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Press Briefing Transcript

CDC Telebriefing on the National Immunization Survey, Vaccine for Children Program, and recent measles outbreaks in the U.S.

Thursday, September 12, 2013 Noon ET

OPERATOR: Welcome.  Your lines are in the listen or didn't mode.  This call is being recorded.  If you have any objections you may disconnect at this time.  I will now turn the call over to the speaker for today.  Sir, you may begin. 

DAVE DAIGLE: Thank you.  Thank you all for joining us today for this telebriefing both on the release of the 2012 National Immunization Survey details in today’s MMWR as well as the increases we are seeing in measles around the country.  Joining us today is Dr. Anne Schuchat. That is spelled S-C-H-U-C-H-A-T. She's the director of CDC's National Center for Immunization and Respiratory Diseases.  She’s going to provide a few opening remarks and then we will go to your questions.  During the question period we are going to be joined by Dr.  Jane Zucker, who is the assistant commissioner in the Bureau of Immunization at the New York City Department of Health. Dr. Zack Moore, medical epidemiologist from the North Carolina Department of Health.  And dr. Rye, immunization branch manager from the Texas Department of  Health Services. So with that we will begin with Dr.  Schuchat 's comments and then take your questions. Dr. Shuchat?

ANNE SCHUCHAT: Thanks so much, Dave.  Thank you, everyone, for joining us today.  What I’d like to do is share good news about our nation's childhood immunization coverage.  And highlight the role that the Vaccines for Children Program played in helping us reach and sustain high coverage levels.  We have come a long way in the twenty years since that program was first established.  There's still work to do, though.  So today I will also discuss measles across the United States.  Summarizing the cases and outbreaks we had so far this year.  The origins of the Vaccines for Children Program and analysis of today's high vaccine coverage and local hotspots tell a story of striking contrast.  Twenty years ago, the VFC program was developed to fix a national crisis of missed opportunities.  Today we have a strong public private partnership for immunizing children that reflects the success of the VFC program.  But today we also have local measles outbreaks representing a very different dynamic.  Instead of our system missing opportunities to vaccinate young children, in some communities people have been rejecting opportunities to be vaccinated. 

Let me start with our National Immunization Report Card— National Immunization Survey of Toddlers, age 19 to 35 months, or the NIS. According to the 2012 NIS, the vast majority of parents are vaccinating their children against potentially serious diseases.  A brief word about the survey, it’s a random digit dial survey.  It is -- there are -- provider verifications, we mail information to providers to double-check the information the parents tell us over the phone.  And this report that we are releasing today describes national, state, and selected local area coverage for immunizations in children who were born between January 2009 and May 2011.  Their immunizations received are -- part of what we are reporting.  The survey results to almost 17,000 children who had provider verified vaccination records.  About half of the subject we gathered from cell phone samples and about half from land line samples.  And this year's survey has a much larger cell phone sample that we think is a much more representative sample than what we’ve had in the past.  The 2012 NIS report shows most that children are complete on the recommended vaccinations.  The U.S. continues to have high rates of immunization coverage at the national level.  Vaccination coverage remains near or above 90 percent for measles, mumps and rubella vaccine or MMR.  For the polio series, for hepatitis B series, and for varicella or chicken pox vaccine.  The percentage of children who received no vaccinations remains low.  Only 0.8 percent or less than one percent of children in this survey had received no vaccines at all.  These are really good results, but there is opportunity for improvement.  Vaccination coverage varies by state.  Both for individual vaccines and for the series measure.  Now for that series measure, I want to give a special shout-out to Hawaii that has the highest series coverage at 80.2 percentage.  When we look across the state we also saw that 15 states had MMR coverage below 90 percent.  That's a warning sign that outbreaks may occur or that the state as a whole may be becoming vulnerable.  We also need to do a better job with vaccine doses that are needed in the second year of life.  The booster doses—of diphtheria, tetanus, and pertussis, Hib, and Pneumococcal Conjugate Vaccine —were all lower than we would like to see.  So getting vaccinates in that second year of life continues to be important for us to focus on. 

