Thank you for coming. The executive director of the bigcity Health Coalition want to say a special thank you to Representative Office for securing the space for us and while i know the congresswoman could not be here today i want to thank her for being a true champion for Public Health also the American Academy of pediatrics for being such a great partner as we planned this event. The Health Coalition started in 2002 is a forum for leaders of the largest metropolitan Health Department for strategies to jointly address issues to promote and protect the health and safety of the residents we have those jurisdictions whose Health Department serves nearly 62 million or one out of five americans well have two jurisdictions here today. You have bios in front of you i will not take up time i want to introduce the panel that i will turn it over to them. The order in which they are presenting doctor kraft is the immediate precedent of aat the commissioner of health in new york city the chief medical officer l. A. County Public Health both came from california so we have a special thank you to them to travel so far. Thank you for finding the time to join us today to share your perspective and now i will turn it over. From the American Academy of pediatrics will do a Measles Outbreak one oh one and why immunization is so important. The American Academy of pediatrics is a nonprofit professional organization with more than 67000 pediatricians we are dedicated to the health and safety and wellbeing of children and adolescents and young adults we publish recommended elimination schedules with the cdc American Academy physicians and gynecologist so lets go back to the history of measles in 1953 it was licensed in a 1968 the vaccine began to be distributed. And then was eliminated so there was no continuous disease transmission for more than 12 months that was due to a highly effective Vaccination Program and better measles control in the United States and the americas. However we have seen measles come back. We had 93 cases in 2010 and now we have 182,019 so it was gone in 2000 and now back with a vengeance. You look at the states reporting in 2019 all of the red states and we see this all over the country it is the acute viral disease by a cough and runny nose red eyes and sore throat and a rash that begins in the face and spread throughout the body common complications include pneumonia ear infections, croup and diarrhea and about one out of four will be hospitalized im old enough to remember to have measles i had them at three years old and so did my two yearold sister, one yearold brother and my infant sister. I remember this as though one time the doctor actually came to our house to cs. I remember a couple of other things also. That my eyes were so sore i can hardly open them my mother kept the shades down and the lights on low because there was so much i paid one i pain. I remember that specifically and also the prayers for my two yearold sister because she got pneumonia and we almost lost her. She was in the hospital and fortunately we covered. We looked at something this very deadly hitting these for little kids at the same time this is very commonplace before vaccination. What we know 130 of those who got them in one night 2019 were hospitalized and 65 had complications like pneumonia like my little sister and encephalitis which is brain swelling acute encephalitis results in permanent brain damage and one out of every 1000 cases and in that era death is respiratory or neurological complications is one or three out of every 1000 cases reported measles is back just as deadly as it was back when i had it. It is extremely contagious so if one person has measles nine out of ten they are in contact with will also get them if they are not protected. The virus is spread through the air when the infected person coughs or sneezes and somebody nearby inhales those infected droplets. That the virus is hearty and it hangs in the air and could be spread for several hours after the infected person has left the room and can be transmitted directly from person to person as well. Was a child gets the measles the first symptoms will not be there between eight and 12 days that they are contagious one or two days before they start with symptoms so you dont even know that they are contagious and then when they finally emerge before the rash breaks out then this will continue for days after the rash appears. Reno where people get them from weather hasnt been the same robust Immunization Program it is commonplace so that is a plane right away for anybody who is not vaccinated if they travel to other places in the world they can come back with measles. Coming back from the ukraine and the philippines and those who got that vaccine one you got to measles were not vaccinated. Is not the most vulnerable but the children less than five years of age in adults aged more than 20 years of pregnant women and women people with compromised immune systems it cannot get the vaccine because of hiv your cancer or other diseases where the immune system is not up to snuff. We recommend the vaccine be given between 12 and 15 months of age and again at four and five years of age. What we know is if you get those two immunizations theres a 97 percent chance you will develop antibodies as a protection i have changed what i had to do a practice because we know during an outbreak mmr should be offered to all people exposed to the outbreak and also we are starting to ask parents of babies between six and 12 months we are starting to