The Measles Outbreak: Why Vaccines Matter


MICHELLE WILLIAMS:
Welcome to The Forum, livestreamed worldwide
from the Leadership Studio at the Harvard TH Chan
School of Public Health. I’m Dean Michelle Williams. The Forum is a collaboration
between the Harvard Chan School and independent news media. Each program features
a panel of experts addressing some of today’s most
pressing public health issues. The forum is one way
the school advances the frontiers of
public health and makes scientific insights accessible
to policymakers and the public. I hope you find this program
engaging and informative. Thank you for joining us. [MUSIC PLAYING] ELANA GORDON: Welcome, everyone. My name is Elana Gordon. And I am a health care
journalist and producer at PRI’s The World. I’m also today’s moderator. Our panelists starting
from my immediate right are Barry Bloom, the Joan L.
And Julius H. Jacobson Research Professor of Public
Health and the former dean of the Harvard TH Chan
School of Public Health. Jess Hackell is a practicing
pediatrician and founding member of Pomona
Pediatrics, which is a division of Boston
Children’s Health Physicians. He’s also Vice President of the
New York State American Academy of Pediatrics Chapter 3. Gillian SteelFisher is
Senior Research Scientist at the Harvard T.H. Chan
School of Public Health and Deputy Director of the
Harvard Opinion Research Program. And we’re also joined by Howard
Koh, the Harvey V. Fineberg Professor of the
Practice of Public Health Leadership at the Chan School
and the Harvard Kennedy School, as well as faculty co-chair of
the Harvard Advanced Leadership Initiative. This event is being presented
jointly with PRI’s The World and WGBH and as part of the Dr.
Lawrence H. and Roberta Cohn Forum Series. We’re pleased to welcome Mrs.
Cohn today in our audience. We are streaming
live on the websites of The Forum and The world. And we also are streaming
live on Facebook and YouTube. This program will
include a brief Q&A. And you can email questions
to [email protected] You can also participate in
a live chat that’s happening on the forum site right now. So let’s start with
a little background. Nearly 20 years ago, the US
officially eliminated measles. Now, the country is
facing the possibility of losing that status. It’s something that recently
happened in the UK, Greece, Albania, and the Czech Republic. Why is that? In the US, more than
1,200 cases have been reported in just this year. The majority are among people
who have not been vaccinated. Measles spreads easily. It can be fatal. It mostly targets kids, though
adults can be at risk too. And last month, an El
Al flight attendant died after contracting measles. Policymakers are
grappling with what to do. And as one example, California
Governor Gavin Newsom signed two bills this
week aimed at limiting vaccine medical exemptions
for school kids. So today, we want to really
dig into the forces that are driving the measles
outbreak in the US and explore broader
questions when it comes to vaccine rates,
acceptance, and trust. So let’s start by taking a look
at this video from Reuters. It was produced in April. So the numbers have
increased since then. [VIDEO PLAYBACK] – The measles outbreak
is getting worse. The number of new cases
in the United States has now reached a 25-year high. The US Centers for Disease
Control and Prevention Monday reporting that there are now
704 confirmed measles cases. Health officials are blaming
the outbreak on misinformation about vaccines, calling
it completely avoidable. They say the vast
majority of cases have occurred in children who
have not received the vaccine. Reuters health editor
Michele Gershberg. – There are a number of reasons
why people may choose not to vaccinate their children. Their children may have
a medical condition that prohibits them
from getting a vaccine. They may have religious beliefs
that run against vaccination. What’s particularly concerning
to public health officials is a growing skepticism and
even fear that the vaccines themselves can cause harm. There’s no scientific
evidence to show that. There was one paper in the 1990s
that suggested vaccines could– were linked to autism. And that paper was debunked. And still, that concern lingers
among certain communities. – The current outbreak
has been concentrated in New York, where
Rockland County declared a state of emergency last
month, and officials on Monday called on the public
to heed the warnings. – Vaccination hesitancy is
one of the greatest threats to public health
throughout the world. So we’re here today
pushing legislation to remove all
non-medical exemptions for children attending
school in New York state. – The CDC is also recommending
people already vaccinated who are living in or traveling
to outbreak areas should consider
getting a new dose. For those not vaccinated or
too young to get a vaccine, the disease is highly contagious
and, according to the CDC, can be fatal, killing one or
two of nearly 1,000 children who contract it. But so far, there have
been no fatalities in the recent outbreak. [END PLAYBACK] ELANA GORDON: Barry, I wonder if
you could help us contextualize this current outbreak, where
exactly it fits into the larger history of preventable
diseases in the United States. BARRY BLOOM: Thanks, Elana. Part of the problem,
it seems to me, is actually the
success of vaccines. In the US, if you looked
at the data before 1963, we had about 4 million people
developing measles every year. There were about 48,000
hospitalized at high cost. And about 400 to 500 children
died every year from measles. The good news is that
about 94% of kids are getting their required
childhood vaccines. The bad news is there are still
pockets in communities where vaccine coverage is very low. In addition to the human
costs of illness and suffering and work losses, there
are huge economic costs that could be saved by
among the cheapest of all known medical interventions. The problem in the
US is bad this year. But that in Europe
is far greater. There were 90,000 cases just
this six months of this year, worse than ever before. And that’s important because
the vast majority of the index cases that started the
outbreaks in this country brought the virus back
from other countries. Vaccines do two things. They protect children and
adults who receive the vaccine. But if enough people in the
community are vaccinated, they create
community protection, which is very important. It is also important to say
that even with highly protected communities, those kids
who are not vaccinated remain susceptible. There is no immunity if
you’re not vaccinated. Vaccines are a unique
medical intervention for a couple of reasons. One is it’s a rare intervention
in people that are healthy and, in this case,
particularly children. The consequences of that
is the safety requirements have to be enormously strenuous
and rigorous if you’re putting anything into healthy children. The hardest question