So, economic disparity and immunization is much narrower than what we used to see.  We do see lower coverage in children living in poverty for the vaccines that require a dose in the second year of life.  And for some of the vaccines that were more recently recommended.  This year's report card is very good and the high coverage we see explains why most vaccine-preventable diseases are at record low levels.  Now, it is always nice to share good news regarding rates among our infants and toddlers around the country.  But for me it is especially rewarding this year as we celebrate the 20th anniversary of passage of the legislation that created the Vaccines for Children Program or VFC.  VFC provides vaccines to children whose parents or guardians who may not be able to afford them.  And it helps protect millions of children from life-threatening vaccine preventable diseases.  It was created in response to a terrible resurgence of measles that our country experienced during 1989 to 1991.  During those years, those three years, about 55,000 cases of measles were reported in the United States.  And 123 people died from measles.  Hardest hit were unvaccinated pre-school age children, many from low income inner city families.  Many investigations were done to understand the measles resurgence and one key finding was that children were in the doctor's offices but were not being vaccinated because they didn't have insurance and their doctors were referring them to the health department clinics to get their shots.  As a country, as a health care system, we were missing opportunities to vaccinate these children in their medical homes.  We don't even know how low immunization coverage was at the time that the measles – the national measles crisis started.  The survey we had used to track immunizations had actually been canceled after 1985 due to budget cuts.  But although kids were getting caught up with measles vaccinations at kindergarten before they entered school we realized that many toddlers and pre-school age children had not gotten vaccinated on time.  And measles virus finds unimmunized people. So this national crisis of measles was because we were missing pre-school aged children with vaccines.  In 1993, the VFC Program legislation passed and part of the program was the requirement that we monitor immunization coverage annually.  The National Immunization Survey was born and the results we’re reporting today are also result of the legislation.  I want to mention we have a VFC digital press kit available and online you can see a coverage graph that looks at the really low coverage we had in the 80’s, the gap in coverage when we stopped doing surveys and then what has happened since. 

So, next I want to briefly discuss the national measles situation so far this year.  It is a far cry from that crisis that we had 24 years ago.  But with measles things can change very quickly.  And we need to stay ahead of this virus which means we need to make sure that immunization coverage is high everywhere.  This year, the U.S. is experiencing a higher than usual number of measles cases.  There are three outbreaks that account for most of this year's measles cases in New York City, North Carolina, and Texas.  From January 1st to August 24th, 159 measles cases have been reported across the United States.  That's the second largest number of measles cases we have had in this country since measles was eliminated in 2000.  During this period, 16 states reported measles cases and the age of cases ranged widely from birth to 61 years.  Thirty-seven percent of the cases were children under  five.  And 18 or 11 percent of all cases were in babies under 12 months who are too young to be routinely vaccinated.  Seventeen or 11 percent of the cases required hospitalization. Four of the patients had pneumonia.  Fortunately none of the measles cases here in the U.S. this year died.  Most of this year’s cases were unvaccinated. One hundred and thirty-one or 82 percent.  Four had unknown vaccinations status, 16 cases or nine percent. Among the 140 U.S. residents, 117 were unvaccinated.  I want to tell you in particulars about why they were unvaccinated because it’s so different than what we were seeing in back in 1989 to 1991.  Seventy-nine percent of the U.S. residents cases that were unvaccinated had philosophical objections to the vaccine. A smaller numbers, 15 cases or 13 percent, were babies under 12 months that cannot directly be vaccinated but rely on those around them being vaccinated.  Let me say a few words about the outbreaks.  New York City reported 58 cases, making this the largest outbreak reported in the United States since 1996.  None of the patients in that outbreak had documentation of measles vaccination.  North Carolina reported the second largest outbreaks so far with 23 cases.  Cases mainly occurred among people who were unvaccinated due to philosophical objection.  And in the current outbreak in Texas, 20—actually 21 cases, more since we’ve made the report in the MMWR, have -- been reported.  The numbers may continue to change as this outbreak may be ongoing.  Seventeen of those cases in Texas were unvaccinated.  As these outbreaks are showing, clusters of people with like-minded beliefs leading them to forego vaccines can be susceptible to outbreaks when measles outbreaks are imported from elsewhere.  Measles, as we know, is highly contagious and can lead to serious complications and even death. We need very high rates of immunization to protect the most vulnerable –children too young to be vaccinated and those who can't be vaccinated due to health conditions.

Importation of measles in the U.S. continues to occur and it poses a threat to our country.  It poses a particular threat to people who are not vaccinated.  All of the measles cases reported in the U.S. in 2013 were associated with importations from other countries.  There were 42 actual importations from 18 other countries.  You can think of an import associated case as being linked back to a traveler who brought the disease into the U.S. from another country.  Half of the imported measles cases we had in the U.S.  originated from Europe.  Not a place that many people think of when they try to update their vaccine records before travel.  Measles is still common in many parts of the world.  And, unfortunately, about 160,000 people around the world die from the disease each year.  Rapid public health response to measles is critical.  Given how very infectious measles is and the fact we still have pockets of unvaccinated people.  We have to rapidly investigate and respond to measles cases.  But thanks to the high vaccination rates and rapid public health response the outbreak in 2013 has been contained and it is – that is at the cost of tremendous effort on the part of public health workers who respond to these outbreaks when they occur.  Frontline public health workers around the country investigate every single case of measles to keep this virus from retaking hold of our communities.  These days many parents and even pediatricians don't remember when a time when diseases like measles were common.  They may never have seen the devastating effects that vaccine-preventable diseases can have on a family or community.  But please remember that these diseases are still out there.  They are literally a plane ride away.  And every day about 11,000 babies are born in the United States completely vulnerable to all of these diseases.  Today's great report card is the result of very hard work by a parent, by pediatric caregivers, and by public health workers to make sure that children are getting their recommended immunizations at the recommended times.  It’s also—today’s very good report card is also very much the result of efforts by policymakers who 20 years ago passed legislation to assure that every child in America, regardless of insurance status, had access to lifesaving vaccines.  So we’ll be happy to take questions now. 

