[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




 
 CONFRONTING A GROWING PUBLIC HEALTH THREAT: MEASLES OUTBREAKS IN THE 
                                  U.S.

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           FEBRUARY 27, 2019

                               __________

                            Serial No. 116-9
                            
                            
                            
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                        
 
 


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                        
                        
                              ______
                          

              U.S. GOVERNMENT PUBLISHING OFFICE 
 36-524 PDF             WASHINGTON : 2020
                         
                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
              Subcommittee on Oversight and Investigations

                        DIANA DeGETTE, Colorado
                                  Chair

JAN SCHAKOWSKY, Illinois             BRETT GUTHRIE, Kentucky
JOSEPH P. KENNEDY III,                 Ranking Member
    Massachusetts, Vice Chair        MICHAEL C. BURGESS, Texas
RAUL RUIZ, California                DAVID B. McKINLEY, West Virginia
ANN M. KUSTER, New Hampshire         H. MORGAN GRIFFITH, Virginia
KATHY CASTOR, Florida                SUSAN W. BROOKS, Indiana
JOHN P. SARBANES, Maryland           MARKWAYNE MULLIN, Oklahoma
PAUL TONKO, New York                 JEFF DUNCAN, South Carolina
YVETTE D. CLARKE, New York           GREG WALDEN, Oregon (ex officio)
SCOTT H. PETERS, California
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     1
    Prepared statement...........................................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     8
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     9
    Prepared statement...........................................    11
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, prepared statement.............................    12
Hon. Kathy Castor, a Representative in Congress from the State of 
  Florida, prepared statement....................................    55

                               Witnesses

Nancy Messonnier, M.D., Director, National Center for 
  Immunization and Respiratory Disease, Centers for Disease 
  Control and Prevention, Department of Health and Human Services    13
    Prepared statement...........................................    16
    Answers to submitted questions...............................    61
Anthony S. Fauci, M.D., Director, National Institute of Allergy 
  and Infectious Diseases, National Institutes of Health, 
  Department of Health and Human Services........................    26
    Prepared statement...........................................    28
    Answers to submitted questions...............................    75

                           Submitted Material

Article of February 5, 2019, ``Collapse Of Health System Sends 
  Venezuelans Fleeing To Brazil For Basic Meds,'' by Jason 
  Beaubien, NPR, submitted by Mr. Duncan.........................    56
Letter of February 26, 2019, from Peter Hotez, M.D., to Mr. 
  Burgess, submitted by Mr. Burgess..............................    59


 CONFRONTING A GROWING PUBLIC HEALTH THREAT: MEASLES OUTBREAKS IN THE 
                                  U.S.

                              ----------                              


                      WEDNESDAY, FEBRUARY 27, 2019

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:01 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Diana DeGette (chair of the subcommittee) presiding.
    Members present: Representatives DeGette, Schakowsky, Ruiz, 
Kuster, Castor, Tonko, Pallone (ex officio), Guthrie 
(subcommittee ranking member), Burgess, McKinley, Griffith, 
Brooks, Mullin, Duncan, and Walden (ex officio).
    Staff present: Kevin Barstow, Chief Oversight Counsel; 
Billy Benjamin, Systems Administrator; Jesseca Boyer, 
Professional Staff Member; Jeff Carroll, Staff Director; 
Waverly Gordon, Deputy Chief Counsel; Tiffany Guarascio, Deputy 
Staff Director; Judy Harvey, Counsel; Chris Knauer, Oversight 
Staff Director; Jourdan Lewis, Policy Analyst; Kaitlyn Peel, 
Digital Director; Andrew Souvall, Director of Communications, 
Outreach, and Member Services; C. J. Young, Press Secretary; 
Jen Barblan, Minority Chief Counsel, Oversight and 
Investigations; Mike Bloomquist, Minority Staff Director; 
Jordan Davis, Minority Senior Advisor; Margaret Tucker Fogarty, 
Minority Staff Assistant; Ryan Long, Minority Deputy Staff 
Director; Kristen Shatynski, Minority Professional Staff 
Member, Health; Alan Slobodin, Minority Chief Investigative 
Counsel, Oversight and Investigations.
    Ms. DeGette. The Subcommittee on Oversight and 
Investigations will now come to order.
    Today, the subcommittee is holding a hearing entitled 
``Confronting a Growing Public Health Threat: Measles Outbreaks 
in the U.S.''
    The purpose of today's hearing is to examine the public 
health surveillance and infrastructure response to the current 
measles outbreaks in the United States.
    The Chair now recognizes herself for the purposes of an 
opening statement.

