so there's no other -- i've got a final page i'm supposed to read. the hearing record will remain open for ten days. members may submit additional information for the record within that time if they would like. i want to thank senator murray again for the way she has conducted -- helped us do this in a bipartisan way. we learn a lot more that way. the next hearing will be tomorrow on higher education. the committee will stand adjourned.

the c-span cities tour visits literary sites from across the nation to hear from historians, authors and civic leaders every other weekend. this month with congress on its summer recess, the cities tour is on c-span each day at 6:00 p.m. eastern. today is our second day in madison, wisconsin where we'll look at the literary life of the state capitol. tonight our washington journal program focusing on community policing. we'll re-air yesterday morning's entire program from richmond, virginia. with your calls and comments, the richmond police chief, the head of their police training academy and richmond mayor dwight jones. the program starts at 9:00 p.m. eastern on c-span. earlier this year, dr. ann

shookette stressed to a senate committee that vaccines are safe and there is no scientific evidence they cause autism. washington d.c., california and several other states are dealing with measles outbreaks, sparking debate that vaccines for such diseases are mandatory for children. >> the senate committee an health education, labor and pensions will please come to order. we're holding a hearing about the reemergence of vaccine-preventable diseases. senator murray and i will have an opening statement and we'll introduce our panel of witnesses. after our witness testimony, senators will each have five minutes of questions. we have two panelists today and two hours for the hearing. we're going to end about noon.

so we'll have an hour for each panel, and i will end the first panel at 11:00. from smallpox to polio, we have learned in the united states that vaccines save lives. yet, a troubling number of parents are not vaccinating their children. last september this committee held a hearing about the ebola virus. our witnesses included a brave physician, dr. kim brantley, who worked in liberia and who contracted ebola, and a brave father in sierra leone who warned us how rapidly the virus was spreading there. many of those infected were dying because for ebola there was and is no cure and there was and is no vaccine. this produced a near panic in the united states. it changed procedures in nearly

every hospital and clinic. i remember one chattanooga public health officer saying it's all ebola all the time every day. in response, congress pro appropriated more than $5 billion to prevent the spread of the virus. the number of ebola cases is declining. at the same time, here in the united states we're experiencing a large outbreak of a disease for which we do have a vaccine. measles used to sicken up to 4 million americans each year. many believed it was an unpreventable childhood illness. but the introduction of a vaccine in 1963 changed everything. measles was declared eliminated, meaning absence of disease for greater than 12 months. from 2001 to 2012 the median

yearly number of measles cases report in all of our country was about 60. today is february 10, 2015, it is the 41st day of the year and already we have seen more cases of measles than we would in a typical year. one measles outbreak in illinois, a suburb about a half-hour from chicago, has affected at least five babies all less than one year old. infants and individuals who are immunocompromised are protected by what is called herd immunity, meaning when more than nine out of ten of the people around them are vaccinated so they don't get sick and that keeps the babies and others who can't get vaccinated from getting sick. measles can cause life threatening complications in children, such as pneumonia or swelling of the brain. our witnesses will talk about

not just what is causing this outbreak but why some parents are choosing not to vaccinate their children. measles is only one example. this hearing which was planned before the measles outbreak reminds us of the importance of vaccines. an analysis of immunization rates across 13 states performed by usa today found the following. hundreds of thousands of students attend schools arranging from small private academies in new york city to large public elementary schools outside boston, native american reservation schools in idaho where vaccination rates have dropped precipitously low, sometimes under 50%. california is one of 20 states that allow parents to claim personal belief exemptions. in some areas of los angeles, 60 to 70% of parents at certain schools have filed a personal belief exemption and those schools vaccination rates are as

low as those in chad or south sudan. the purpose of this hearing is to examine what is standing between healthy children. it ought to be vaccinations. sound science is this. vaccines save lives. they save the lives of people who are vaccinated. they protect the lives of the vulnerable around them like infants and those who are ill. vaccines save lives. they protect us from the ravages of awful diseases like polio which invades the nervous system and can cause paralysis. i can remember as a child how parents were frightened by the prospect of polio for their child. i had classmates who lived in iron lungs. our majority leader, senator mcconnell, contracted polio as a child. whooping cough is another example which causes thick mucous to accumulate in the air waives and make it difficult for

babies to breathe. or dip theory ya that can damage your heart, kidney and nervous system. we have learned that vaccines save lives. so it is troubling to hear that before we've seen reached valentine's day this year, 121 americans are sick with measles, a disease eliminated in the united states 15 years ago. it is troubling that a growing number of parents are not following the recommendations of doctors and public health professionals who have been making those recommendations for decades. at a time when we're standing on the cusp of medical breakthroughs never imagined cutting edge personalized medicine tailored to an individual's genome, for example, we find ourselves retreading old ground. i turn to senator murray for her

opening statement. >> thanks to our witnesses for coming and sharing your expertise with us today. keeping our children and families healthy could not be more important, so i'm glad to have the opportunity to hear from all of you about the threat vaccine-preventable diseases still pose in the united states and discuss what we should be doing to take these threats off the table. there's no question we have come a long way when it comes to what was once widespread and extremely dangerous illnesses. vaccines are truly one of our country's greatest public health successes. thanks to them, we know how to prevent illnesses that struck so many children as recently as a generation or two ago like polio and whooping cough and measles. but recent news about the measles outbreak in many states and including in my home state of washington made clear that vaccine-preventable diseases are still a threat and that we can't afford to become complacent about protecting the progress that we've made. bottom line, this means children

across the country need to be vaccinated. it also means we need to be vigilant about breaking down any barriers that families may face when it comes to accessing certain vaccines and we need to ensure that in any cases where takeup rates are low, we're providing information and spreading awareness so that more people can be protected. the hpv vaccine is a great example. it prevents life threatening cancers including cervical cancer which impacts thousands of lives in the united states each year. despite that, cdc reports that takeup rates for the vaccine are still unacceptably low, meaning people continue to be exposed to harmful illnesses that could have been prevented. several of our witnesses have done a lot of work on this issue and i'll certainly have questions about what we can do to encourage broader use of vaccines. i'm looking forward to an update from the doctor about the recent measles outbreaks and the work

the cdc is doing to continue to encourage vaccines. i'm eager to hear from dr. kelly moore about the role in states in preventing and responding to outbreaks like this one and i know that dr. sawyer and dr. jax will be able to provide valuable insight into ongoing nationwide efforts to increase immunization rates and keep children and families healthy. i want to thank, again, all of our witnesses for the important work you're doing and for taking the time to be here with us today. thank you very much, mr. chairman. thank you, senator murray. thank you to you and your staff for working together so that we jointly invited the witnesses today. that always produces a better hearing and a good variety of views. each witness will have up toru five minutes so i'll ask you full summarize your views in five minutes so senators can have a chance to give their questions. then i will introduce -- then we'll take an hour.

i said before some of the senators came in, we'll have to end the first panel at 11:00 so we'll get to the second panel which will go until 12:00. doctor, as the director of national center for immunization and respiratory diseases at the centers for disease control and prevention. she's worked at cdc since 1998 on immunization, respiratory and other infeshs disease. she's an admiral in the public health service commission corps and was named assistant surgeon general in 2006. welcome. >> good morning, mr. chairman and members of the committee. thank you for the opportunity to speak with you today. our nation's immunization system is strong, protecting the health of americans, saving lives and money. but this year's outbreak of measles demonstrates how interconnected we are.

many threats including measles are just an airplane ride away. despite high national immunization coverage against measles, last year we had more cases of measles in the u.s. than we had since 1994. since january 1st, we've already had more measles cases this year than we've had in most full years since 2000. when home grown measles was eliminated in the u.s. from january to february 6th this year, 121 people from 17 states have been reported to have measles. most are linked to an ongoing outbreak that originated at disney parks in california during december. most cases were not vaccinated or didn't know if they had been vaccinated. recent patients with measles have exposed others in a variety of settings including at school, child care, emergency departments, outpatient clinics and airplanes. these episodes require a rapid

response coordinated across local, state and federal jurisdictions. the back bone for such a response comes from the public health immunization infrastructure. the systems and people that protect our communities from vaccine-preventable diseases. today we're talking about measles but we could be talking about a resurgence of whooping cough, or adapting to a shortage of a popular combination vaccine. we need a strong immunization system that takes care of the every day prevention and assures the quality of clinical practice but is also robust enough to respond to emergencies and ready to launch mass vaccination for the next pandemic. whether a vaccine is given in the private doctor's office or at a community clinic, the public health system plays a critical role in making sure vaccination is accessible, safe and effective, and used in the

best way to protect all americans and that our policies are based on a strong, scientific foundation continually reviewed. our priorities for maintaining a strong program include preserving core public health infrastructure at the local, state and federal levels, maintaining adequate vaccine purchase to provide a safety net for uninsured adults and for responding to outbreaks and making strategic investments to enhance the infrastructure and evidence base and improve efficientsy. coverage for many childhood vaccines is above 90% and reported cases for most vaccine-preventable diseases are down by more than 900%. most parents are vaccinating their children with most of the recommended vaccines. less than 1% of toddlers have received no vaccines at all. immunization continues to be one of the most cost effective