immunize our kids if they will be at risk because of the highly contagious nature of measles. There is a concept called herd immunity or Community Immunity because we are not cattle but if we immunize and protect people around us that we will protect that one vulnerable individual who cannot be vaccinated for any reason. Individuals who work in communities with high vaccination rates are protected and those people who cannot get vaccines are protected. Its important for a very Young Children for those that are emu no compromised. If you have healthy non vaccinated individuals in a few vaccinated individuals they can get the disease as they are vaccinated that one child that one compromise person who cannot get the vaccine will still be protected because most of the people around them have gotten that immunization. So federal legislation of the vaccines act was introduced by representative doctor schreier who is a pediatrician and doctor burgess who is an obstetrician. This bill is important because it authorizes the campaign on the importance of vaccines. Attitudes towards vaccines and to develop strategies to help us protect more people and vaccinate more kids. So, the reminder before the measles Vaccination Program started in 1963, an estimated three to 4 Million People got measles in the United States. About 50,000 cases were reported to the cdc. Of these people, four to 500 a year died. 48,000, including my baby sister were hospitalized. And since bed, widespread use of the vaccine letter to a greater than 99 reduction in the cases compared with the pre vaccine era. And we dont want to go back to this era. We still need to educate families and communities on the importance of the vaccines. Our enemy is the disease. The way we combat this enemy is by education and vaccination. Thank you. [applause] so now youve learned a little bit about measles. Im going to quickly set the scene about the role of the Health Department and the different branches of government. I should have also said we are going to hold questions until the end but we will have time at the end. Local Health Departments on the fronwere onthe front lines prevd responding to outbreaks. They keep communities healthy and safe and get the communities healthier and safer support example in the outbreak they investigate every case in you will hear more about this and what happened on the ground in new york city and la county. They have Legal Authority for the orders done in both cases. They look to ensure the community is sufficiently vaccinated and they provide the vaccine when necessary. And they also provide simple and accurate messaging on the vaccination and work with part is to do so which is an important part also that we will talk a little bit about. So, the role of the federal government. Local Health Departments and on the ground respond to many or most Public Health issues that are inherently local. The federal government still has a role to play and resources to bear when needed. They can expand the capacity of the locally and state departments for subject matter expertise when needed. They have the bully pulpit and we have the surgeo the surgeon e head of the cdc. Important people that can push out messages to the broader population thats not as localized. And also the federal government can provide reliable dedicated funding. Ive highlighted for funding streams, the Immunization Program, the epidemiology capacity that is a lot easier, the Public HealthEmergency PreparednessFunding Program come and the prevention and Public Health funds. And again, both doctors will talk to you about how they use the funding streams in responding to the epidemic of the outbreaks. So, this is a ten year funding history as the site says of the cdc Immunization Program. You can see in 2010 it was at 61, and today the projected number for 2020 from the cdc budget justification is by 33. So, we have come down over ten years, despite the fact that weve had many preventable outbreaks. Also important is that this program is not just include vaccine purchase and infrastructure support to distribute vaccines and communities, but also other activities to achieve National Immunization goals and keep the vaccination rate high to prevent death and disability from these diseases. It also supports what is known as a 317 Immunization Program as well as the infrastructure for the vaccine fo vaccines for chin program. On the graph, the red bar shows dollars from prevention and Public Health fund with cuts to overall appropriations to the Immunization Program. The funding is always on the chopping block and as a way to pay for other priorities. So, this is to illustrate how important it is for the ability of local and state Health Departments to do their job protecting the Public Health. As we are sitting here on capitol hill, its important to speak about what congress can do to move the needle. Its not just about funding and there are numbers introduced on both sides of the capitol with key components to help us move forward to not only try to stop that also address the next outbreak of these diseases. But the really important piece for me is that we need to support activities that focus on prevention and not just response. So, speaking about surveillance of these rates we dont have good numbers how many people were vaccinated. Many cities and localities do, some states do that varies across the country. We need more research on the hesitancy. We talked about the National Campaign to increase awareness with vaccines and combat the