DAVE DAIGLE: Thank you, Dr. Schuchat, and Calvin we are ready for the first question. 

OPERATOR: Thank you. Our first question comes from Mike Stobbe with the Associated Press, your line is open. 

MIKE STOBBE: Hi. Thank you for taking my question. I just wanted to -- doctor, you said 159 through August 24.  Is there a more updated figure and could you comment on, you know, what you think the numbers will be for -- for the whole year given the current pace?  I had a second question, too, about why we seem to be high this year but there are only 55 last year, you know, the year of the London Olympics. 

ANNE SCHUCHAT: Right. I think the 159 is the best number to use through August 24. We update those numbers every week in the MMWR. But, a key thing to say is that you can go from the average of 60 cases that we have every year to a very high number, very -- very quickly.  In France a couple of years ago, they had a large outbreak.  After years where they had 40 to 50 cases a year, their outbreaks eventually reached 20,000 cases. So, we can see wide widespread of the disease if there are enough unvaccinated and people and if we don't respond quickly enough to importation. So, the large number this year is because when we have had imported cases, some of the communities it’s reached has had larger numbers of unimmunized people. So, relatively large numbers with the 159 cases so far this year, or the 222 we had a couple of years ago. The frontline public health workers jump on these cases and contact people and make sure we vaccinate around the cases there are unimmunized people. But if we have travelers coming back to a community with lots of unimmunized we can have a very big outbreak. And if we don't stop the spread, we can have several generations of transmission. You had a follow up question? 

MIKE STOBBE: Why do you think, you may have partly answered this, but why didn't we have more last year? The year of an international Olympics when we had, presumably, a lot of people going to Europe and coming back. 

ANNE SCHUCHAT: Well, we have lots of international events every year. I can say that we did quite a bit of alert around the Olympics in London with many messages to travelers to remind them that measles was circulating in that country. But we have sporting events every year, we have large population gatherings, and so we know that every day people are traveling to the United States from countries that have measles circulating. We’re really dependent on high immunization coverage everywhere. So I think that is a critical factor with measles.  The virus is potentially coming in every day to every community. If you and your kids aren’t vaccinated it can spread in your own backyard. 

DAVE DAIGLE: Thanks, Mike. Next question, please, Calvin.   

OPERATOR: Thank you. That's a reminder, if you would like to ask a question please press star one your telephone keypad. The next question comes from Jonathan Serrie with Fox News, you line is open.  

JONATHAN SERRIE: Thank you. Hi, Dr. Schuchat. You had mentioned that people who don't get vaccinated for philosophical reasons tend to cluster together.  Could you describe what the typical cluster would be?  Would it be a group of multigenerational families living together? Would it be at the neighborhood level? Would it be at the regional level? 

ANNE SCHUCHAT:  Thanks for that question. We’ve seen many patterns. We’ve seen extended families at gatherings like weddings where many cousins will gather. We’ve seen religious organizations, we’ve seen schools.  You may recall 2008 where we were shocked as to high numbers of unimmunized kids in schools in some schools in San Diego. So it can be a number of circumstances. In the modern era, it may not be the geographic neighborhood but more the social neighborhood that you circulate in.  But a thing to remember about measles is you don't have to be closely connected to somebody to get measles from them. You can bring measles virus into an arena and anybody who’s not vaccinated in that arena who’s never had measles is going to get that virus.  It is very, very transmissible and can affect virtually anybody who is susceptible who’s in the vicinity.  We know that during the measles resurgence in 1989 to 1991, there was a problem in doctors' offices because the measles virus can hang out in the air. If you are in the same waiting room as someone with measles you will get measles if you never had it. But if you come into that waiting room within four hours of the person who’s infectious with measles you can also get the virus because it can be there after the person has left. So this is an extraordinarily contagious virus.  And the strong -- the incredibly low numbers of measles that we have relative to the pre-vaccine era are a testament to that extremely strong system we have and high coverage in those areas. 

DAVE DAIGLE: Thank you, Jonathan and next question, please, Calvin. 

OPERATOR: Next question comes from Erika Edwards with NBC News. Your line is open. 

ERIKA EDWARDS: Hi. Thank you.  I was wondering if you could repeat the number of reported cases from this year's measles outbreak in Texas.  I believe you said it was updated from the MMWR number that came out. 