public health interventions. for each dollar invested in the childhood program, there are $10 of societal savings and $3 of direct medical savings. u.s. childhood immunization has prevented over 300 million illnesses, 732,000 deaths and resulted in $1.4 trillion in costs. in many ways, though, cost savings. in many ways though, we are a victim of our own success. because of our success, fewer and fewer doctors, nurses and parents have witnessed the serious and sometimes life-threatening consequences of these diseases. because of our success, parents may wonder if vaccines are necessary and may worry that the risks or temporary discomfort of can vaccinating may outweigh the benefits of protecting families from vaccine preventables. cases. measles is very contagious and

quickly uncovers pockets of undervaccination. in the 1980s and early '90s, measles outbreaks uncovered systemic problems with poor children having access to vac seen ins leading to the creation of the vaccines for children program. today measles in the u.s. is an indicator of how globally interconnected we are. when we see outbreaks associated with importationsmacials uncovers those people and areas in the u.s. that are opting out of immunization and we have indications that some of those unvaccinated microcommunities may be getting larger. ourismnization system has risen to challenges in the past and cdc will work with partners to keep measles from regaining a foot hold in our country again. working together we can keep these numbers down, keep measles from returning and threatening the health of our communities and sustain the enormous health and societal benefits that our partnership has achieved.

thank you. >> thanks, dr. schuchat. about ten years ago, senator frist, our majority leader and also fids, led a group of to us south africa. and there we found maybe it's 12 years ago, found the president of south africa had rejected the science on hiv/aids, decided it wasn't caused by a virus and that the cure was elimination of poverty. setting back south africa for years in terms of its ability to deal with hiv/aids. now today, there's information that's on the internet which is where we were told the president had found his information some years ago. that says that there was a study published in lan set in 199 by andrew wakefield alleging a connection between measles mumps and rubella vaccine mmr and

autism. let's say you're a physician or pediatrician and a parent comes in and said i've been on the internet and i'm concerned because i found that according to this medical journal, there's a relationship between this measles and mumps vaccine and the possibility of my child being autistic. what would you say to that parent? >> autism is a terrible condition. that paper that you're mentioning has been totally discredited. it was found to be fraudulent and is not the case. there have been dozens of studies of vaccines and the question of autism. vaccines don't cause autism. they are highly effective and safe and are a good way to protect your children from vaccine preventable diseases. >> when you say totally discredited, what do you mean by that? >> the information in that particular report was found to

be fraudulent by a british investigator, some of the information wasn't correct in terms of the notes that were submitted. but there have been dozens of studies that were better to try to understand whether there is a link between vaccines and autism. it was a natural question some parents had because of the on set age for autism. but those studies have been incredibly reassuring so when i talk to the public or to parents, i like to explain that as a physician and as a public health expert i can tell you vaccines are safe and effective and while autism is a terrible condition one thing we know is vaccines is don't cause autism. >> so you would say to the parent that that article was just flat wrong that's right. >> and numerous studies have shown that it was wrong. >> that's right. >> what happened to the author of the article? >> he lost his medical license. >> because why? >> because of the fraudulent behavior. >> because of the fraudulent behavior. we've been talking about a variety of vaccines.

it struck me as we were so worried about ebola in the fall last fall, we're still worried about it, that many of the public health people would point out to me from tennessee that we had the flu season coming up. how many americans die each year from the flu -- from flu? >> flu is variable. but it can be between 3,000 in a really good year to about 50,000 in a severe year. this is a quite severe year for flu. >> so 3,000 to 50,000 could die from flu. is there a vaccine for flu? >> that's right. there are several different vaccines for influenza. right now about 46% of americans get a flu vaccine each year. we'd like that to be much higher. so we do recommend everybody six months and over get a flu vaccine every year. >> go back to themacials for a minute. measles is not just a runny nose. is it? it's a serious disease. what would you say to a parent who comes in and says i'm going

to opt not to get themacials vaccine? what are the risks of that? how many children who contract the measles die? >> you know, before there was a measles vaccine in the u.s., 400 to 500 children in this country died. the risk of dieing is much higher in countries that are poor where malnutrition is a problem. so we have about 150,000 deaths from measles around the world each year. used to be millions and that's actually an improvement because of high uptake of measles vaccine. >> would it be accurate to say if your child contracted measles in the united states, the chances of a death would be about one in 1,000? >> that's right. but remember, there are other problems with measles not just that rare risk of dying. measles it even a mild case of measles is a scary thing for a parent. my mom was telling me about when i had measles she was scared to take my temperature because i

looked so horrible and it had been so high and she was worried it wasn't coming down. measles can be pretty scary for parents, even the mild cases. there are other complications besides death. children can get pneumonia, dehydration, they can also get a neurologic problem, encephalitis which can be scary and severe. >> thank you, senator murray. >> dr. shuck chat, thank you for all the work you do to protect our families and children across the country. there is no doubt that challenges remain with regards to immunization rates and american families broad access to no cost vaccines is clearly a key factor in maintaining and improving our vaccination rates. in my home state of washington, we have a universal childhood vaccine program which provides recommended vaccines for all children. but i know there are a number of important federal programs that ensure access to free vaccines

in our country. can you describe cdc's effort to ensure all americans do have access to the vaccines they need without cost? sharing including through vaccines for children program and particularly why that's so important? >> the cdc admin officers the vaccines for children program and we just celebrated 20 years of that program. it's been extraordinarily effective. it provides free vaccines to children uninsured, medicaid eligible, american indian, alaskan native. truly to financially vulnerable children in the country. it actually provides vaccines for almost 50% of children in the united states. this program has greatly overcome racial ethnic and financial barriers to vaccination and we see much higher coverage now in the era of the vfc program. as i mentioned we think it's saved over 300 million illnesses prevented those illnesses in the past 20 years and saved $1.4

trillion. cdc also supports the states in a discretionary immunization program to try to bridge some of the gasp that are not addressed through the vfc program. in particular, supporting the public health instruct for immunization so state and local health departments have imization programs that work with the clinicians in those areas. they don't just investigate outbreaks like the measles outbreak but workday in and day out in supporting provider education, in dealing with vaccine short actions, in distributing vaccines so that they get to the provider's offices and your own state of washington has absolutely fantastic program. >> thank you. you know, for me and for a lot of my colleagues, disease prevention was a key priority when we wrote the affordable care act. i'm very proud of the fact that health plans now do have to cover recommended vaccines without cost sharing. as health insurance coverage is increasing, can can you tell me what cdc is doing to help health

departments bill insurance providers for vaccines provided to cover individuals? >> that's right. the affordable care act means that more people have insurance and more insurance is excellent for vaccines because the aca requires that insurers provide all recommended vaccines with no copays or deductibles when they're given a network provider. so cdc has been supporting 35 states to set up billing practices so if insured people need to get vaccinated for instance in a public health clinic, that that health clinic will be able to bill the insurer and recoup the money. we're trying to make sure that the scarce federal dollars that are discretionary really go to protect the infrastructure and that the insurers pay their way. >> okay, good. and i just wanted to mention, i'm really proud of a number of organizations in my home state where they're truly global leaders in promoting vaccination worldwide. we have the gates foundation and

path and the reality is, we're incredibly lucky in this country to have people who have witnessed death by diseases like mealses or polio or whooping cough. i know you have worked with these issues across the globe. can you tell us what you perceive are the key challenges to achieving optimal immunization rates here as opposed to developing countries? >> you know, we are fortunate here to have a strong health system and access to vaccines. in many countries even without the alliance that provides vaccines for free for some of the poorest countries, the infrastructure is very weak. strength ling health systems overseas so that they can deliver vaccines is vitally important. there are a number of public/private partnerships helping in that arena. measles rubella initiative are responsible for more than a billion children getting measles vaccines through campaigns and other areas. we think that about 15 million

children have been prevented from dying from measles in the last 15 years through the measles rubella initiative working with governments around the world. >> so the public health infrastructure that we have here is critical for issues like this? >> absolutely. even fun every single american were insured we still need public health to make sure that we are addressing the needs of the communities. >> thank you. thank you, mr. chairman. >> thanks, senator murray. we'll now move to five-minute rounds of questions. senator collins, senator mikulski, senator cassidy, senator warren for the first four. for the senators who just arrived we're going to move to the second panel even if we haven't finished the senators' questions. that will take 15 minutes and we'll pick right up where we left off with the senators next in line. so senator collins. >> thank you, mr. chairman. dr. schuchat, the president's budget request includes a $50

million cut to the centers for disease control and prevention section 317 immunization program. you've just responded to a question from over in murray about the importance of the state and local public health infrastructure. and more than just paying for vaccines, the section 317 imization program supports outreach awareness, surveillance efforts by the state and local public health agencies. it's puzzling to me that the administration would propose to cut this program when we're in the midst of a measles outbreak when you would think that you would want increased public outreach awareness and surveillance. you've just talked about the