 OPENING STATEMENT OF HON. DIANA DeGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Today, we will examine a serious public health emergency 
that is threatening communities across the country. Since the 
start of this year alone, more than 159 people across 10 States 
have been infected by measles.
    This is a highly contagious and potentially deadly disease 
that was once declared eliminated here in the United States, 
thanks to the development of a successful preventative vaccine.
    Yet, despite the previous success, as we sit here today, we 
have communities across the country scrambling to protect their 
residents and we have parents who are reading daily headlines 
about an outbreak, worried how they are going to protect their 
children and their families.
    If there was ever one topic that should transcend politics 
or party lines, this should be it. On behalf of the American 
people, it is this committee's job to ensure that our public 
health agencies are doing everything they can to prevent the 
spread of this disease.
    And I can tell you, right now, this committee has serious 
concerns about how our Nation's public health system is 
responding to the current outbreak. What we accomplished less 
than 20 years ago in eliminating this disease was truly amazing 
and we want to know exactly can what this administration is 
doing to once again stop the spread of this highly contagious 
disease.
    We also want to know how we got ourselves back into this 
situation and what our agencies are doing to prevent another 
outbreak, such as this one, from happening again.
    Before the measles vaccine was developed in 1963, there 
were half a million cases of the measles being reported every 
year to the CDC. Forty-eight thousand people a year were being 
sent to the hospital and, as a result, as many as 500 people a 
year died.
    It wasn't until the development of the measles, mumps, and 
rubella vaccine--known as the MMR vaccine--that we, as a 
country, were able to stop this horrific illness.
    But despite that success, here we are again, as I said, 
less than 20 years later, dealing with the fear associated with 
yet another outbreak of the disease.
    As of now, there have been 127 reported cases of the 
measles in 10 States, including in my home State of Colorado. 
In fact, in my district last month, the Denver Public Health 
Department was forced to issue a measles exposure warning when 
an adult acquired the measles after traveling internationally.
    Now, that seems to be isolated, but the recent outbreaks 
are a real cause for national concern. The national measles 
vaccination rate of children between 19 and 35 months old is 
currently at 91 percent.
    That may seem high to some, but given the highly contagious 
nature of measles, it is well below the 95 percent vaccination 
rate that is required to protect communities and give it what 
is known as ``herd immunity.''
    This so-called ``herd immunity'' is particularly vital to 
protecting those who cannot be, or are not yet, vaccinated 
against the measles, such as infants or those with prior 
medical conditions who are at a higher risk of suffering severe 
complications from the vaccine.
    As our public health agencies have repeatedly emphasized, 
reaching that 95 percent vaccination rate is critical to 
preventing outbreaks such as the one we are experiencing today.
    While the overall national rate of MMR vaccinations is 
currently at 91 percent, the rate in some communities is much 
lower. Some are as low as 77 percent. In fact, Colorado has one 
of the lowest rates of kindergartners vaccinated for MMR in the 
country, well below the rate necessary to protect vulnerable 
children from this potentially deadly disease.
    Outbreaks, like the one we are seeing with measles, remind 
us of just how interconnected our communities are. They remind 
us of how the decisions of one community can directly affect 
other communities across the country and we have--as a nation, 
to stop the spread of deadly diseases, we have to address the 
root cause of the problem and we have to identify concrete 
steps.
    We have to provide parents and community leaders with real 
science-based information, not only about how vaccines are 
safe, but why they are so important. We need to support 
additional research into vaccine safety to further increase 
consumer confidence in these vaccines.
    And we need to strengthen our public health infrastructure 
at all levels of our Government to better prepare for and 
respond to these outbreaks.
    We have to work together to protect the most vulnerable 
among us and we have got to ensure that an outbreak of measles 
once again becomes a rarity in this country.
    I want to thank our witnesses, Dr. Messonnier, who is here 
on behalf of the Centers for Disease Control and Prevention, 
who is on the front lines of preventing this, and, of course, 
Dr. Anthony Fauci from the National Institutes of Health, no 
stranger to this committee on a variety of issues, who is here 
to talk about his in-depth knowledge of the vaccines and how we 
can prevent these diseases from spreading in the U.S.
    Thank you both for being here, and I am now happy to 
recognize the ranking member of the subcommittee, Mr. Guthrie, 
for 5 minutes for his opening statement.
    [The prepared statement of Ms. DeGette follows:]