for me to answer when I have talked on
this subject when people ask, how can you scientists be
so sure that vaccines are safe? It requires some humility. And it requires some data
to answer that question. There are adverse effects. The targeted for vaccines
is about no more than one in a million kids. That’s about as good
as you can imagine it. But there are indeed
adverse effects. The stringency for
testing vaccines, clinical trials, FDA
approvals following reporting of any adverse effects
is about as good as the system could be made. There is no possibility
to be perfect. Another key issue is, how
do people and parents, particularly, get their
health information? We know one thing, that the
best and most trusted source is from their physicians. We also know there’s a lot of
misinformation and confusion about the information, much of
it coming from the internet, or spread through social media. And in that context,
there’s a small number of anti-vaccine
advocates that provide malicious misinformation. And that is a real concern
to us trying to help parents make the appropriate decision. The challenge that
we have is simply to persuade parents
who have concerns to accept vaccines
to protect their kids and their communities. ELANA GORDON: Thank you. And so Jess, you work
as a pediatrician in Rockland County,
which has been really in the thick of a
lot of the outbreak that we’ve been experiencing. Tell us about your experience. JESS HACKELL: Well,
in Rockland, we’ve had over 300 cases of
measles since last October. And down the road
in Brooklyn, there have been almost 600 cases. Most of these
cases have occurred in orthodox Jewish communities. And the two communities
in Rockland and Brooklyn are very closely intertwined. There’s a lot of interaction. And parents and children travel
back and forth frequently, thus facilitating the spread of
disease within the communities. Measles is highly,
highly contagious as a viral infection. It’s spread by the
respiratory route. A person who goes in a room
and leaves the measles virus there will essentially
leave that room contagious to somebody else
for as much as two hours, even after normal cleaning. It’s a disease that has a
risk of serious complications, among them pneumonia. Think of infants on a respirator
with measles viral pneumonia– not treatable with antibiotics,
requiring intensive care and intensive support. It can cause encephalitis,
both acutely during the illness and, more troublingly,
even several years afterwards after a recovery
apparently has occurred. And it can lead to death
with a case fatality ratio somewhere in the
rate of one patient– one death per 1,000
measles patients. It’s not a benign illness. It’s not a rash that
gives you an excuse to stay home from school
and be real happy. And as you all heard,
it’s been eliminated from the US for almost 20 years. And it’s come roaring back
over the past year or two. And it’s important to
emphasize despite that, it is preventable
by vaccination. I can have a couple of different
perspectives on the question of why vaccines matter. First of all, as a
pediatrician, obviously, my duty is to keep children as
healthy as possible. In addition to the 1,200
plus cases in the US this year, there are
outbreaks worldwide. Children and adults
are dying in Africa. They’re dying in the
Philippines and even in Europe in an area where
we should have first world type of health care services. My friend and the
co-author with me of the American Academy of
Pediatrics clinical report entitled “Countering Vaccine
Hesitancy,” Kathy Edwards, has recently been in
New Zealand, where they’re having an outbreak. And she told me that they’re
having 100 new cases of measles per week in New Zealand,
a country a population of 4 million. If we translate that
to the US, that’s the equivalent of over 8,000
cases of measles per week. I can’t think of a greater
public health emergency than to have that
occur in the US. And again, we’ve seen an
increase in our practice workload because we’re
catching kids up with vaccines. And we’re having to
have extra time spent to counter the hesitancy that
we’re seeing with parents. I can also look at these
outbreaks as a taxpayer. Between New York and
Rockland, they collectively spent over $9 million responding
to the current outbreak. Now, this doesn’t include
the cost of vaccines, which would be given in any case. This includes the extra clinic
time, the extra personnel time required to immunize
people, to track cases, to track case contacts, and to
be involved with the government and develop protocols for
isolation and for reducing the spread. In Rockland, we gave 27,000
doses of the MMR vaccine in the previous 11 months. That’s about three times
the normal incidence, the normal administration
of vaccines. So the cost to this for the
logistics alone is significant. And we’re all paying
for it as taxpayers. Finally, as a scientist, I
see opposition to vaccines. And in fact, science denial
in general is on the rise. It’s fueled in part by
the availability of, on the internet
and social media, of large amounts
of misinformation. Some of it’s there
inadvertently, but unfortunately, some of
it is there intentionally. And it troubles
me greatly to see that what we’ve considered
for a long time to be settled science is being so casually
discarded and ignored. So vaccines do matter. They matter to individuals. They matter to the
nation as a whole. And they matter to
the greater society. I’m honored to be able
to lend my perspective to this discussion. Thank you. ELANA GORDON: Thank you. And so Gillian,
I’m really curious about parental attitudes
towards vaccines. You’ve done a lot of polling
on this and vaccine policy in general. What have you learned? GILLIAN STEELFISHER: Well, it’s
an important question and sort of a lead off because you
said, thinking about some of the societal level. And I think that’s
kind of my role here is to talk about the
sort of public views on this. And so it’s great
to have a chance. And thank you also to the Cohn
family for having this forum. And it’s such a
timely moment when it’s really a kind of
a learning opportunity, I hope, and a
teaching one as well. And so I think public views are
really important and critical as conversation from
two perspectives. One is really related
to the public’s view in shaping policy. And so I’m going to
have a chance to share with you a little bit of
results of a recent poll that we did with our
colleagues at SSRS and to show a couple of slides. And so I’m going to call
to our handy slide team and say, OK, let’s look at
this first slide here and say, I’m going to sort of
unwrap here a story that I think gives kind of
a good news, a little more worrisome news kind
of a tale here. So the first slide really
talks about the overall support for the kind of policy
we’ve heard on the news clip and we’ve talked
about today, which is kind of the best
policy lever which we have around vaccination,