importance of the state and local roles. could you explain to us why this cut has been proposed? >> the public health infrastructure at the state, local and federal level is vitally important to protecting americans. as i mentioned earlier, these threats like measles are an airplane ride away. the reduction in resources requested through the president's budget will be accounted for through a reduction in vaccine purchase and the idea is that instead of paying for vaccines for insured people, the health departments will be able to bill the insurers so that they will pay their way. but absolutely protecting the public health infrastructure at that state and local level is critically important as is the communication outreach and the provider work that we do. >> well, it just seems to me that this is exactly the wrong time for us to be reducing funding in this area given the

importance that you've just outlined. historically access to health care and the cost of vaccines had been the major barriers to achieving high vaccination rates but increasingly, it's clear that other factors have come to bear as we're seeing declining vaccination rates in some extremely wealthy areas of our country. for example, there was a recent article in the atlantic magazine that recently compared unfavorably the vaccination rates in wealthy areas of los angeles to the higher rates in the south sudan. how should our public health strategy change to reach those parents? you would not think that that would be the area since they obviously can be afford the cost

of the vaccines and have ample access to health care. certainly better than those in the south sudan. >> yeah, 25 years ago, we were dealing with a problem of children not having access to vaccines. and what we're seeing more and more these days is parents opting out of the system and not wanting their kids to be vaccinated. i like to start with the premise that every parent wants their child to be healthy and safe. that's number one. i think that for a number of parents especially in some of these communities where opting out is common, they really don't realize that the diseases are still around. and as we're seeing this year, when measles virus comes into a community, it's those communities where lots of people aren't vaccinated that are at higher risk. so i hope parents in those communities are recognizing that the threat is actually real. another factor is misinformation and, of course, in today's world, it's really easy to get information of all types. much of it isn't very good.

so we at the cdc try to have the best information possible available and to make sure people see the sources of the information and can really check the facts themselves. we also work closely with clinician groups like the american academy of pediatrics because what our research suggests is parents want to hear about these things from their own doctor who knows them and their family and their circumstances. so i think a lot of the attitudes out there may be from complacency that these diseases haven't visible, but unfortunately the disease is getting more visible this year. >> thank you. i think that the "lancet" study also played a huge role, unfortunately. i think that there are a lot of people who still mistakenly believe there is a link to autism and are unaware that that study has been thoroughly discredited. thank you, mr. chairman. >> thank you, senator collins. senator mikulski.

>> thank you, mr. chairman. doctor, my question was going to be fairly identical to senator collins' question on the reduction of 50 million dollars and the 317 grant program which is to take care of the uninsured as well as vaccine safety outreach and education. now, you're saying that that reduction of $50 million will have no impact on those services? related to vaccine safety outreach and education? >> no, i can't say that those reductions will have no impact. what i'd actually try to say is that the way that we would address those changes would be to reduce the discretionary vaccine purchase and try to really increase the il billing of insurance so it's of course, vital that the public health infrastructure be protected. >> well, we feel the same way and particularly on the issues related to outreach and

education. i'd like to join with the gentle lady from maine because this is not an aappropriations hearing but when we do move to labor hhs, i think this is a valid area of inquiry and bipartisan cooperation. this then takes me to science and the misinformation. does cdc track the correlation between vaccine compliance and rates of autism? and specifically, mississippi that has almost virtually a 100% come compliance rate? what is the autism rates in mississippi? >> i don't have that information, but there are a number of ways that we've tried to understand trends in autism. and vaccine exposures and a number of different study designs have really discredited any link between autism and vaccines. >> here's my question. i believe that the solution to misinformation is more information.

and that it be science and evidence based. exactly your whole professional career, doctor. so my question though is, do you track that? do you track the correlation? >> we track the trends going on in autism and the trends going on in vaccination around the country. the trends in vaccination are that almost everybody is getting vaccinated with most of the vac an scenes state by state, there are differences in particular vaccines. mississippi has a -- does not allow personal belief exemptions and many people feel that the only exemptions an that ought to be allowed are medical ones because of course, some children can't get vaccines because of health risks. >> what i'm trying to get into is the epidemiology that where there are high rates of compliance, how does that correlate? >> there's not correlation between vaccination uptake and autism. >> and you have the epidemiology

to support that? >> right. >> which then goes exactly who outreach and education. now i want to go to a different -- because i really think and i think the committee ought to really think about our efforts in the area of autism. i know we've been very focused on issues related to alzheimers and others but it really is an epidemic in our country. mothers will do anything and fathers, as well to protect their children. they need good information, they need real science. and for families facing these challenges, they need to have answers. it's another area i think we should take a look at on a bipartisan basis. but i want to shift gears to immigrant children. and their vaccinations. i know this can get controversial. but what are the outreach efforts and how do we deal with this because for example, 60,000 children came to america last year. many of them are in maryland. and hopefully they're in the

sunshine going to schools and so on. but are you -- has cdc an effort with states where there's high rates of new immigrants both legal and not legal where the immunizations of the children are addressed? because there's this is whoa attitude they shouldn't be in our schools, they shouldn't get our public health infrastructure and this is exactly what we're talking about. in my own hometown, central american kids are going to school side by side with the gentry kids. so how do we insure that the needs of those children are addressed? and therefore, the needs of american children to be protected are also addressed. >> vaccine preventable diseases don't respect borders. it's important for individuals to be vaccinated for their own health and also to protect the people around them. so the state and local health departments work hard to make sure people are imized regardless of their country of origin.

it's very important in an era wheremacials has been eliminated from north and south america for us to continue to make sure there's strong immunization efforts in other parts of the world where it is still circulating. for vaccine preventable diseases it is important to make sure people have access to vaccines regardless of where they're from. >> thank you. senator cas sid. >> of those folks infected in the california epidemic, how many were native born americans and how many had emigrated here? >> i don't have that information, but what i can say is that most of the importations that we have of measles each year are in americans who are traveling abroad. >> when you say an american though, an american -- >> u.s. born. >> u.s. born american. >> right. >> got you. so we've heard a lot about how the families from the wealthy

communities of santa monica and the westside of los angeles are not vaccinating their children but is that where we are seeing these cases? do you follow what i'm saying? i did my residency in los angeles. there are a lot of immigrants and a lot of those may have fall between the cracks. so again, do we have any sense of who is contracting this? >> right. for the measles outbreak, we are seeing spread in some of the wealthier communities in california, for instance. years ago, we had a lot of importations of measles from latin america which is where we have a lot of immigrants. but the americas really took on the elimination of measles and did major campaigns around all of the countries. and had great success. >> can i ask, when someone ep greats what is their requirement in terms of immunization? if somebody is coming from the philippin philippines, what is the requirement now? >> there's a requirement for documentation of vaccination against account vaccine

preventable diseases. the vaccines for children program makes sure that the refugees would have access to vaccines. >> that would be for children by definition less than 18. what if an adult emigrates from a country like the philippines? >> right. that's not it the case there, but most of the spread is coming from -- most of the risk is in children -- if you survive to adulthood in most countries you've actually already been exposed to measles. >> so of those adults going to the philippines and coming back and they are the ones bringing the cases, is there any -- i assume there's a travel advisory if you go to the philippines to get immewized. is there any effort in the philippines? you've mentioned how the americas have bucked up their immew nation efforts. what about the philippines? >> there are efforts there. unfortunately the philippines suffered that horrible hurricane and after the weather problem, up of their immunization

infrastructure has destroyed. they've had a really bad measles outbreak in response and cdc and others have responded to help them work on their immunization campaigns. the biggest outbreak we had last year of measles was in travelers, a couple amish adult who's traveled to the philippine who had never been vaccinated and brought the virus back to ohio. it turned out the amish community stepped up to to be vaccinated but that was a large community where very few people had been imized. fortunately in the u.s. most communities have high immunization rates. it's just these newer communities where parents opt out that we're worried about. >> when we travel overseas often we need aim mewnization record. a fellow from my church went to a mission conference in the feel means. was he required to show his record to go and is it required mmr? >> he wasn't, but we hope that

we're reaching him through our outreach efforts. we were concerned with the ohio outbreak we hadn't reaped those travelers. they hadn't realized they should have been immewized. >> that seems like an easy thing to do if you apply for a visa that says listen you're traveling to a place with endemic measles. >> yeah, there are a lot of electronic prompts that alert you. with our alerts they're not 100% in terms of people following them. >> is that something when we approve a visa, it seems like there should be some process by which somebody is traveling to an endemic country that we would remind them of their risk. >> yeah, i definitely think we could looking into that. >> what about immunization rates since 2009? risen or stayed the same? >> they've risen for newer vaccines abstable for the others. we track very closely the percent of children who receive no vaccines at all by age 2. >> somewhat stable. i'm wondering about senator murray's statement.