misinformation. And then this new piece and i dont know when we stop saying d saying social media is new we need to set the impact of social media in accelerating the vaccines and things like that. Obviously, if any of the programs are implemented, bowers would be needed to support them so that they can be carried out. And now, i will turn over to the doctor to talk about the experience. Good morning, everyone. So, it is my pleasure to talk with you about the response to measles in new york city. Today, im going to cover the following, the epidemiology of the outbreak in the final case count and the response being fought on two fronts. That of the Communicable Disease related specifically to measles and then on the second front, combating the misinformation. I will talk about the funds that were used during the outbreak, Lessons Learned and then future challenges. So, this is to pay a 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 the lower circle and bird park. These are both highly populated communities. In new york city, and this is kind of as i like to say a geeky slide helps illustrate a number of things. The outbreak began in the beginning of october, 2018. And then on this side of the slide, you will see that it extended until september 23, and even though in each of the bars it represents new cases that were tallied for particular week and generally we dont declare an outbreak over until thereve been two incubation periods, so thats what this shows. The other thing it shows the majority of cases that were seen her in williamsburg. It also helps me to illustrate that in addressing the Measles Outbreak in new york city, we took a measured approach that was intended to meet the epidemiology that we are seeing at a particular time. We didnt jump to the most aggressive measures that we could have taken early on. So this first one really entails addressing issues of transmission within schools. The second phase addresses transmission within the communities. And then the third phase is when we issued our Public Health emergency order, and we havent taken that kind of drastic measure in years in new york city. The last time that was done was during the h. One and one outbreak in 2009. Thankfully, during that time we didnt need to enforce any of the summons and violation measures that we had to do here in this particular outbreak. So the emergency order is essentially calls for immediate vaccination of individuals living in the zip codes that were most affected by the measles and those that were found not to be at risk with financial penalties. What we then saw overall is that our final case count, the final number of individuals affected were 654. You will see from the slider that the majority of them were children from one to four years of age, and that of this group, 49 ended up in the hospital, which i was listening to the numbers, it is about one third of the individuals affected in the United States who were hospitalized 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 require oxygen therapy. So, as she was speaking, remember i am a pediatrician by training as well and in my training ive been in the business about 30 years and ive never seen a case of measles. So, this is the situation for many of the providers. Its something that we thought we had seen the last of, but clearly we have not. So, in the preventable cases you see, the majority of them were children 12 months and older, meaning that this is the age at which most children should be immunized and these children had not been. So that is the bulk of the preventable cases that we saw in the affected outbreak. And so im going to go back. What we did here is we have a very aggressive response collaborating with our Healthcare Delivery partners as well as our Community Partners, and we also lowered the age at which to immunize children so we recommended six months to 11 months which generally we reserve children traveling to these areas but with the situation we wanted to do it for the domestically transmitted pieces. So, the provider outreach you will see was very extensive and included both Technical Assistance and primarily to ensure Healthcare Delivery sites were not ongoing transition of altransmissionall the way throue that there was enough nmr on hand and distributing the educational material in english and yiddish. The bulk of individuals in this particular outbreak that were affected were members of the ultra Orthodox Community in new york city in those neighborhoods in new york city. And so, this is a slide that shows what every Public Health practitioner wants to see. And that is a measures that we put in place had the desired outcome and the measures we put in place for intended to increase the number of individuals that were vaccinated. So, this is a slide that looks at the Previous Year and what we see is typically we have a backtoschool rush. The dark line is the 2018, 2019 period and the dotted line is the year before. Whawhat baseball is at the beginning of the outbreak, when we declared it, we saw a significant spike in the number of individuals who received the mmr vaccine. And then over time, it dropped. We started issuing exclusion letters and walking more aggressively. We saw the spike their independent we have a low and when we issued a Public Health emergency, we saw another spike in the number of individuals who were immunized. What you see here is august and september the number of individuals in this school year getting immunized in the backtoschool rush is lower than the previous and we