support for children getting vaccinated before
they can go to school. And what we see is
that overwhelmingly, the vast majority
of adults actually support a policy like this. So 84% of adults in the US
say that children should– or parents should be
required to vaccinate their children in order to
have them attend school. And so that’s kind of the
good side of the story that we have support for
this policy at the moment. And I think this policy has
a medical exemption as we also heard in the new story. So children who
can’t get the vaccine are not required to get it. And so where the
conversation becomes a little more
challenging, and where I think there are
opportunities where anti-vaccine activists and
sentiment can kind of play a stronger role, is
in some of the debates around these
additional exemptions. And those are usually
state level policies. But I think it’s
important to pay attention to what’s happening
on a national level because it gives us
insights into where there’s windows of opportunity where
we need to be really cautious. And so let me turn
to the next slide. And I think what
I’m showing here is really that this is
happening kind of in a larger context of doubt. And so when we asked
people whether or not they believe that childhood
vaccines are generally very safe for children to get, we
see that about half of adults say very safe. Half’s like, OK, half. Feels like when you’re
talking about vaccines, you want people to be in
that very safe bucket. Like we’re talking
about, as we said, something goes into
a healthy child, turns out that when people
don’t think it’s very safe, they’re much less likely
to do it, to support it. It matters. You’ve got to get
in that bucket. The very safe bucket
is critical here. Somewhat safe just
doesn’t cut it when it comes to these things. So this is about
the vaccine itself. And then my next slide, I
think, is going to be perhaps a humbling moment
for those of us on the panel who
would like to think that we are a voice of authority
and that, if we simply state a fact, it will be believed. And it turns out not true. It turns out that, in fact, we
have a really pretty low level of trust. Only 37% of adults say that they
trust public health agencies to provide accurate information
about the safety of vaccines for children. That number could be higher. I would feel better
if it were higher. Again, you need to be sort
of in that great deal. The somewhat just
doesn’t cut it. And I think what’s especially
worrisome is that this is changing over the generations. And so the next
slide, you can see that some of these changes– that the youngest generation
is less trusting of the old– than the oldest generation. And it’s not surprising,
but it’s important that you see the data. And you say, like, oh,
that’s what it really means. So when you talk about believing
vaccines are very safe for most children, now, we’re under
half for those in the 18 to 34 category compared to 61%
of those 65 and older. When we talk about trust
in public health agencies, we’re down at 31% when
we talk about 18 to 34, as opposed to 44% of
those 65 and older. So if we sort of have a crystal
ball vision from this polling, it’s not a great picture. Picture cloudy. And we kind of–
we need to think about how we can address that
and also acknowledge it humbly as we try to reach out. The other perspective that
I think polling data really brings to the table is to
talk about parent perspectives themselves because this
mistrust manifests itself in actually decisions
once that person moves from an adult to a
parent when they actually have to make that
decision about whether or not to vaccinate their child. So we asked parents
of children under 18 whether or not
they had ever been enough concerned about
the safety of vaccine to either delay or
not have a vaccine. And what you can see as a
result on the next slide, we have about 15% who said
they have delayed or not given a vaccine
for safety reasons, not just about access,
or structure trouble, or payment, or any
of the other things. This is about safety concerns. So there’s a little
bit of a sobering start to that conversation. But I think if we
lay this out, then we can begin to think about both
acknowledging it and addressing it in some of the
solutions that I hope we’ll get to today as well. ELANA GORDON: Well,
speaking of public agencies, [LAUGHTER] Howard, you’ve
worked on both state and federal policy. So tell us about
your experiences and how it applies to today. HOWARD KOH: Thank you very much. Well, I’ve had the
great privilege of overseeing many
vaccination efforts at the state and federal level
as Massachusetts Commissioner of Public Health and then as
Assistant Secretary for Health working with the CDC and FDA,
the National Vaccine Program Office, and many other offices
across the Department of Health and Human Services and
across the country. And reflecting on
those experiences and hearing from
my colleagues makes me think of that wonderful
saying an ounce of prevention is a ton of work. [LAUGHTER] When you
stop and think about it, this is a miraculous system
that has arisen because of the dedication of
so many professionals who have come before us so that
we can drive these rates down in the United States
and around the world. But here, we have
this resurgence that we’re dealing with. And so just to re-emphasize the
basics, here we have a vaccine, the MMR vaccine,
that’s effective– 93% effective after one
dose, 97% after two doses. It’s safe. That safety has been established
not only through over a dozen rigorous trials, but
also by tracking outcomes for millions of children
over many, many years. It’s affordable because of
some major policy developments that we can talk about later. So every family and every
child can get this for free. And then from a health
policy point of view, it’s cost effective. It saves lives. And it saves money. And you can’t say that about
all prevention interventions. So despite all that good
news, in the face of it, we have this challenge now. And the opportunities
that we have to pursue are that we need to keep
that community prevention– community protection level over
95%, as Barry has stressed. The country has pretty good MMR
coverage rates, about 90%, 91% over recent years. But there are pockets
of these tightly knit, under-vaccinated
communities that have closely shared beliefs. And the vaccination rates
in those communities may be in the 70s,
or even below. And so it literally
takes one person coming back from overseas to
start some of the outbreaks that we’re seeing here in
New York and Washington State and elsewhere. So that’s the
challenge we face, not just here in the United
States, but, in fact, globally. So we’ll be talking
more about all this. ELANA GORDON: Great. So we’re going to shift
the conversation now to what can be done to
combat this outbreak and prevent others. And we want to get
everything from the one-on-one
conversations all the way up to the federal level. And so to kick this part