you seem to concur that the affordable care act may have improved immunization rates. i think we know with the chip program and vaccines for children program, i've done a lot of immunization work among children that cost has not been a barrier for an sometime because of vfc and public health units. would you accept that? >> that's right. it's adults where the rates are low and we have lagging coverage in teenagers. >> vfc would not require hepatitis coverage in a adult i assume? >> no just through 18. >> ac app would not either? >> no, they would cover vaccination of an adult with hepatitis b if they were in a recommended. >> if they're at risk. a gay man or something like that. >> of course. >> i think it's important for the record for childhood immunization the affordable care act is not hurt but it's not augmented that which is which was previously there. the vaccines for children

program has had a huge impact. >> the vfc but not the aca. >> i yield back, i'm sorry. >> thank you, senator cassidy. senator warren. >> thank you. when the polio and measles vaccine became available for the first time, parents lined up to make sure their kids would be protected. they had lived in a world of infectious diseases that destroyed children's futuresen and desperately wanted to leave that world behind. these vaccines work so well that the memory of these diseases has faded and the importance of vaccination has become lets obvious. last month, it the pew research center report found while nearly 80% of baby boomers and seniors believe vaccines should be mandato mandatory, only 59% of people under 30 hold that belief. and now measles is back. so dr. schuchat, you are the top immunization official in the united states. i want to walk through the science on this with you. is there any scientific evidence

that vaccines cause autism? >> no? is there any scientific evidence that vaccines cause profound mental disorders? >> no, but some of the diseases we vaccinate against can. >> the diseases can but not the vaccines. is there any scientific evidence that vaccines have contributed to the rise in allergies or autoimmune disorders among kids? >> no. >> are there additives or preservatives in vaccines that can be toxic to kids? >> not in the amounts that they're in vaccine ooze. >> is there any scientific evidence that getting kids their vaccines further apart or spacing them differently is healthier for kids? >> no, it actually increases the risk period for children. >> so it adds to the dangering? >> right. >> is there any scientific evidence that kids can develop immunity to these diseases on their own simply by eating nutritious foods or being active? >> no.

>> how do the risks of a child responding negatively to a vaccination compare with the risks of skipping vaccinations and risking exposure to a deadly disease? >> vaccines are safe and highly effective and it's important for parents to know they're the best way to protect their kids. >> so i think every parent wants to protect their children, parents should know that all of the credible scientific evidence suggests that modern vaccines are safe, modern vaccines are effective, and modern vaccines are our best chance of protecting our children from diseases that can kill them. is that right? >> that's right. >> thank you. thank you, mr. chairman. >> thank you, senator warren. senator roberts. >> thank you, mr. chairman. i appreciate you holding this hearing. in kansas, we had 19 cases of vaccine preventable diseases last year.

the most prevalent was measles. we have not had any new measles cases reported yet this year. our public health workers are concerned. our parents are concerned, however, i'm concerned. the problem is that our immunization rates are down. for the 2013 year to the 2014 school year, the percentage of youngsters that have received the necessary vaccinations is now below 90. that's not good. for the record i had measles and chicken pox and mumps and everything else that people had back in the day. but what i'm asking if i can get to it here very quickly, if immunization rates continue to decline, what advice do you give to these youngsters parents who have to rely on others in their community to choose vaccination to help protect their own? >> the lower the rates are, the more your children are at risk.

so you want to be making sure your own children are vaccinated but also it's important to have those around them vaccinated. some kids can't get vaccines because they have leukemia, for instance. they can't get live viral vaccines. our best protection is that community level of vaccination. >> you high lie three reasons parents don't vaccinate. the fear of side effects, religious, or philosophical objections. and there's a whole bunch of paragraphs here in the background information on which states are easier to get a religious exemption and which are easier to get a philosophical objection, a simple letter signed by a doctor. how often, however, about the mistrust of recommended vaccines schedule, how often would you say it's the latter that the vaccine schedule is too rigorous and reassurances could you provide to parents on this concern? >> many parents do mention the number of shots the children get

at a particular visit as something that concerns them. we like to let people know that the vaccines are recommended at the time times they're recommended because of the way they work and because of the disease risk. so our advisory committee on immunization practices reviews the science of the vaccines and diseases and updates the schedule every year based on the best information available. so we -- i strongly recommend parents get their children vaccinated on time and according to the schedule. >> in answer to the chairman's question which really nailed the issue right off the bat, there was a major danish study published in 2002, 540,000 children showed definitely there was no relationship between mmr, ie measles vaccination and any kind of problem with autism. an institute of medicine report

in 2004 did the same along the way, there have been studies from the national institute of health, the centers for disease control, hundreds of other reliable academic groups. all of these examinations point to the same conclusion, the body of evidence was firmly established a long time ago. however, this is a state issue. and that seems to be the problem cdc is doing the very best that you can to try to convince every state. mississippi leads. we're at the bottom. not at the bottom but you know, fairly close to it. i'm very concerned about it. but at least the media i think today realizes that one study which was totally discredited that there should be a very strong statement by everybody involved that they should go ahead and get these vaccinations. so i strongly represented that and i thank you for your

leadershi leadership. >> thank you, senator roberts. we'll now go to senator -- i want to mention again to the senators at 11:00, we're going to excuse dr. schuchat and call the second panel for 15 minutes but then any senator who hasn't had a chance to ask a question will be the first one, first one up. senator baldwin. >> thank you, mrs. chairman. i also want to thank the ranking member for holding this hearing. our nation's vaccine program has greatly reduced human suffering and saved lives by preventing and reducing the outbreak of preventable diseases. and thanks to national policies including the affordable care act, now millions of families have access to free immewizations. and it's why i'm so concerned as

i know many colleagues are about the recent measles outbreak and the surge in misinformation exacerbated by the media and even some national figures. and then misinformation, of course, is surrounding vaccine safety. to prevent against future outbreaks, i think it's vital that we continue to invest in our nation's vaccine production capacity. support cutting edge science and enhance public education surrounding vaccine safety. so i have a number of questions especially around our production. over 20 years ago, partially in response to a measles outbreak, congress recognized the critically important roles of vaccines by passing and creating the cdc's vaccine for children program. which provides recommended pediatric vaccines to low income

children. the cdc also maintains a stockpile for pediatric vaccines. so far dr. schuchat, could you tell us the current state of our national pediatric vaccine stockpile, and is the measles vaccine included in that supply and can you elaborate on the role of the stockpile in addressing outbreaks as well as how cdc works to maintain it? >> yeah, the vaccines for children program includes a symptom o stockpile that is approximately 50% of enough vac even for 50% of the pediatric population to be vaccinated for a year. so we currently have over 3 million dozes of mmr vaccine. the vaccine stockpile has been used both for outbreak response but it's also been used for vaccine shortages and even with a robust vaccine manufacturing industry, there are many

vaccines where there's only one or two manufacturers that produce them and when there are interruptions in supply will have to go to our stockpile to make sure that there's not an interruption in use. so it's really been a critical safety net for the vaccine security. >> i want to explore a little further this issue of production and interruptions in production. both with disease preventable or diseases that are prevented by vaccines but also you know with the influenza vaccine where they might not be 100% match to the strain that's prevalent in a given flu season. two issues. one is, well three issues. domestic manufacture versus overseas manufacture in the case of an epidemic that's particularly legal has been a long issue. i understand we've improved domestic production. anything you can elaborate on

that would be helpful. secondly, production is usually still slow and based on chicken eggs. and there have been many efforts to transition to a cell based production in the influenza vaccine where are we on that, and thirdly, with regard to diseases that are preventable by vaccine, we have had drug manufacturers who have decided to exit that area and oftentimes with little notice to the medical profession. i've heard from frontline pediatricians who say we don't have enough in our clinic and we have people coming in and we can't meet the demand. is there better notice given to the cdc? do we have more safeguards in place to make sure we don't have an alarming shortage? >> yeah, we had a big wake-up

call about ten years ago in october, 2004, where overnight half of the expected influenza vaccine supply wasn't coming through. and that was a really prompted an enormous amount of re-evaluation on different parts of government. we're in much better shape now. that year we eventually had about 5 million doses of flu vaccine. this year we have nearly 150 doses of flu vaccine distributed. there are multiple new manufacturers or additional manufacturers producing for the u.s. market. and we also have a number of formulations besides the egg-based that have been approved by the fda and are being used. so cell based and we come bin nant influenza vaccines are included amonging this year's supply and looking towards the future, there's a lot of enthusiasm across the government about and across academia around investments in towards a universal influenza vaccine that

might give us broader and better, a longer lasting protection than the vaccines that we use today. so there's a lot of progress in the past decade. there's more work to be done. in terms of the communication with the industry. >> dr. schuchat, i'd like to try to get senator franken in before you leave. >> we're good. >> is it all right if we -- thank you senator baldwin. senator franken. >> thank you, mr. chairman for that. you know, i'm thinking that maybe this outbreak in measles is a bit of a wake-up call. as senator warren said that you know, a lot of baby boomers and some of us who are and some of the senators are older had measles and remember it. and maybe this is a really good time for especially some

educated people who were foregoing this for their children to understand things like herd immunity. you get a critical mass of people not getting immewized, you have outbreaks like this. and what the costs are, well, just like the financial cost. there was a 2005 nih article that attempted to quantify the economic impact on health infrastructure and researchers estimated that one case of measles costs the federal state and local health departments more than $140,000. to respond to just one case. and this you talked about the return on investment of all of these immunizations. i think it's one of the most -- it's obviously cost effective, also prevents a lot of

