine era and we dont want to go back to the pre vaccine era. We still need to educate families and communities on the importance of vaccines. Our enemy is the disease. The way we combat this enemy is by education and vaccination. Thank you. [applaus [applause] thank you so much. So now youve learned a little about measles. Im going to quickly set the scene about the role of Health Departments and the role of the different branches of government. I should have also said that were going to hold questions until the end, but we will have time at the end for questions. So, both the Health Department are on the front lines of responding and preventing outbreaks. They keep communities healthy and safe or help get your communities healthier and safer. In an outbreak they investigate every case. Your going to hear more about this what happened on the ground in new york city and l. A. County and they also have Legal Authority to quarantine emergency orders done in both cases. They look that theyre efficiently vaccinated and provide when necessary and they also provide clear, simple accurate messaging on vaccination and work with their partners to do so. Which is an important point, also. I think that the dr. Barbeau will talk about. The role of the federal government. So, local Health Departments are on the ground. Response and many or most Public Health issues are inherently local, but the federal government still has an Important Role to play. And they have resources to bear when needed. For example, they can extend the capacity of local Health Departments. Share expertise when needed. They have the bully pulpit. The head of the c. D. C. Really important people who can push out messages to a broader population thats not as localized. And then also, the federal government can provide reliable dedicated funding. So ive highlighted four funding streams here. The Immunization Program, the epidemiology and Laboratory Capacity or elc, which is a lot easier to say. The Public HealthEmergency Preparedness funding program. And then the prevention and Public Health fund. And again, both dr. Barbeau and the doctor will talk to you about how theyve used the funding streams in talking about the epidemics or the outbreaks, rather. And this is a ten year history of c. D. C. s Immunization Program. You can see in 2010, it was at 561 and today, the projected number for 2020 from the c. D. C. Budget justification is 533. So weve come down over ten years despite the fact that weve had many preventible outbreaks. And also important is that this program does not just include vaccine purchase or infrastructure support to distribute vaccines in communities, but other activities to achieve National Immunization goals and keep those high to prevent death and disability from the preventible diseases. The funding supports whats known as the 317 Immunization Program as well as the vaccines for children program. Importantly on this graph is that the red bars shows prevention on Public Health funds and this fund is always on the chopping block on as a way to pay for other priorities. So this is just to illustrate how important it is, the fund is, for the ability of local and state Health Departments to do their job, protecting the Public Health. So as were sitting here on capitol hill, its important to think about what congress could do to help move the needle. Its not just about funding and there are a number of bills introduced on both sides of the capital that have key components to not only try to stop, but to address the next outbreak of vaccine preventible diseases and dr. Kraft touched on this. The really important piece for me is that we need to support activities that focus on prevention and not just response. So thinking about surveillance of vaccine rates. We dont have good numbers about how many people are vaccinated. And many cities do and many localities do, some states do, but it varies across the country. We need more research on Vaccine Hesitancy. Dr. Kraft talked about a National Campaign to increase awareness of benefits of vaccine and combat misinformation and then this new piece and i dont know when we stopped saying social media is new. Ill go with it new today. We need to assess the impact of social media in accelerating or mitigating Public Health crisis, antivaccines and things like that. If any of the programs are implemented doctors would be needed to support them so they can be carried out. Now, ill turn it over to dr. Barbeau to talk about new york city. Good morning, everyone. So its my pleasure to talk to you about the response to measles in new york city. Today im going to cover the following, im going to talk about the epidemiology of the outbreak and our final case count. Im going to talk about the response being fought on two fronts, that of a Communicable Disease related specifically to measles and then on the second front, combatting measles misinformation. Ill talk about the fund that were used during the outbreak, Lessons Learned and then future challenges. So this is to kind of situate us in new york city. These are the two principal communities that were affected by the Measles Outbreak. Here in the top circle, williamsburg and here in the lower circle, borough park and these are both highly populated communities. In new york city, this is kind of, as i like to say a geeky slide, but it helps to illustrate a number of things. One is that the outbreak began in the beginning of october, 2018, and that on this side of the slide youll see that it extended until september 3rd. And even though in each of these bars represents new cases that were tallied for a particular week. Generally, we dont declare an outbreak over until there have been two incubation periods. Thats what this slide shows. The other thing it shows the majority of cases that were seen were in williamsburg. It also helps me to illustrate that in addressing the Measles Outbreak in new york city, we took a measured approach that was intended to meet the epidemiology that were seeing at the particular time. We didnt jump to the most aggressive measures that we could have taken early on. So, this first phase really entailed addressing issues of transmission within schools. The second phase addressed transmission within communities, and then this third phase was when thank you, was when we issued our Public Health emergency order and we hadnt taken that kind of drastic measure in years in new york city. The last time that it was done was during the h1n1 outbreak in 2009. Thankfully during that time we didnt need to enforce the summonses and violations measures we had to do in this particular outbreak. It called for immediate vaccination of People Living in the four zip codes most affected by the measles and individuals found not to be immunized were found to be at risk for financial penalties. What we then saw overall is that our final case count, the final number of individuals that were affected were 654. Youll see from this slide that the majority of them were children one to four years of age, and that of this group, 49 ended up in the hospital, which i was listening to dr. Krafts numbers which is about a third of the individuals affected in the United States, who were hospitalized, were in new york city. Additionally, 19 of these individuals required being admitted into the intensive care unit. Many of them were in there because of severe pneumonia, many required oxygen therapy. So, and as dr. Kraft was speaking, im a pediatrician by training as well. In my training ive been in this business for about 30 years, ive never seen a case of meas