                Prepared statement of Hon. Diana DeGette

    Today, we will examine a serious public health emergency 
that's threatening communities across the country.
    Since the start of this year alone, more than 159 people 
across 10 States have been infected by measles.
    This is a highly contagious and potentially deadly disease 
that was once declared eliminated here in the United States--
thanks to the development of a successful preventive vaccine.
    Yet, despite that previous success, as we sit here today, 
we have communities across the country scrambling to protect 
their residents--and we have parents, who are reading daily 
headlines about an outbreak, worried about how they are going 
to protect their children and their families.
    If there was ever one topic that should transcend politics 
or party lines, this should be it.
    On behalf of the American people, it is this committee's 
job to ensure that our public health agencies are doing 
everything they can to prevent the spread of this disease.
    And I can tell you, right now, this committee has serious 
concerns about how our Nation's public health system is 
responding to this current outbreak.
    What we accomplished less than 20 years ago--in eliminating 
this disease--was truly amazing.
    And we want to know exactly what this administration is 
doing to once again stop the spread of this highly contagious 
disease.
    We also want to know how we got ourselves back into this 
situation and what our agencies are doing to prevent another 
outbreak, such as this one, from happening again.
    Before the measles vaccine was developed in 1963, there 
were half a million cases of the measles being reported every 
year to the CDC. 48,000 people a year were being sent to the 
hospital and, as a result, as many as 500 people a year died as 
a result.
    It wasn't until the development of the measles, mumps, and 
rubella vaccine--known as the MMR vaccine--that we, as a 
country, were able to stop this horrific illness.
    But despite that success, here we are again--as I said, 
less than 20 years later--dealing with the fear associated with 
yet another outbreak of this disease.
    As of now, there have been 159 reported cases of the 
measles in 10 States, including in my home State of Colorado.
    In fact, in my district last month, the Denver Public 
Health Department was forced to issue a measles exposure 
warning when an adult acquired the measles after traveling 
internationally.
    Now, that seems to be isolated, but these recent outbreaks 
are cause for real national concern.
    The national measles vaccination rate of children between 
19 and 35 months old is currently at 91 percent.
    That may seem high to some, but given the highly contagious 
nature of measles, it's well below the 95 percent vaccination 
rate that's required to protect communities and give it what is 
known as ``herd immunity.''
    This so-called ``herd immunity'' is particularly vital to 
protecting those who cannot be, or are not yet, vaccinated 
against the measles--such as infants or those with prior 
medical conditions who are at a higher risk of suffering severe 
complications from the vaccine.
    As our public health agencies have repeatedly emphasized, 
reaching that 95 percent vaccination rate is critical to 
preventing outbreaks such as the one we are experiencing today.
    While the overall national rate of MMR vaccinations is 
currently at 91 percent, the rate in some communities is much 
lower--some are as low as 77 percent.
    In fact, my State of Colorado has one of the lowest rates 
of kindergartners vaccinated for MMR in the country--well below 
the rate necessary to protect vulnerable children and people 
from this potentially deadly disease.
    Outbreaks, such as the one we are seeing today with 
measles, remind us of just how interconnected our communities 
are.
    They remind us how the decisions of one community can 
directly affect other communities across the Nation.
    We, as a nation--to stop the spread of these deadly 
diseases--have to address the root cause of the problem. And we 
have to identify concrete steps.
    We have to provide parents and community leaders with the 
real, science-based information--not only about how vaccines 
are safe, but why they are so important.
    We need to support additional research into vaccine safety, 
to further increase consumer-confidence in these vaccines.
    And we need to strengthen our public health infrastructure 
at all levels of our Government to better prepare for, and 
respond to, these outbreaks.
    We have to work together to protect the most vulnerable 
among us, and we have to find ways to ensure that an outbreak 
of measles once again becomes a rarity in this country.
    I want to thank our witnesses who are here to testify 
today.
    Dr. Nancy Messonnier, who is here on behalf of the Centers 
for Disease Control and Prevention, and is on the frontline of 
preventing this.
    And Dr. Anthony Fauci from the National Institutes of 
Health--who is no stranger to this committee--is here to talk 
about his in-depth knowledge of the vaccines and how we can 
prevent these diseases from spreading in the U.S.
    Thank you both for being here.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Guthrie. Thank you, Chair DeGette, for holding this 
important and timely hearing, and this is an area of bipartisan 
interest. Measles is an extremely contagious virus. It can 
cause significant respiratory symptoms, fever, and rash.
    In some cases, the consequences can be severe. One in 20 
children with measles develops pneumonia. One in a thousand 
children develop brain swelling that can cause brain damage. 
One or two in a thousand children who contract measles will 
die.
    Fortunately, measles was declared eliminated in the United 
States in 2000 because the Nation had gone more than 12 months 
without any contagious disease transmission. Public health 
experts believe this progress was achieved because of the very 
safe combination of measles-mumps-rubella--or MMR--vaccine, 
very high vaccination rates and a strong public health system 
to detect and respond to outbreaks.
    However, elimination does not mean the disease was 
completely eradicated. The disease remains in many parts of the 
world. There are about 20 million cases worldwide each year.
    Measles returns to the U.S. when the infected travelers 
bring the disease back to parts of the country where some 
parents have chosen not to vaccinate their children. Because 
measles is so contagious, it is estimated 93 to 95 percent of 
people in a locality need to be vaccinated to achieve 
population immunity.
    This level of population immunity provided by very high 
vaccination rates prevents outbreaks and sustained transmission 
of measles. According to CDC tracking, while national 
vaccination rates remain high, estimated MMR vaccination rates 
among 13-to-17-year-old teenagers can vary widely, ranging from 
77.8 percent to 97.9 percent across States and local counties 
in the United States.
    We currently have multiple measles outbreaks in the United 
States. As of February 21st, 2019, the CDC reported that there 
are 159 confirmed cases of measles this year in 10 States.
    My home State of Kentucky was recently added to the list. 
Unfortunately, this current outbreak is continuing a recent 
trend. An average of 63 measles cases were reported to CDC from 
2000 to 2007.
    However, from 2011 to 2017, the annual average of reported 
cases increased to 217. The CDC told the committee staff that 
in the last 5 years there have been 26 measles outbreaks 
involving five or more people. Seventy-five percent of those 
cases spread in the local close-knit communities with groups of 
unvaccinated people.
    These outbreaks are tragic, since they were completely 
avoidable. Every State except three have enacted religious 
exemptions for parents who wish not to vaccinate their 
children. There are 17 States that allow a personal or 
philosophical exemption, which means that most people can opt 
out for any reason.
    For example, in Washington State, just 0.3 percent of 
Washington's families with kindergartners use a religious 
exemption while 3.7 percent of families use a personal 
exemption and 0.8 percent use a medical exemption.
    Vaccine exemptions have increased in the past 3 years to a 
median 2.2 percent of kindergartners among all States. With 
recent links to pockets of undervaccination, some State 
legislators are looking to tighten or eliminate certain types 
of exemptions that allow parents to not have their children 
immunized.
    After the Disneyland-linked outbreak of measles in 2014, 
the State of California ended a religious and personal 
exemption for vaccines. The Washington legislature is working 
on legislation that substantially narrows the exemptions for 
vaccination that would eliminate the personal or philosophical 
exemption while tightening the religious exemption.
    In recent weeks, State legislators in New Jersey, New York, 
Iowa, Maine, and Vermont have proposed eliminating religious 
exemptions for vaccines. However, last week the Arizona House 
Health and Human Service Committee approved three bills to 
expand exemptions for mandatory vaccinations.
    Given the concerns raised by the measles outbreak in 
various parts of the Nation and recent State legislative 
activity, it is appropriate to have this hearing to provide 
greater discussion and examination at a national level.
    I welcome our two expert witnesses, Dr. Messonnier of the 
CDC and Dr. Anthony Fauci of the National Institute of Allergy 
and Infectious Diseases.
    I look forward to your testimony, and I yield back my time.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared statement of Hon. Brett Guthrie