suffering. we live in a global world. and i just want toed to ask you about that investment that we put into global public health. and what the importance of that is. so in terms of our investing in this in africa and other places. can you respond to that? >> yeah, meeses has been eliminated from the americas but it's still iraq cue lating around the world with about 20 million cases a year. and in some of the countries that have had major outbreaks, it's really investing in their health infrastructure and supporting their ability to have strong immunization systems that will protect americans as well as strengthen their health. so we're really keen to be partners in the polio eradication nashiative and measles rubella initiative and ways that we can help protect

children everywhere with vaccines that are safe and effective. it strengthens our communities protection at home and the right thing to do overseas, as well. >> because measles in particular is highly contagious and you're one plane ride away from another -- for american getting infected. speaking of which, what other n enif he cannious diseases may be on the horizon? what might be the next measles and what might come from mers or what else are we looking for in the near future snug possibly. possibly. >> with infectious diseases you really have to be ready for the idea that the microkroebs are changing faster than we are as people. so this past year we with dealt

an enter row virus d 6 problem, a severe respiratory illness in children we haven't sheen. the last two years we've been dealing with the middle east pis rememberer to zom that was causing very severe disease in the middle east and travelers returning from there with two cases in the u.s. >> that's the mers. >> right. so we really think it's critical to be strengthening public health infrastructure and capacity for global health security in countries around the world so that you we don't let an epidemic like ebola get as bad as it got but can be jump on it right away. we recognize these diseases overseas and help the countries deal with them had swiftly. >> and that's why the cdc is so important. i really want to thank you for your service to this nation and to the world. thank you, doctor. thank you, mr. chairman. >> senator franken.

dr. shuk chat, maybe i misheard something. the state department website says that u.s. emigration laws requires immigrant visa publics to require certain ux mewny zass so an adult immigrant to the united states who obtains a visa is required to obtain certain vaccinations, is that correct? >> i think that's correct. >> i'm leading off the state department website. i didn't want to leave the impression i didn't want to leave a different impression if it was untrue. >> thank you. >> dr. shuk chat, thank you so much for your time. there are a couple of senators who haven't had a chance to ask questions but i hope they will understand we want to invite the second panel to come up now. and they will be the first ones up after the next 15 minutes of testimony. >> i'll now move ahead and introduce the second panel to save time if i may. first we'll hear from dr. kelly

moore. dr. moore is director of up mynization program at tennessee department of health and responsible for promoting proper use of recommended vaccines as well as overseeing the response to outbreaks of vaccine preventable disease. she has her undergraduate medical degrees from vanderbilt, plasters of public health from harvard school of public health, and i'm completely objective but tennessee department of public health is one of the finest in the country. dr. mark sawyer is professor of clinical pediatrics and a pediatric infectious disease specialist at the university of california san diego and raiddy children's hospital in san diego. he's also the medical director at san diego immunization partnership and involved in a variety of immunization practices projects.

dr. tim jacks is a pediatrician and the father of two children who recently were exposeded to measles in arizona. he's an every chide by two immunization champion. it is a non-profit dedicated to increasing vaccination among children. his wife is in arizona caring for their children. i'm grateful he could be here to tell their story. dr. moore, let's begin with you. if the three of you could summarize your comments in five minutes, we'd appreciate it. then the senators will continue questioning. >> thank you, chairman alexander and senator murray for holding this hearing on the benefits of immunization and invoting me herrer who to testify on vaccine employee ventable disease. most people are unaware that even in a state with a strong history of imknewnization, a single case of measles requires a major public health response. i'd like to acknowledge governor bill haslem and first lady krissy for their commitment to

immunization as an essential step in promoting and protecting the health and pos prart of tennesseans. could you say tennessee has a culture of immunization. for the past two influenza seasons, the majority of entennesseans aged 6 months and up and received a flu vaccine. in 2013, 95% of kindergartners were imknewized with all required vook scenes including both doses of in mmr. just one out of 100 claimed exem 00 and one over in a thousand were exempted for medical reasons. the program has removed barriers to access for eligible children since 1994. our state's online immunization information system supported by federal funds ensures that authorized users such as clinics and schools have access to immunization records to see what vaccines a child may need or verify that they're protected. we have more work to do to reach

had high rates with vaccines designed for teens and adults that prevent diseases such as meningitis, cancer, pneumonia, and shingles. public health partners with our clinical and pharmacy colleagues to address misinformation and concerns about safety, health benefits, and affordability. two improve access, our department is using federal prevention and public health funds to help local public health clinics become in network providers for commercial insurance plans so we can provide represented vaccines to their beneficiaries with no out of pocket costs. when it comes to disease outbreaks, few realize how much public health work goes into one case you have measles. i vividly recall each of the nine cases tennessee has had in the decade i've directed our immunization program. our most recent experience is a good example. on a friday afternoon, last april, a doctor called his regional public health office about an adult with an uncertain

immunization history and recent overseas travel who was in the er with the classic symptoms of measles. the diagnosis was not in question. a game plan was quickly developed in a call with the state program to identify those who may have been exposed in the four days the unsuspecting patient was highly enif he cannious. 124 people were identified. the mmr vaccine could protect the most recently exposed susceptible contacts if local public health could find them quickly enough. 25 contacts with uncertain immew nit were the vaccinated on saturday. >> others counseled what to do if somes developed. among the 1249 contacts just three cases among other adults developed. for these, the same isolation contact cab tracing and notification process was practiced but faster. no additional cases occurred. in total, 406 k 6 contacted wer evaluated. we worked with the media

statewide to educate account public through state alerts and an educational web nar. cdc measles experts provided consultation and specialized testing that helped us optimize our management tactics. a great deal of credit in this story goes to the hard work of public health at all levels. this result, however, could only have been achieved in a community where a very high percentage of the population was already immune. had this imported case landed among those who were unimmewized and sus eptable, there would have been a very different outcome. congress's sustained commitment to immunization and in second 316 funding will continue to equip us to meet the educational and operational challenges of keeping individuals and communities healthy and safe through affordable accessible and effective immunization services. thank you for the opportunity to testify here today.

i've provided a more detailed written testimony for the record. i'm glad to answer your questions. thanks. >> thank you, dr. moore. dr. sawyer. >> chairman alexander and ranking member murray, thanks very much for holding this hearing on a very important topic, the re-emergence of vaccine preventable disease and what we can do to prevent further outbreaks. i'm a pediatric inif he cannious disease specialist in san diego. i'm also a member of the committee on enif he cannious diseases of the american academy of pediatric. my testimony today has the strong endorsement of aap. vaccines are one of the greatest public health achievements pointed out by dr. schuchat and several of the senators. prior to the introduction, children suffered regularly from serious illnesses likemacials. diptheria, polio, even bacterial meningitis. the development and widespread use of vaccines led to a reduction or eradication of

these once common childhood illness. because of the success of vaccines, i have never seen a case of polio diphtheria or tetanus in my 30 years of practice in pediatric inif he cannious disease. in a teaching session i held last weeking with 20 pediatric residents in training i asked them if any of them had seen the measles. none had. however, as we have seen from our current measles outbreak and continues outbreaks of pertussis or whooping cough around the country, we are witnessing a re-emergence of vaccine preventable diseases here in the united states. unfortunately, my residents are going to get a chance to see the measles. ped electrics are concerned the ere-emergence of disease is a signal bigger outbreaks are yet to come. most of the cases are from california and 13 are from my own community. but outbreaks liking this are increasing in frequency and size. this measles outbreak like all other measles outbreaks are

occurring because we have too many intentionally unimmewized children in the united states. and it illustrates the problem created by unimmewized populations. a simple trip to disneyland led to a multistate outbreak of measles involving more than 100 people. it's one of the very few inif he cannious diseases that flies through the air. it is completely predictable that such outbreaks occur again if rates stay where they are or get worse. while most parents do choose to vaccinate their children there are can the pos of up be immewized children all over the country. in san diego, we have 1500 kindergarten students not fully immewized. that number has been increasing steadily over last decade. the current outbreak reminds us about an important fact of these diseases. they are a shared public health problem. when one person is infected, people they don't even know become infected. the decision of a parent to

leave their child unimmewized however well meaning is a decision that affects us all. although our public health community has done an excellent job of controlling this current measles outbreak when too many people make the decision not to vaccinate their children, outbreaks will no longer be controlled. why is this happening? all parents want what is best for their children. many parents are choosing to not have their children immewized because they have received inaccurate information about the risks and benefits of vaccines and the diseases they prevent. i have held a number of forums in san diego county meeting with vaccine hesitant parents to hear their concerns. based on what i've heard in these discussions i conclude that the internet can be a dangerous place for parents looking for information about vaccines. the internet is replete with anecdotes and misinformation that leads parents to think that vaccines have caused harm. what is overlooked by parents is the fact that just because an

adverse health outcome occurs in the time after a vaccine, doesn't mean that the vaccine caused the problem. it takes science to prove or disprove a linkage between two events and our parents are not hearing the science. the vaccine schedule recommended by cdc and aap has been developed with strong scientific standards and has been proven to be both safe and effective. in every case for every vaccine, the risk from the disease outweighs any risk from the vaccine. in my opinion, the best way to decrease the number of families refusing to vaccinate their children is to improve communication about vaccine safety and effectiveness, to increase the science literacy of our population, to limit the philosophical exemptions from school entry requirements for vaccination and to continue to carefully monitor the safety of all of the vaccines we use. taking these steps can ultimately help reduce the number of children who choose not to vaccinate their children.