of the conversation off, we want to watch– we’re going to watch
two PSAs from the CDC. [VIDEO PLAYBACK] [MUSIC PLAYING] – Babies require persistence,
patience, a sense of humor, and protection. That’s why nearly all
parents choose immunization. It’s safe, proven protection
against 14 serious diseases, like measles and whooping cough. So give your baby the
recommended vaccines before age 2 and
get a little help in the protection department. For more reasons to immunize,
talk to your child’s doctor or go to cdc.gov/vaccines. [END PLAYBACK] ELANA GORDON: So
those are PSAs we just saw as examples of
the kind of messaging that goes out to the public
about vaccinations and measles. Communication, as we’ve
heard, is really critical. And so I’m really curious
about these best practices and examples. But just having viewed,
Jess, those messages, how effective have you found
that these kinds of messaging is? JESS HACKELL: Well,
the vast majority of parents who have
questions about vaccines are not refusing vaccines. But they’re hesitant and
they’re confused about them. They’re confused about the need
for them, about the safety, about the efficacy. And so what we’re dealing with
generally is not hard core people who are
opposed to vaccines and who won’t even listen to
an argument that we might make, or a PSA, or an
announcement from the CDC. Their concerns can be
specific about fear of autism, for example, or a
fear of reactions, or fear of injecting so
many different things into their child. Or they can just be
kind of general concerns as well as sort of a vague,
free-floating anxiety. “Gee, I’m just not sure.” But study after study has
shown that parents consider their pediatrician to be
the most important source of accurate information
about their child’s health, the child’s
growth and development. And they do listen to
us as pediatricians. So on the microlevel, we
provide accurate information about the diseases
that we’re preventing, about the risks and
severity of these illnesses. We provide accurate
information about the vaccines, their safety, their efficacy. And most importantly, we provide
reassurance to the parents. This is an ongoing process. This is not a one and
done kind of thing. We have lots of visits with kids
when they’re receiving vaccines in their first
two years of life. And these conversations
happen with every visit. They happen many times
a day in our office. And the one thing that we’re
also faced with more now than we used to be is the
internet and social media. If you search for vaccine
information on the internet, you are far more
likely to come up with negative information
about vaccines, about safety and efficacy,
than you are to come up with positive information. We’re not doing
a good enough job in making the positive
information front and center. And finally, in terms of
social media, what we find is that people
tend to search out social media sites
which reinforce their pre-existing beliefs. So rather than getting
a balanced viewpoint by doing searches and by
dealing with social media, we find that people’s
misinformation and misbeliefs tend to get amplified
and reflected back. And we face this,
again, every day when we talk to parents who
have read, or heard, or seen something. So again, communication is key. We need to do it in our offices. We need to make sure we’re doing
it widely through social media. We need to be out
there and continue to reinforce this message. ELANA GORDON: When I think
about messaging and what works, I wonder, Howard,
if you might be able to talk about your
experience of what does work? HOWARD KOH: Sure. So there are many strategies
for effective communication and messaging. Let me mention a couple of them. One message is that if
you vaccinate your child, you’re not only
protecting your child, but you’re also
protecting your community. That’s what community
protection is all about. A second strategy is to
humanize this whole process and make it personal. When doctors and health
officials recommend vaccination, you could
also add, by the way, I recommend this for my own
family, for my own kids, for myself. I’ve gotten the flu
vaccine on camera several times as part
of public service. GILLIAN STEELFISHER:
Sometimes, in the same season. [LAUGHTER] HOWARD KOH: And my major
memory from serving as Assistant Secretary
starting now 10 years ago was at that time, the H1N1 flu
pandemic was on the horizon. And everybody
around the world was terrified about this threat. And as the new
presidential administration started addressing
this, everyone was clamoring for a new
vaccine against the H1N1 flu. So I got to see in
the trenches what it takes to get a new vaccine
tested and then licensed by the FDA, lots of safety
testing before licensure, of course, then afterwards,
getting millions of doses of flu vaccine up and
distributed around the country. During that summer
and fall 2009, we were absolutely
concerned about assuring safety of this new vaccine. So we were tracking outcomes. In fact, a new vaccine
surveillance system called PRISM was created
then just to track outcomes for this new H1N1 vaccine. And I personally ran
many of the meetings and calls coordinating the
data, looking for signals, making sure this was safe,
and then sending the message that your safety is
our highest concern. So that fall of 2009, the nation
saw two simultaneous influenza vaccination campaigns,
seasonal flu and H1N1 flu. 10 years later, people probably
don’t remember this very much. But it was, I thought,
a heroic effort. And over 80 million
doses of a new vaccine was disseminated safely. So those are some
efforts that go on every day in public
health that people don’t remember any more. But I think the more we talk
about these systems that protect people and track
outcomes to assure safety for everyone, hopefully, it’s
an effective communication strategy for all of us. ELANA GORDON: I also think
about when you were mentioning misinformation, or online,
and think about technology, and where we are
today, I wonder, Barry, if you could talk
about what to do about that, or if there are policies,
or things to address that. BARRY BLOOM: Thanks, I’ve had
two thoughts on the subject. And having been a
dean, number one would be we need more
research because we really don’t understand where the
parents, particularly, that are hesitant are getting
their information from and how to reach them in a
way that would develop trust. So that’s been–
there’s much more work going on in laboratories
creating vaccines than there is
understanding how to get at a percentage of parents
who are hesitant to use them. And CDC really needs to get the
support it needs to provide us with that information. I think the second thing
is very straightforward and has, in a way,
voluntarily begun. There is malicious
misinformation by anti-vaccine activists
on social networks. And at least some of the
major social networks have indicated they