    Thank you, Chair DeGette, for holding this important and 
timely hearing. This is an area of bipartisan interest.
    Measles is an extremely contagious virus. It can cause 
significant respiratory symptoms, fever, and rash. In some 
cases, the consequences can be severe. One in 20 children with 
measles develops pneumonia, and one in 1,000 children? develop 
brain swelling that can cause brain damage. One or two in 1,000 
children who contract measles will die.
    Fortunately, measles was declared eliminated in the United 
States in 2000 because the Nation had gone more than 12 months 
without any continuous disease transmission. Public health 
experts believe this progress was achieved because of a very 
safe combination measles-mumps-rubella--or MMR--vaccine, very 
high vaccination rates, and a strong public health system to 
detect and respond to outbreaks.
    However, elimination does not mean the disease was 
completely eradicated. The disease remains in many parts of the 
world. There are about 20 million cases worldwide each year. 
Measles returns to the U.S. when infected travelers bring the 
disease back to parts of the country where some parents have 
chosen not to vaccinate their children. Because measles is so 
contagious, it is estimated 93 to 95 percent of people in a 
locality need to be vaccinated to achieve population immunity. 
This level of population immunity--provided by very high 
vaccination rates--prevents outbreaks and sustained 
transmission of measles. According to CDC tracking, while 
national vaccination rates remain high, estimated MMR 
vaccination coverage among 13-to-17-year-old teenagers, can 
vary widely, ranging from 77.8 percent to 97.9 percent across 
States and local counties in the United States.
    We currently have multiple measles outbreaks in the United 
States. As of February 21, 2019, the CDC reported that there 
are 159 confirmed cases of measles this year in 10 States. My 
home State of Kentucky was recently added to this list.
    Unfortunately, this current outbreak is continuing a recent 
trend. An average of 63 measles cases were reported to CDC from 
2000 to 2007. However, from 2011 to 2017, the annual average of 
reported cases increased to 217. The CDC told the committee 
staff that in the last 5 years there have been 26 measles 
outbreaks involving five or more people. Seventy-five percent 
of those cases spread in local close-knit communities with 
groups of unvaccinated people. These outbreaks are tragic since 
they are completely avoidable.
    Every State, except three, have enacted religious 
exemptions for parents who wish not to vaccinate their 
children. There are 17 States that allow a personal or 
philosophical exemption, which means that most people can opt 
out for any reason. For example, in Washington State, just 0.3 
percent of Washington's families with kindergartners used a 
religious exemption, while 3.7 percent of families used a 
personal exemption and 0.8 percent used a medical exemption. 
Vaccine exemptions have increased in the past 3 years to a 
median 2.2 percent of kindergartners among all States.
    With recent outbreaks linked to pockets of 
undervaccination, some State legislatures are looking to 
tighten or eliminate certain types of exemptions that allow 
parents to not have their children immunized. After the 
Disneyland-linked outbreak of measles in 2014, the State of 
California ended religious and personal exemptions for 
vaccines. The Washington legislature is working on legislation 
that substantially narrows the exemptions for vaccination that 
would eliminate the personal or philosophical exemption while 
tightening the religious exemption. In recent weeks, State 
legislators in New Jersey, New York, Iowa, Maine, and Vermont 
have proposed eliminating religious exemptions for vaccines. 
However, last week, the Arizona House Health and Human Services 
Committee approved three bills to expand exemptions for 
mandatory vaccinations.
    Given the concerns raised by the measles outbreak in 
various parts of the Nation and recent State legislative 
activity, it is appropriate to have this hearing to provide 
greater discussion and examination at a national level.
    I welcome our two expert witnesses, Dr. Nancy Messonnier of 
the CDC, and Dr. Anthony Fauci of the National Institute of 
Allergy and Infectious Diseases. I look forward to your 
testimony, and I yield back.