the re-emergence of vaccine preventable diseases is alarming and must be confronted if we are going to prevent further outbreaks like the one we're currently experiencing. thank you for allowing me to testify. i look forward to your questions. >> thank you, dr. sawyer. dr. jacks. >> senator alexander, senator murray, esteemed members of congress, my name is tim jackson. i'm a board certified pediatrician on the frontline of this vaccination issue. i daily recommend vaccinations to my patients and address concerns and questions they have. lately, i've also been addressing many questions over the ongoing measles outbreak. but i'm not here today as a medical professional. i'm here today as a father. three weeks ago, my infant son and daughter who is battling leukemia were exposed to measles. since her diagnosis of with leukemia,ism months ago, our

home life has revolved around my daughter maggie's care. she's been admitted to the hospital six times and spent nearly a month there. she's on a very regimened schedule of treatments and she day up to six medications at a time. we have weekly visits to an outpatient clinic where she has procedures, she has blood work kraun and she gets her chemotherapy infusions. at one such clinic visit my children were exposed to measles. we were informed of this exposure and instructed to return for shots of the measles anti-bodies which we did. now, these anti-bodies are not perfect protection, but in the case of my children it's the only thing we can do to prevent them from actually coming down with measles. right now my two children are at home under quarantine. while we are waiting the three weeks to see if they develop measles or if they exit quarantine without any symptoms,

i typed an entry into maggie's blog, and this this blog is something i use to update family and friends to her treatment progress and just to let people know how she's to go. typically i get 100 people reading this blog. needless to say, it has gone viral. the title of had this blog entry was, to the parents of the unvaccinated child who exposed my family to measles. in this blog i vented my frustrations, my anger at the situation, and i explained and hopefully educated some people as to why my children and many other children like them are at risk. eli my ten month old son has received all of his immunizations on schedule, but is too young to receive his first dose of mmr. and my daughter, maggie, who was also previously fully immunized is at extra risk right now because of her weakened immune

system due to her leukemia as well as her treatment. the blog went viral. am over two weeks it received over 1.3 million shares on facebook and has been read countless times. i have been contacted and interviewed by cnn, fox news, many other local and national media outlets. i have taken these opportunities to share our story and hopefully raise awareness to this issue. my hope that we can prevent some families from going through the same thing that we've gone through these last three weeks. i also hope that we can prevent more families from getting measles all together. prevention is simple. vaccinate. as immunization rates drop her the hurt immunity starts to break down and this is the only thing protecting my two young children from being exposed to measles or whatever the next outbreak is. i urge a strong unified

bipartisan voice supported the scientific evidence that vaccines are safe and that they save lives. we need a consistent message from the presidency to capitol hill down to our local state legislators, schools and even day cares. i urge congress to take action supporting the programs and infrastructure already in place to get these vaccines to those that need them most and contain outbreaks such as we are seeing today. i will care for my family. i will work to promote health among my patients and through partnership with organizations like every child by two and the arizona partnership for immunization i will advocate for timely vaccinations for children. thank you for your commitment to this issue. with your help we can stop the spread of vaccine prevent i believe diseases and protect the innocent. we can protect our children. we can protect my children. thank you. >> thank you, dr. jacks, for

your personal story and thank you, dr. sawyer and dr. moore. now we will go to the senators who have not yet had a chance to ask questions and we will begin with senator casey. >> mr. chairman, thank you very much. i appreciate this hearing. we certainly want to thank the witnesses for bringing to this hearing room today your experience, your knowledge, your significant time that you've dedicated your lives to on these issues and, dr. jacks, we are especially grateful that you are bringing your own personal story. these issues are difficult enough, but ever more so when you have a loved one, in your case a daughter that is the sub of your own -- your own efforts. so we're plateful for you bringing that to us. i'm tempted to ask, but i won't, i will just refer to it, kind of the why question here. why this failure to vaccinate

also become to significant. that may be for -- that may be the question that we are all asking is. but i guess he maybe a better question to ask is what can we do to push back against it. we're to go that today and obviously each of your testimonies have referred to that. i wanted to get to some of the ground level work that has to get done kind of day in and day out about which i don't know much and maybe some members of the panel do. what happens this our schools, what happens am had communities and what happens even in the offices of pediatricians. dr. sawyer, you mentioned you were talking about the fact that you if this all your years had never been exposed to this this as a -- in a direct way as a practitioner. i wanted to ask you specific questions about pediatrics. do you think we're reaching the point where there has to be pediatric training that speaks

to this? in other words, a change in the training that reflects the reluctance had a some parents have to vaccinate? >> yes, i think that's an excellent question. there are efforts underway from the american academy of pediatrics nationally and in my case locally, i have a curriculum for residents about immunization and three or four years ago i added a whole section of that curriculum to teach residents in training about how to communicate about vaccine safety and address the concerns of these parents in an open, nonconfrontational way with the hope that if we can just educate our families and give them good accurate information they will make the right decision. the problem is there's so much inaccurate information circulating, highly educated families who get on the internet and read something and take it to heart before they really critically look at the source of that information. is so that's what we need to try to address. i mentioned in my statement to raise the science literacy in

the united states. that's a tall task but i think without that we are never going to win this battle. >> thank you. dr. moore, referring to your testimony on page 3, you talk about in the second full paragraph, am tennessee -- and i'm quoting -- in tennessee local school nurses and coordinated school health directors are among our most important champions of immunization. can you tell us about that and the importance of that? because as much as we have an obligation in washington to get a message out, try to get the policy right, a lot of the best work will be done in those settings. >> that's true. i can't speak high youly enough of our local public health nurses and the school nurses and school administrators who work with families because truly these parents often hesitate to be -- to vaccinate their children out of fear. they want to do what's best for their child, these bells go off when they hear scary things about vaccines and it's very hard to unring that bell, but the people best which happened

to do that are the people they trust and are in had close relationships with. when i talk to local public health thursdays they care so deeply about these families that they work with and a lot of -- a lot of this can be overcome with credible information from trusted sources, good relationships and that's what these folks provide. i'm always a phone call away when they have a question on a technical thing, i can help them with that but they are the ones with the relationships with the families to help them overcome these fears and i think our immunization rates are a testimony to that ability for them to work through this with families. >> i appreciate that. i will wrap up with just one statement. i know that in the debate about how to respond to the ebola crisis among the best pieces of advice we all got here was local validators are a lot better than validators outside of a local area. i won't say washington, but i think you know what i'm talking about. thank you for your work and grateful that you are here today. >> thank you, senator casey.

senator murphy. >> thank you very much, mr. chairman, ranking member for this hearing. thank you all of you, especially dr. jacks for taking the time to tell your sorry. i wanted to talk for just a minute, ask a few questions about the nuts and bolts of how ex mpgs work. because we've seen a pretty rapid rise in exemptions am my state, for instance, which has fairly loose rules regarding getting exemptions, a feature we share with california, frankly. we've seen just in the last three years the number of people who are applying and getting religious exemptions is has doubled, just in three years. so i heard in your testimony, dr. sawyer, that you are actually proposing eliminating the philosophical objection. can you just speak for a minute on why you've made that proposal? >> well, i made that proposal because as you pointed out i live in california where up until last year in order to

exempt from child from school vaccinations you simply flipped over a paper at the registration and signed it that you had a philosophical objection, not a religious exemption, not a medical reason, you just don't believe in vaccines. just as you mentioned in your state we have seen a steady rise am those exemptions in california over the last deck achltd there are very few religions that specifically advise their followers to not vaccinate. it's this philosophical exemption that's causing the problem and i think it's driven by ms. information. i'm certainly in favor of eliminating such is philosophical exemptions, the state senator in california just introduced a bill last week to do just that and i'm certainly going to be supporting that effort in california. >> let me suggest an alternative to the elimination of the exempti exemption. as you mentioned all that you need to do in a state like california or connecticut is simply sign a piece of paper, you actually get no information about the consequences of not

getting a vaccination. yet the studies are pretty clear that the more information that you give the less likely it is the people will take the exemption and, in fact, the less likely that you will have outbreaks here is a stunning one were 2006. in states that had higher bars for exemptions they were 50% less likely to have whooping cough outbreaks. and you can -- you can recite other literature that says the same thing. so i ask this to dr. sawyer, but happy to get comments from the rest of the panel. let's say we just raise the bar for a philosophical objection and we said, for instance, that you have to consult with your physician first or you have to review information about the risks of not getting your kids vaccinated. do you think that that would be helpful if we weren't successful in eliminating the exemption? i said to dr. sawyer but i would be glad to hear other pan lists.