would either give them lower priority when you
search for vaccines, or none. Again, when H1N1 came up,
I went on the web as dean because deans are supposed
to talk about everything they don’t know about. And so I had to give
lectures on flu. And of the first 200 sites that
came up under flu vaccines, there were only two that
had credible information. And much of the
information were sites that were signed by
physicians themselves. So I think getting
mischief off the internet is something that really
is important to do. ELANA GORDON: When you
think about getting that off the internet or
having more of the focus on credible sources, how
do you propose doing that? Are you seeing things or
movements towards ways to combat it? BARRY BLOOM: Google and
Facebook and Pinterest have voluntarily indicated
that they would screen for it. They don’t guarantee they
will all take it off. They’ll put it at
a lower priority. And that’s not
good enough for me. ELANA GORDON: And
so Gillian, I’m really curious too when you
think about understanding where some of this information is
coming from in the messaging, I wonder if you could kind of– what your takeaways are too
in terms of better messaging. GILLIAN STEELFISHER: So I think
I want to take it back and say, the messaging sounds like, OK,
well, we can just give people some information. They will get this message. And then they would be somehow
miraculously convinced. And what we see
over and over again is that is not how it works. This is really about engagement
and about relationships. And I would say that
one of the biggest themes from the
research that we’ve done both in the US and globally– and I work a lot on
polio eradication and other vaccination
immunization issues, and it’s across the board– is really about the
importance of trust in the person who’s
giving you the vaccine. So we see that this is on
the doorstep when you’re in Pakistan and Afghanistan. And we see that it’s
important in the US. We see it across the board. This is really kind of
a universal human issue, I think, in many ways. And so trust is so key. And I then want to put this
into the context of information and communication in
the states and say, the sort of vaccine
distrust that we see is not just specific
to vaccines at the moment. So we just think
about the context. We’re at the lowest
level of trust in almost every institution
you can think of– the government generally,
not just public health. We don’t have to just
blame ourselves for this. There’s more to it. It’s also distrust in
the medical system. And as doctors are
more part of hospitals, fewer have private practices,
there’s less of a connection. There’s a lot of pieces
that I think go to that. And so we can see kind of
unraveling of trust in that. And that’s worrisome. And I think we’ve talked a lot
about the information that’s out there. But I think the key is to try
to understand what catalyzes. It’s not as though everyone
who’s walking on the street says, like, oh,
rumor is coming by. I think I’ll believe it. No, it’s not how
it works, right? There’s a reason that
it makes sense to you. And so if we think about the
reason that it gets catalyzed, that it suddenly makes
sense to you, I think it’s– that can give us some
insights about what we can do. So one thing that we’ve
seen that can happen is that, of course, that
information comes to you, and it’s wrapped
in a cloth of trust when you get it
from social media because it doesn’t come from
an anonymous news organization. It comes from your mom. It comes from your aunt
who used to be a nurse. It comes from your
brother-in-law. It gets wrapped in this
trust because someone who cares about you sent it to you. And that’s why they
sent it to you. People do have less experience
with the horror of childhood illnesses because they’ve
lived in the luxury of having the vaccine for
such a long time. And so it can sort
of– you suddenly say, well, it opens the door
to beginning to question. So it’s a little bit of a
catalyst is how that happens. And then I think when people
have negative experiences in the health care setting, that
adds fuel to the opportunity where the door
opens even further. And they say, oh, maybe there’s
something to those rumors because when I went, it
just didn’t seem like anyone really cared about me. I had a really short visit. They didn’t really
listen to my questions. I got pushed around. I didn’t know who was who. We’ve all been in
those settings. And we know that that’s
happening at an increasing rate. And so you think
about, like, well, what we can do then
to counter that. I don’t have a solution for
the full trust in government. I don’t have a
solution for that one, or trust in all institutions. That’s maybe another
forum or two, maybe three. But I think what
we can to do is, a, try to support
trustworthy interactions in the medical system,
supporting more opportunities. These conversations
are not reimbursed, how we do that, providing
more training to physicians, trying to take advantage
of that opportunity because physicians
are so trusted. We need as public health to
be humble about our role in it and to partner with
physicians and nurses and pharmacists who
are trusted so it’s not just an institutional
voice saying, you should get vaccinated, but
people that do care about you. And we connected to them. And so it’s not just a message. It’s a whole communication
and engagement strategy in that way. We do need to call in
traditional and social media to be better partners in this. This is a hard thing to do. Turns out building trust is much
harder than tearing it down. So I think we all know that. And so we need to, I think,
ask them to do more, I think, as Barry’s pointed out. And I think also
we take advantage of these teachable moments. This has been– this
outbreak in the United States is really a tragedy on a
lot of different levels, both because of the illness
and suffering that it’s caused these families,
and because of the larger issues that it brings
up, and the worry about where this is going. And so I think this
is an opportunity to start having
those conversations, and to build on the
momentum, and to have more support for
things like research that can help us understand
and to support physicians and others in that process. So I think it’s a
multipronged effort that’s beyond messages and more about
engagement and respectful listening to the community. ELANA GORDON: So I
guess a nice transition to speaking of our trusted
doctor, pediatrician on the panel, I wonder if
you could kind of take us inside the– that patient room and what
are those conversations, or turning points? Where do you get to that? BARRY BLOOM: Well,
if you’ve seen one parent who’s
hesitant about vaccines, you’ve seen one parent. They’re all different. Everybody’s concerns
are different. They range across the board. And as I said, these are
ongoing conversations that we have from
the prenatal visits even before the
child is even there. And we talk to parents about
