Careening in this room for us and i know that the congresswoman couldnt be here today, i want to thank her for being a true champion for Public Health. Also want to thank the American Academy of pediatrics for being such a great partner to us as we start this event. So, Big Cities Health Coalition was founded i was a former leaders for Health Departments to Exchange Strategies and address issues to promote and protect the health and safety of the residents. There we have 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 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 becaus 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 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 childt are emu no compromised. If you have healthy non vaccinated individuals in a 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. And since bed, widespread use of the vaccine letter to a 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 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 diseases. But the really important piece for me is that we need to support activities that focus on prevention and not just respon 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 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 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 majoritrve children tro 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 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 until get immunized and that is a good thing for us. So what this ended up resulting in is over 188,000 doses of measles given during the 2018 20182019 outbreak, which is over 23,000 more than the Previous Year in those particular neighborhoods. So, it was a massive effort was led by our department in collaboration with the Healthcare Delivery system that couldnt have happened without the engagement of our Community Part nurse. So, what the outbreak highlighted for us is in certain situations, traditional partners were not enough. When we are up against this information, up against issues that we have never encountered before, it was critical to engage the leaders from within the Orthodox Community. So, this community hav has been targeted by the antivaccination messages, and they were targeted through rowboat calls, direct Mailing House while school the importance here is talking about the consequences the vaccine has and the degree to which misinformation here can take hold in certain communities. And its not just the phenomenon that we are seeing here in the United States, the outbreak that began in new york city actually began in israel, the year before and got a big actually began in the ukraine before that. So, this is a worldwide phenomenon, not just in the United States. And the Common Thread is the propagation of fear and lies, so it new york city, there was a pamphlet that was distributed that was filled with really inflammatory and conspiracy based theories about the dangers of vaccines and how it was much safer to get measles than to have to vaccination. Th Science Behind the safety and efficacy of vaccines. As a part of the effort of combating the measles of the second front of this information, we put out a lot of educational materials and emphasized the importance of spreading the truth, not measles. The importance of getting vaccinated, having materials in the edition as well as english. We also have materials in spanish and chinese. And then i think i am particularly this particular graphic i think does a very good job at conveying the herd immunity, and that is with one infected individuals, there are otherothers and the like that at able to get vaccinated that are at risk for illness. By the numbers at the end of the day there were 547 staff that were deployed for this and over 100,000 personnel are spent. 21,000 new yorkers were trucked down to a the exposure and you will see the both of the colors used to address this for city dollars. The next level is the state dollars. You will see this after we declared a Public Health emergency and the lower line, our federal dollars. And even though that is a much smaller curve, it is important because this is where we have the capacity to do our laboratory testing. This is where we have the capacity to do our disease surveillance. We wouldnt have been able to mount a robust aggressive response that we did were it not for these funds. I think the other important thing to note is that this line also includes Emergency International transmission, we now have measles reintroduced into the population and it is critical for us to a double our efforts to ensure families have appropriate and Accurate Information that we have individuals within a number of different communities and Healthcare Provider communities be it the religious communities armed with information they can share with their neighbors and be trusted messengers about the importance of and the safety of vaccinations and also the ongoing Public Health campaigns regarding the importance of the vaccinations clearly not just with measles old vaccinations. And then the importance of having more granular surveillance because in new york city, we have a 99 Immunization Coverage for children of school age. For this outbreak showed us is that there are pockets where there are high numbers of individuals that are susceptible to the virus and so having more resources to do the granular surveillance is the key for us. And then leveraging the Community Relationships develop new alliances, not just for this particular outbreak, but for Public Health emergencies moving forward. What we clearly have learned through this experience is that the partnerships that weve put in place will also help us with emergencye transm the country, and it really gives us the urgency to continue the efforts that we put in place. And so, as i mentioned the future challenges also include continued education to spread misinformation. This particular instance with the ultraOrthodox Community but in other parts of the country its been other communities that have been targeted by the misinformation. So i do not in any way, shape or form want to give the impression this has anything to do with religiousness. It has to do with the misinformation taking hold in not having to messengers to counter it. For the funding to sustain the educational efforts and response efforts. Thank you very much. [applause] from Los Angeles County i do want to thank you for helping set this up and christy and her team from the coalition to get this organized. Its a pleasure to be here. Weve not yet had to make the same Los Angeles County b a verg having 88 Incorporated Cities including los angeles, which is a little over 14. 4 billion other cities over 100,000. And in the location wit a locatn 200 languages spoken. You can imagine the Communicable Diseases and outbreaks can be a challenge to control when they occur. And we see measles as a serious threat to the residence, so we are addressing this as strongly as we can. As of today, our department has been successful at containing three Measles Outbreaks in the last five years. This has not been easy, and it has been very costly. The first is the wellpublicized disney land associatedisneylandk in which a single individual infected about 40 other persons late in december of 2014. This resulted eventually in about 148 cases, which occurred in many counties throughout the state of california. About a half dozen other states and also 50 people who lived in canada and mexico. Contacts we had to interview for the process. Fortunately, due to the herd immunity or community immunity, ended in early 2015. So, about two years after that outbreak almost to the day, we had another outbreak which was somewhat different. And i do want you to understand there are these different kind of outbreaks that can occur. So disneyland was a massive exposure that affected 4 40 peoe that were suddenly affected and traveled around the state in other parts of the country. Whereas this one is one individual, similar, from new york coming back into a group that was unvaccinated. So single, unvaccinated individual is a member of a largely unvaccinated group. Infection spread through several families come each with multiple unvaccinated children. Eventually causing the total of 18 cases in our county and six cases in other nearby jurisdictions. The social Group Despite a lot of communication outreach was largely unwilling to cooperate with our investigation and refused to accept any of our offers of vaccination. This light is a little bit detailed, but it gives an idea of the kind of information we are tracking on a daily regular basis. You do see how well our efforts are going. This is our final summary of this outbreak and it displays the amount of work that we performed to prevent further spread. Shown on the case timeline at the bottom, they were spread out again over for waves and similar to the disneyland outbreak, even though the number of cases in the county was lower, only