>> we have just done that in california, last year requires a law for parent to exempt their child, have a form signed by a healthcare educator that they have been educated. that led to a 1% drop in the rate of exemptions in california as a whole but it is still at 2.5 do 3.5% in different communities within california. we will see next year whether that form continues to drop the rate. my concern is we've seen the benefit of a one time drop and we're going to go back to the steady gradual increase am exemptions, whether people stick to philosophical ones with their doctor's information or whether they as you pointed out start to exercise religious he can empgss that they didn't before. >> just quick comments. >> tennessee is one of the vast majority of states that does not have a sill sofkel he can empgs and has no intention of developing one. >> only 20 states have them. >> correct. about 29 or so have no fill sofk

exemption including tennessee. i think we have to decide as a community do we want to protect it the most vulnerable among us or do we want to provide choices and options for protection. we can't do both at the same time with a disease as contagious as measles. if we're prepared to accept the consequences of outbreaks like this then personal choice is perfectly fine. if we want to protect the vulnerable like dr. jacks' children immunization needs to take place to do that. it's the best way to do that. >> thank you, martin luther king. my office is looking at some legislation, proposed lenls operation had a would provide some incentives for states to increase the information that they are giving to parents, not necessarily dictating what exemptions are used but admit as a national health priority make sure that the best information is dwich out. if you're getting a medical exemption am most states you actually have to have a note signed by a doctor but if you're using a philosophical he can empgs or religious exemption

often all you have to do is sign the back of that form. it seems like we should at the very least try to pear those two standards together. thank you very much, mr. chairman. >> senator bennet. >> thank you, mr. chairman. thank you very much to you and the ranking member for holding this hearing. it strikes me listening to the it em that we've been victimized by two things, one, a generation that has not experienced these diseases because of vaccines and have lost sight of what they look like, and interestingly to dr. sawyer's point the unedited content on the internet that people, you know, more affluent families i guess are reading. i wonder, dr. sawyer and then i would ask the other panelists -- let me also say, dr. jacks, thank you for your testimony i hope maggie is having a chance at least to watch you while you're doing this or maybe doing something more interesting at home but thanks for being here. dr. sawyer, could you use this opportunity to tell us what the biggest falsehoods are that are

being trafficked on the internet and what the answers to those falsehoods are? and the other panelists would like to join in that would be great as well. >> as has been mentioned here several times today, autism remains one of the major concerns of parents even though as a dr. shuck cat has pointed out science has discredited that. the other thing is we're overwhelming children's systems with too many too soon. the whole pills fee is to protect children as soon as we can for as many things as we can. delaying vaccines is really counter intuitive to the whole purpose of the vaccination program. if we were overwhelming children's immune system i'm an infectious disease doctor, those kids would get getting unusual infections but we don't see that at to two months, four months and six month. and then the last major theme that you hear about are the ingredients in voon and the

concern that perhaps some of them are toxic. once again, thea been discredited, looked at very careful three. podes fda approve these vaccines in large part based on their safety record. >> i will add to dr. sawyer's list that the blue vaccine causes the flu, i hear that every year over and over from well-educated folks and that's certainly one that we work to counter act because of the benefits of flu vaccine. so that's a common one. and then that hpv vaccine might cause promiscuity, we hear that from time to time as well. with people concerned about the hpv vaccine given to preteens. >> just to be clear to anybody listening to this, these are all things that are scientifically demonstrably incorrect. dr. jacks, i wondered, you are a pediatrician, do you have advice for pediatricians across the country about how to handle the

conversation that they have with parents about vaccines? >> yeah. you know, with regard to families that do have questions and concerns, it's really just that, it's addressing their questions and concerns. you know, back in the day physicians could take somewhat of an authoritative stand and there was a great deal of respect. nowadays it's really more of a working with families to come to a conclusion of what's best for their children, whether it's immunizations or whether or not we want to treat an ear infection. so as it pediatrician my goal is to, number one, develop relationship with my families so that we do have that rapport and then for me to make my recommendations and address their concerns specifically. >> anything dr. sawyer to add you train mpedestrian trigss --

this question of whether there are things pediatricians can do. >> right. so the curriculum that we've developed locally in san diego as well as the academy's curriculum basically takes people through the appropriate way to listen tentatively to people's issues and be respectful in addressing them but to continue to convey the skien in the most clear way one can so families reach the right conclusi conclusion. >> thank you. thank you, mr. chairman. >> i surprised the chairman because i was finished early. >> that's 43 seconds. >> let the record -- i will never get that time back. >> we'll put it in the bank. >> i'll take that. >> we have time and i'm sure all of us would probably like to ask -- have a second round of questions. dr. moore, i believe you said the case in measles were tennessee was in memphis, delta memphis, right? >> it was actually a delta in west tennessee. >> west tennessee.

but you described you moved in quickly and the number of people that just that one case that you had to be in touch with was how many? >> 124 that people had come am contact with that one case before the four days before they were diagnosed. >> this is an area where the vaccination rate for measles is what? >> very good. it was clear because 124 people were exposed and only lee people got sick that it was very high. >> as dr. sawyer was talking earlier i was hig about the flaz going viral and c jack used it. i think modern -- this generation understands the idea of going viral. you're talking about measles flying through the air. that's unlike ebola that through the country and a near -- well, complete panic actually last fall when we spent $5 billion, changed every hospital's procedures, dominated what was going on, all the public health departments and that could only

be caught by an exchange of bodily fluids. this flies through the air. this goes viral. this is a disease that goes viral. now, we senators in a bipartisan way understand the problem of dealing with highly educated people who get bad information on the internet. that happens to us every -- every day. we deal with that. we know what it is. but let's go back to the going viral. what if this person in west tennessee who dr. moore acted on quickly and what if that person had been discovered in a part of los angeles where the immunization rate is 60 or 70% instead of 90 or 95%? describe the number of people and the multiplying of people that would have to be contacted to make certain that the disease didn't spread. >> well, i can share the experience we had in san diego in 2008 which was our last

outbreak. we had 12 cases in over 800 people were exposed to those 12. is so it quickly goes up expo then shael the number of people you have to track and millions public health is there to track those people and keep them quarantined it could easily get out of control. >> you had 800 people but then each of them might have infected someone else, right? >> exactly. in that outbreak we had close to 100 people were quarantined for three weeks just to prevent that next wave. we are all crossing our fingers with this disneyland outbreak that maybe we are near the end but i notice that the case number went up by 20 just this last week so i'm not sure we're done with this yet. >> when you say flies through the air we have an example of going viral in modern -- in modern parlance, i suppose. dr. jacks, this may not be an exact comparison, but people is ask me why i continue to play the piano when i was young and i remember responding i didn't

remember my mother giving me a choice about it. i guess i had a choice and we are not talking about taking choices away today from parents, but we are talking about a conversation with a -- between the pediatrician and a parent that -- that probably wouldn't start by -- without -- i mean, even in this day of parents who deal differently than my generation of parents, let's say, how strongly do you recommend to your parents that they vaccinate their children? i suppose the most persuasive thing you can do is tell them the story of your own children. but do you just -- do you just make a neutral observation about it or do you come to a conclusion and say, i think you should to it? >> i it definitely come to a con can collusion of recommending that we do vaccinate. i oftentimes don't approach it quite that way because i want to get their thoughts and opinions

and their fears first. so i can address those. but, yeah, i talk to families from, you know, a couple that still pregnant that hasn't had their first child yet to that first visit after they're born to the routine visits where we would do vaccinations and every visit whether they are 100% getting vaccinated or whether they are still trying to decide i'm talking, i'm answering questions and i'm urging them to make, you know, a good informed decision and my understanding, my opinion is that, yes, vaccines are absolutely one of the best things they can do to protect their young child. >> i'm out of time but i assume -- i assume that -- i know in our state years ago my wife led an effort to establish a medical home for every -- every child about to be born, prenatal healthcare and i assume thinking in prenatal healthcare that allows a parent to know more about the value of

vaccinations before the child is born is a very effective way to keep the vaccination rate high. senator murray. >> thank you, mr. chairman. dr. moore, i wanted to ask you about this because i'm especially interested in learning more about what can be done to increase uptake of the hpv vaccine. we are really of the to have a vaccine today that can prevent most forms of cervical cancer, which i'm sure you know is the second leading cause of cancer deaths among women in the united states, about 12,000 women get cervical cancer every year, about 4,000 are expected to die from it. and we know that those are deaths that can now be prevented. i wanted to ask you what can state and local health departments do to more effectively promote the hpv vaccine? >> that's a wonderful question and certainly we know that a lot of young women and men are not being protected against this virus yet who could be. in tennessee our immunization rates are about one in three and

we'd like it to be much higher. we're working collaboratively with cancer advocates because they have wonderful experience raising awareness about bre exams and pap smears and we are collaborating together to try to help families understand that it this new vaccine is a cancer prevention tool that can help reduce the risk of an abnormal pap smear for a young lady later in life. we are also trying to make sure people understand this vaccine is safe, it lasts and it's very, is very effective. we bundle it with other routine vaccines. so it's given at the same time at t dap vaccine for pertussis protection in middle school and first meningitis shot and part of the preteen immunization bundle. we're trying to help people understand that there's nothing exceptional about this except it is phenomenal cancer prevention and incredibly exciting to have a tool in can you remember our hands that the last generation didn't have to protect women and