how important vaccines are, why we give them,
what we’re preventing. Those of us who have been
practicing for as long as I have have some
experience with vaccine-preventable diseases. And that’s a really
powerful message. Not all, well, today, because
some of these diseases have been virtually eliminated,
newly trained physicians don’t have that experience. But they need to pay
attention and learn to those of us who have had
it and be willing to transmit the messages. Personally, I’ve never
seen a case of measles. I know about it. I know enough about it. And I’ve seen enough
and heard enough that I communicate the
severity to a parent. And I do that. So there is no one
response that’s necessary to a parent who’s
hesitant about vaccines. The most important
thing that we can do is listen to their concerns. First and foremost,
we listen, and we address the specific
concerns as they come up. In 38 years, medicine’s become
a whole lot less paternalistic. It used to be you walked in. The doctor told you
what you were doing. You did it. And you left. Now, it’s a much more give
and take engagement, both with parents of children, but
in general with health care. And that’s all for the better
because it engages the parents. It engages the patients and has
them committed to participating in their own health care. Yeah, it’s time-consuming. Yeah, we’re not compensated
for the time that we spend. But having done it both ways,
I would never want to go back. So engaging the
parents by listening, by finding out their
specific concerns, and if they’re hesitant
to talk about them, you need to be motivational
when you talk to a parent. “I see you’re concerned
about something. Is it OK if we address it?” So find out their specific
concerns and respond to them. And again, you’ll
find out they’re all over the place from
what their aunt told them, to what they saw on
Facebook, to the fact that the pharmaceutical
companies have all been charged with all kinds of crimes,
so how can we trust them when they produce a vaccine? So they’re all over the place. And one of our challenges
as pediatricians dealing on a one-to-one basis is to
have the answers ready when we’re hit with these questions. And usually, we’re
pretty good at it. But occasionally,
we do get stumped. So there’s no one
real turning point. It’s a process. It’s not a single
episode by which we can bring hesitant
parents around to understand why we need
to vaccinate their children. And if you’re not
willing to invest the time in that
process, probably should be doing something else. ELANA GORDON: I
want to get to some of the regulatory questions too. But just going off
of that, do you find when we think about,
like, community partnerships and things, that you’re stepping
outside of the pediatrician’s office still as a
pediatrician, what– is there a connector? Is there’s something
else that you’ve found is helpful in
building that trust outside? BARRY BLOOM: Very much,
and interestingly, as we saw with the measles
outbreak, in my practice, the vast majority of our
parents were very much in favor of vaccinating
their children and even within the orthodox
community, which is not a monolithic community at all. We had parents– orthodox
parents in our office telling us they
did not understand how somebody could not want
to vaccinate their child. So it starts within the
office, but it reaches out to the community. What we found in Rockland
once this outbreak started was that there was an anonymous
pamphlet being circulated with a tremendous amount
of misinformation, both scientific misinformation
and religious misinformation. And it was being circulated. It was anonymous. You couldn’t trace it
down where it came from. One of the members of the
community who specializes in communication
took it upon herself to produce a booklet with
scientific information, with religious information,
and with civic information. She engaged all the leaders
in these various spheres to produce a booklet, which
was then produced and supported by the medical and
religious community and distributed
community-wide to get the actual scientific factual
information out there. And I think that’s one
of the factors that helped to bring about
the end of the outbreak and convince more and
more people to vaccinate. So it started in the office, but
it went out further from there and involved all levels
and all stakeholders within the community. ELANA GORDON: And
so I want to get to this theme of the legal
and the regulatory approaches. Howard, I’m wondering
if you can talk about how you kind of
ensure that accessibility, but also when we’re looking
at some of the policies now that some of these
states are wrestling with. HOWARD KOH: There’s a
lot to say about that. First, let me
stress that in terms of accessibility
and affordability, there’s been so much progress. The Affordable Care Act
requires insurance plans to cover high value
preventive services at no cost to the beneficiary. And so that’s a major
prevention facet of the ACA, which, of course, is
under a legal review right now. And then there is a program
that people don’t talk very much about called Vaccines
For Children, VFC, that was established in
the 1990s, which makes MMR and other childhood
vaccines available for free for every family, every
child, at any income level without cost. So those are some great advances
that we should all appreciate. Funding is always challenging,
those so-called section 317 grants that every state
commissioner looks forward to learning more about
each budget year. And so those grant challenges
are one of the issues that every public health
official has to deal with. Now, on the regulatory
side, it’s really important to stress that the authority
for implementing these programs and then granting or
narrowing exemptions rests at the state level. It’s not a federal function. So we have seen
what New York State has done, what Washington
state has done, what California did after the
Disneyland outbreak in 2014. So it’s very important that
public health officials and leaders in the public
sector engage closely with their community in
state and local environments so that trust is engendered. So if exemptions are narrow,
those are accepted widely. There’s been a lot
of discussion about so-called non-medical
exemptions, philosophical and religious. But as Jess just
mentioned, oftentimes, the best community leaders, for
example, in Rockland County, are religious
leaders like rabbis who often were very
public about vaccination was a way to protect
your children and protect your community. So actually, in this era of
social determinants of health, we’re looking for
non-traditional partners and non-traditional leaders
like religious leaders to help promote vaccination
prevention for the future. ELANA GORDON:
There’s so much more to talk about with all of this. But we want to move into the
question and answer portion. But before we get
to that, I would like to invite Dr. Michael