ANNE SCHUCHAT: Yes. I believe there are 21 so far.  I'm not sure if – Saroj, would you like --

DAVE DAIGLE: Dr. Saroj Rai, would you like to jump in? 

SAROJ RAI: Yes.  Actually, the number -- that is correct. Twenty-one. 

ERIKA EDWARDS: Thank you. 

DAVE DAIGLE: Thank you, Erica. Next question, please. 

OPERATOR: Our next question comes from Neil Osterweil with Medscape Medical News. Your line is open. 

NEIL OSTERWEIL: Hi. This is -- a question about what the physicians in practice can do to help convince patients about getting vaccines. Are -- is there any research into what works, scare tactics, you know, coaxing, cajoling?  How do you get patients who are vaccine shunners, vaccine refuse, to take up vaccination? 

ANNE SCHUCHAT: Well the first thing I want to say is that -- all parents want to keep their children healthy and safe. We know that virtually all parents -- more than 99 percent of today's toddlers have received at least some vaccines. We know that the conversation that a physician or nurse has with a family is very important. And provider or clinician recommendation is the strongest influence on what a parent decides to do. These days, many clinicians haven't seen measles, they haven't seen meningitis, they haven't seen the kinds of pneumonia we can prevent with vaccine. And it’s very important for us to keep alive and remember what these diseases can do.  A clinician's strong recommendation is very important.  It’s also important for clinicians to listen and to make sure they understand what concerns and questions the parents have and that they address them and take them seriously. Because, bottom line, the parents want to keep their children healthy and they want good information in order to do that.  Unfortunately several years ago, there was a lot of bad information circulating about the measles containing vaccines and -- we think that that is very much a minority of the problem right now. But we know that pediatricians and clinicians can have a very strong influence on their patients reminding them that we’re saving about 42,000 lives every year in the United States by vaccinating babies against vaccine preventable diseases.   

DAVE DAIGLE: Thank you, Neil and next question, please, Calvin. 

OPERATOR:  The next question comes from Michelle Diament with Disability Scoop.  Your line is open. 

MICHELLE DIAMENT: Hi, yeah I’m actually if you could comment all at about the other MMWR report data about children with neurologic and/or developmental conditions and rates of flu vaccine. 

ANNE SCHUCHAT: Yeah, let me just briefly say that we’re – that among the vaccine preventable diseases is influenza, and among the most vulnerable for influenza related complications are children with neurologic disabilities. Today's MMWR reports on a survey of parents and providers about vaccinating kids who have those disabilities. And we found that we have room for improvement. It’s very important that we vaccinate these children and that we vaccinate people around them to protect them. So, another area where we have room for improvement and just reminding us how vulnerable children around this country need to be vaccinated but also those around us need to be vaccinated. 

MICHELLE DIAMENT: Were you alarmed by the numbers that were found in the survey? 

ANNE SCHUCHAT: I think that we have lots of room for improvement with influenza vaccinations. Certainly during the 2009 H1N1 pandemic we saw such horrible -- really had record numbers of deaths in children and we know that the neurologic conditions contributed to disproportionately to those deaths, so I hope that we can do better in the future. 

DAVE DAIGLE:  Thank you, Michelle. Next question, please, Calvin. 

OPERATOR: One moment for our next question. No further questions. Once again, press star one if you would like to ask a question. 

DAVE DAIGLE: Calvin, we have time for one more question if there is somebody on the line.  If not, Calvin, we want to thank everybody for joining us.  Do you have one? 

OPERATOR: Yes. 

OPERATOR: we have David Sell with the Philadelphia Inquirer. Your line is open.   

 DAVID SELL: Thank you for taking the call. Sorry for the late button pushing.  Anyway, one question. Would you like to see pharmaceutical companies do something differently in how they talk to the public to help the cause for greater vaccination? 

ANNE SCHUCHAT: Thanks for that question.  I think there's a challenge when the pharmaceutical company does the messaging around vaccines.  There may be questions that the public has about their independence and why they are speaking.  We know that we wouldn't have these vaccines if the manufacturers didn't produce them and through quality control and really through the science and research that gets us the vaccine.  But we also know that the public and parents in general want independent messaging about vaccinations. So, I think it is very important that we recognize immunizations as a huge partnership of the private sector, the industry that creates the vaccines, researchers that study them, the private clinicians, docs and nurses, pharmacists and so forth who give them out as well as the public themselves.  Parents who are learning what they need to about these products and how to protect their children.  Taking their kids for all of the appointments to get their vaccines as well as of course the public health sector which is doing so much to make sure we have a good running system and make sure measles does not take hold in the U.S. 

DAVE DAIGLE: Thank you, David.  This concludes our press briefing for today.  Thank you, Calvin, for your help.  Take care. 

OPERATOR: Thank you.  That concludes today's conference.  You may disconnect at this time.

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