men from cancer for their lifetimes. >> thank you. i appreciate that. i also wanted to mention in my home state we have an incredible public/private partnership it's called vac northwest. the at a time when my state had had the highest vaccine exemption rate in the country our state health department came together with key health promoting organizations including group health foundation, within reach and seattle children's hospital to create this really innovative partnership which addresses vaccine hesitancy through work with parents and our healthcare providers alike. it had support from the gates foundation, which was helpful, and the engagement of a lot of partners, but vacs northwest is doing amazing work which is being rigorously evaluated with the intent of sharing lessons they're learning with other states. i wanted to ask you, dr. moore, how can working with private and nonprofit partners help health

departments in their efforts with vaccines? >> health departments have a major role had in promoting i'm zag, we've long ago stopped being the medical home for most children, they go to their own private doctors offices for i'm sfwlagss now which is providing the best possible holistic care for the upbringing of that child, but we partner with these organizations in order to help support them in doing the right thing because what i find in clinical practice pediatricians are incredibly busy with everything they have to do and it really helps them if there is a group in public health focused on promoting the evaluations if we can provide support like our immunization information system that makes their jobs easier. so our role when it comes into doing site visits about quality of their immunization care through the vhc program, site visits that we do in their office its, educational programs we provide, promotional materials we help them do the best possible job for the

patients because they are primarily the ones vaccinating our children. i'm all about relationships and these relationships have been great at developing strong collaborations and bolstering immunization in tennessee certainly. >> okay. thank you. dr. jacks, thanks for being here today. i really appreciate your willingness to come. since you started speaking out about your own family's situation have you been surprised to know how many people don't know that some people can not be vaccinated? >> surprisingly no, actually. there has been a lot of good support, a lot of positive feedback, there's certainly a small amount of negative feedback from certain populations, but it seems like it's -- the knowledge is there. i just don't think it's in the public conscience when they are making the decision to vaccinate or not vaccinate and that's why i'm doing this. i want it to raise awareness of this issue so it can be part of the discussion. >> okay. i appreciate that. i just wanted to ask you as a

pediatrician what do you think are the key barriers to vaccine uptake? >> largely education and the misinformation that's out there. >> okay. thank you. thank you, mr. chairman. >> thank you. senator cassidy. >> yes. first i'd like to request unanimous consent to enter into the record a statement from the march of dimes. >> will be done. >> thank you. obviously we have declining resources on the federal level. i see that the administration is cutting the 317 money dr. moore that you referenced. but i will also note again as a fellow who used to work in a public hospital system that we -- i wasn't a pediatrician i just did a lot of pediatric immunization work there's always a great concern about immunization. sometimes i would see people come to speak to our pediatricians about immunization and it was like call to new castle. these folks cared about it. jackson sawyer care about this

parks natalie. can we use our 317 money for effectively? let me ask you -- and i ask had this not to challenge just to suggest. when i look at that map of california, you can isolate those communities which are not immunizing. we ought to pay jacks to come in and speak with that family so if they have a domestic helping them in their home whose child was unvaccinated and came from another country their children are at risk. dr. jacks to do that very effectively. are we still using our 317 money in a paradigm of 20 years ago before vtc, before we had immunization registries that could pinpoint where we had pockets of the unimmunized and before we realized many people are basing their decisions based upon emotion not upon their physician's recommendation. so simple question. 317 as our programs rated 20

years ago or are they adapting to our ability to use data to pinpoint where we immediate our intervention? dr. moore. >> thank you for that very question. i can say under dr. shuck cat's leadership the 317 program is folk ulsed on where we are today with our immunization programs. the 317 funding is going to support our immunization information system that provides as i mentioned clinical decision support for clinicians who need to keep up with the complex current immunization schedule to provide optimal care, it can provide that support, it makes it easy to issue an immunization certificate. we also are using those funds to provide education not only for clinicians it in large conference set ng but also one-on-one education. we will send a public health immunization expert into a clinic to spend half a day -- >> but my point is those clinicians, again, they don't need a half a day. they just need to have posted online their clinic's results compared to other clinics, the

natural competition is going to drive that. we know he that from infection disease rates in or's. if you post a clinic's immunization rate and they're lacking they are going to come up. i suspect if you did that for an elementary school, we're going to post the rate of the children immunized here, enter but beware because over 50% are not immunized. do you follow what i'm saying? it's a petri dish for measles. so dr. sawyer what are your comments on that? >> first i'd like to agree with your very last comment about posting these rates for schools because we want parents to be informed about vaccines in general, we should also want them to be informed about the environment that they're putting their children in. and there's no doubt that a school with 40 or 50% of unimmunized children is where the next outbreaks are going to occur. once they get going they'll spread. >> is there a push to do so? that should be something we should be letting parents know as much as is possible about both -- because i read the pediatrics article that staff

provided. if a peed rigs pushes immunization she is more likely to ins have the mom to vaccinate than if she is a passive, okay, that's fine, i will sign the note. to what degree are we posting individual clinics and or individual schools? seems like you should be doing that in santa upon can a. >> i can certainly comment for california. the rates of school vaccination are public information, they are posted on the state's website, but you have to go look for them rather than putting them right in the face of the parent as they talk wauk in on the first day of school might be more effective. >> dr. jacks, any comments? thank you. well, i will yield back my 43 seconds. thank you. >> this time bank is getting full. we have senator franken. >> i don't think i'm going to take very long. i appreciate all your testimony and all your answers to the questions. i just had -- it may be very -- it may be too early to know the answer to this, but maybe -- and

all of you are on the front lines of this obviously and, dr. jacks, with your story you are hearing a lot. what is the public reaction to this in the last week or so? because hopefully we're dis sem nagt some information here and the news has been -- and what do you sense has been the reaction to the outbreak and to all the public information and all the discussion on the if you say, et cetera? what has been the reaction from those parents who waived the immunization for the child? is this being helpful? is this a learning moment for america? >> i would say absolutely. i've certainly heard stories from local pediatricians who have been trying to convince

families for years to immunize and when this measles outbreak happened they were walking in the door wanting to be immunized. i think the publicity is very important to raise awareness about the fact that these diseases are still out there and i think, again, the senators for organizing this hearing to partly do that. >> yes. i have had great experience getting a lot of good questions from the media and from families, particularly focused on our immunization exemption which is low, but notably the wealthiest county in tennessee has almost four times an exemption rate as the county next door, davidson county from metro nashville among kindergarten students. i think that caught everyone's attention. even though our he can empgs rates don't compare to california and some other places it's maybing people realize the consequences of their choices. >> dr. jacks, you look like -- >> i would just echo that

they're saying. there has definitely been a lot of good awareness about the issue, a lot of families have come in to get immunized both against the measles as well as other immunizations. i just had a family this last week that the parents were kind of split on do we vaccinate, do we not and i remembered them and they came in and they got all their vaccinations. >> you know, this land sid article from years ago i think probably did a lot of damage and, you know, we've seen and a -- not explosion, but a big -- well, maybe -- growth in autism, at least in the diagnosis of it, whether it's a genuine increase or just better diagnosis.

parents -- it's a devastating -- it's a devastating thing, autism, and so i know that that fear resonated with people. so i think that, again, that this is maybe a wakeup moment, learning moment and i hope that it is and i want to thank you for being here today and i want to thank the chairman for calling this hearing. thank you. i give you a minute 16, but i'm the end anyway, so -- >> thank you, senator franken. senator murray, do you have closing remarks? >> i just wanted to thank all of our witnesses today and for being here and all the work you're doing to help keep people safe from vaccine preventable diseases and i particularly want to thank or chairman, senator alexander for holding it this hearing at such an important time. thank you. >> well, i thank senator murray for her work and her staffs in putting together such an extraordinary group of witnesses

today. this has been very helpful not just to us i think but anyone who -- who has been listening. dr. moore, we're, again, so proud of our public health department in tennessee. i think back not just on this, but on the quick reaction to the fungal meningitis episode where your organization saved lots of -- lots of lives. dr. sawyer and dr. jacks, thank you for your leadership in your field and your testimony. i think the hope we have is that dr. jacks' message goes viral more rapidly hand measles -- than measles does and that it goes fast. keeping -- i have a hard time keeping my old governor hat off and it makes me think of the importance of our state organizations. i mean, cdc really work through the states, the am medical

associations work lieu hair legislatures and associations and they are in touch with parents every -- every day and we would like to take some step to solve all this problem, you but the truth is in my view post of that reaction has to be with those who are closest to the parents and who see them regularly, and i think that the idea of a medical home for every child who is about to be born is probably the surest and best way for states to you approach it this because parents are talking to their pediatricians, are going to make sure their children are -- are vaccinated. i have some closing remarks i'm supposed to make. the hearing record will remain open for ten days. members may submit additional information and questions for the record within that time. the mention hearing will occur tomorrow at 9:30 and we will