Mina is here in the audience, recently joined
faculty at Harvard. And Dr. Mina has some
really interesting research on measles itself when
it comes to immunity, something called
immunity amnesia. And so I’m wondering
if you would, before we get to some
questions, kick things off. MICHAEL MINA: Sure,
well, thank you for giving me an opportunity
to say this much. So one thing that,
besides all of the policy, I think one of the things
that’s truly lost in particular with measles more
so than perhaps other infectious diseases
that are vaccine-preventable is that the infection was
far from a benign infection. And there’s sort of a
rumor in the public sphere that it was a benign infection. But what are really
lost are all the voices of individuals who didn’t
necessarily survive measles 90 years ago, a
hundred years ago, and never lived to
tell their grandparents and their grandchildren
about how devastating their infection was. And those are both
due to acute effects. And the acute effects of
measles can be severe. They put people in the hospital. They lead to encephalitis. And they have
devastating consequences. But one of the things
that we’ve been studying and that we’ve really been
discovering more and more about is something which we’ve
termed immune amnesia, as you mentioned. And these are actually
long-term effects that can happen due to measles,
where measles can actually eliminate somebody’s immunity
to all other infectious diseases and can actually cause a
child who gets measles to be at increased risk for
other infectious diseases for a number of years
potentially after they actually had the infection. And the problem is these are
sort of stealth infections, or this is a stealth problem
associated with measles, because these children
who get measles, they end up going on and
getting a bacterial pneumonia, or influenza, or some
other infectious disease that you could chalk
up to just being a kid, and getting infectious disease,
and landing in the hospital. But actually, looking
at the population data, we see that there’s
a very strong link between previous
measles infections and an increased use of medical
health care, antibiotics, and even in a lot of
underresourced countries, very high deaths for
two to three years. And so I think that this
is a new line of research. I think the evidence
is very strong. And I think it’s
something that I hope that can maybe get out
there that measles is truly not benign. And there’s even these
very long-term effects that could really have
large, large ramifications at a public health and at
a clinical level and so. ELANA GORDON: It’s very
powerful to think about. Thank you. we’re going to move
now to some questions that we’ve been
getting from online. And so I want to
start with a question from Joyce Frieden, Washington
editor for MedPage Today. And it has to do with
Gillian’s polling data showing that only 31%
of those ages 18 to 34 trust public health
agencies to provide accurate information about vaccines. And so the question is, why
do you think public confidence in these agencies is so low? Wonder what can be done
to improve that number? GILLIAN STEELFISHER:
So I’m glad someone– this is such a
critical issue for me and I think is one
I think about a lot. And the answers aren’t simple. So it may be
disappointing to say, oh, I wish I just had a solution. We’d just crank that
number right up. I think the reason
that it’s low has to do with this broader societal
distrust of institutions, and government, and what’s
happening more broadly. And then I think there are some
incidents around that people feel individually that
they weren’t connected. And they may not see
the total distinction between the medical
system and public health. People don’t understand. It gets kind of
muddled in their mind. But they just say, like, they’re
not giving me the real story. They believe there’s collusion. There’s all sorts of things
they begin to connect. And I think that we need more
examples of how much it works, and to connect people to public
health, and for public health to say, OK, well, we
actually need to partner with these other trusted
institutions and building trust by example. I think the success
of actually containing the measles outbreak, that is an
example where we say, actually, this is something public
health did really well, and showcasing that, and
partnering, and getting the people out who were
involved in the front lines and saying hey, look, this
is what it looks like. It’s not just like some
monolith in a gray building. There’s actually a person. And there was a
child who was saved. And that’s what it looks like. And that can build it. And we do see that. Under certain circumstances,
we do see that trust go up. And so we want to take
advantage of those opportunities where public health
does such a great job, and to showcase that,
and to also partner with other institutions– other
people who do make that case and can show the compassion
on a personal level. So I hope she’ll put
that in her story. [LAUGHTER] ELANA GORDON: We’ve
got a question I wanted to ask from
somebody who e-mailed in. We have a nine-month-old
and are traveling outside the country,
which gets me thinking a lot about the kind of global
aspects right now with measles. Are additional
recommendations being issued around measles
vaccinations in cases like this, given that the
first vaccination is generally given at 12 months? And I’m also curious how
that connects to some of– we talk about these
global themes. JESS HACKELL: Well, the– as you said, the measles
vaccine has an indication for 12 months and up. And two doses after
12 months of age separated by at least
28 days is required to complete immunization. Having said that, in children
as young as six months of age, the measles vaccine may
have some effectiveness in producing an immunity. Under six months,
not at all because of transferred maternal antibody
from prior to delivery. So the recommendation has
been in Rockland County with the outbreak, all
children six months of age and over were given a dose. Given that the outbreak
has decreased then, if parents are
planning on traveling with a child between 6
and 12 months to an area where measles is endemic– and that, unfortunately,
includes a whole lot of the world right now– we do recommend that
the child receive a dose of a MMR vaccine at
least two weeks prior to travel. That will not count
as one of the two doses required for immunization
for school entry for example. So two more doses after a
year will still be necessary. But you can give the
child some protection during that vulnerable period
during the time of travel with that earlier dose. ELANA GORDON: Another
question that we’ve received has to do with supporting
immunization requirement laws at the state level. And so California,
as we referenced, recently tightened its
physician oversight. But lawmakers have
also received threats while passing legislation. And so what sorts
of paths forward do you see in states
when lawmakers are facing these sorts of tensions when
they sponsor legislation, as well as what sort
of support requirements are there for immunizations? I wonder, Howard, if you might
be able to take this one. HOWARD KOH: Well, in California,
where they narrowed exemptions after the Disneyland
outbreak in 2014, there’s been an evaluation
of what happened afterwards. And the rates of unimmunized
kids entering school went down significantly. And so the coverage
was increased. And that’s been well-documented. So I think because this
is a state by state issue, there has to be, first of
all, good communication, as I mentioned before. And then when these
policies are changed, we need very, very
good evaluation, as high level science
as possible, and sharing that with others so that
when their time comes, they have some
experience to build on. I’m not sure I can say much
more than that because this is such a dynamic area. And I know that when we
have outbreaks like this, every state looks and
says, OK, what are we going to learn from this? And how can we protect our
public even more strongly? So I think these discussions are
healthy because we cannot take our public health
systems for granted. They’re always very fragile. They’re always underfunded. The staff and the front line
physicians are very overworked. And these can be opportunities
to educate people what public health is all about
and change the regulations and laws accordingly. BARRY BLOOM: May
I make a comment? [LAUGHTER] There are only two
states that have not had exemptions for non-medical
reasons, Mississippi and West Virginia. And they did not have any major
outbreaks for a very long time. But the serious point
I wanted to make is when you raise the legal
issue, the courts decided in a case called Kaufman
versus the United States in 1905 that all freedoms
have some constraints, or restrictions. And the court decided that it
was the state’s obligation, and I quote, to “protect
the public health and the public safety
confessedly endangered by the presence of a
dangerous disease,” and that decision has
been legally binding and confirmed through the
Supreme Court ever since. So there is a legal
basis for imposing, to protect the public
good, constraints on individual freedoms. ELANA GORDON: We’ll do
one more question, which comes from someone who
has been working in polio and other immunization for many
years in India, Kenya, Somalia, and has been thinking
a lot about looking into the confidence that people
have in public health programs. And the question
is about how much use of social media
platforms is done for health education about vaccines? And what’s the outcome of that? Gillian or– GILLIAN STEELFISHER:
Sure, I mean, I can talk about it certainly
in the polio context because I do a lot of work with
UNICEF around polio vaccine. And I think that we’re
trying to figure out how to use social
media effectively. So people may be aware that
this spring, in Pakistan, there was a very negative
social media that went out that was untrue
about the effect of the virus on children. And it had really
terrible effects, not only in terms of
reduced vaccination, but in terms of actually
assaults on vaccinators and so unrest,
burning of buildings. Like it was really
quite devastating. And so people, I
think, are a little bit wary about social
media because they can see that it goes hot fast. And yet, we need
to engage people where they are, and so
trying to figure out both calling on social media
to be responsible around trying to reduce and
hopefully eliminate the source of information,
but also think about how you partner effectively in
that where you can actually sort of leverage the
networks that exist. I mean, this, I think, goes
to Barry’s earlier point, which is that we don’t
totally understand what it’s like out there. And we need to engage
that in a respectful way, and learn from
people, and figure out how we can have a social
media-based conversation that doesn’t suddenly run hot. And yet, it engages people in a
way that where they really are. And so I think we’re kind
of at the front of that. We’re trying different things. And we’re also trying to
engage not only people, but also vaccinator–
parents but also vaccinators and trying to create a
more shared community where people can share a lot of their
positive experiences as well. ELANA GORDON: Well, we’re
going to wrap up now because I feel like we’re
just getting started. So many questions. But I want to give all
the panelists a chance for some closing remarks. Barry, we can start with you. BARRY BLOOM: My closing
remarks would be very simple. And that is there is no place
in the world from which, from the point of view
of infectious diseases, we are remote and no one from
whom we may not be connected. So it’s one world from the point
of view of infectious diseases. JESS HACKELL: I also
have a simple statement. And that’s basically
that no child should suffer from a
vaccine-preventable illness. We need to continue to counter,
to be aware of the science denial, the vaccine hesitancy,
and the misinformation. And we need to remind parents
consistently and continuously of the necessity, the
safety, and the efficacy of the vaccines. And we need to respond to
parental confusion and fear with support and trust. And it’s an ongoing process. And we just need
to continue that. GILLIAN STEELFISHER: I
want to echo and build off of what you just said
in terms of where this goes in terms
of understanding connecting with parents. Parents come and have
concerns about vaccines because they love
their children. And that is a universal. And so if we take
that as the premise, as we understand that is
that they are concerned, they are genuinely concerned,
and they love their kids, and they want to do
the best for them, that is a respectful
place to start. And that’s where we
have the conversation. And we understand
that perspective. We don’t demonize it
from public health. And we engage with
them respectfully, both at a macro level
and an individual level, I think we have a chance. HOWARD KOH: Well, one
of my favorite sayings about prevention is
when prevention works, absolutely nothing happens. And things are very
boring, dot, dot, dot. Let us all pray for
a little boredom. And that’s what public
health is all about because when public health
and prevention work, you get to enjoy the
miracle of an absolutely normal, healthy day. That’s what vaccines have
done for millions of kids. And so our job is to keep
that message of prevention alive and going forward. ELANA GORDON: Thank
you, everybody, for this really
powerful conversation. That basically wraps things
up for now at The Forum. But please be sure to tune into
the next one on mental health and wellness for students
of color and transitioning to college. So that is on September 18
at noon at forumhsph.org. [APPLAUSE] [MUSIC PLAYING]

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