    Ms. DeGette. The gentleman yields back.
    The Chair now recognizes the chairman of the full 
committee, Mr. Pallone, for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Madam Chair.
    This committee has a long history of addressing public 
health concerns and infectious disease crises. Today, we are 
here to discuss the troubling increase in the number of measles 
cases here in the United States.
    This issue hits close to home for me. Just this past 
December, 33 cases of measles were confirmed in Ocean and 
Passaic Counties in my home State of New Jersey. And Madam 
Chair, my written statement actually says that, fortunately, 
the outbreak in New Jersey is now over.
    But the reality is I have to change my written statement 
because I was reading through my press clips this morning and 
this was front the Bergen Record, which is a publication--a 
daily newspaper in the northern part of the State--and it says, 
I quote, ``Confirmed cases of measles exposure reported in 
Bergen County. A New Jersey man who has been diagnosed with 
measles may have exposed people in Bergen County to the disease 
earlier this month, particularly at two locations in Hillsdale, 
State health officials said. Exposures would have occurred 
between February 17th and Monday,''--this past Monday--``a 
spokeswoman for the State health department said.''
    So it isn't true that the outbreak is over in New Jersey. 
This is--these are--this is a case now in a county where 
measles had been previously reported.
    So as of this morning, there have been--and that doesn't 
count this--there have been 159 measles cases reported across 
the Nation already this year, and there are now six outbreaks 
of three or more cases in four States. Not only are we seeing a 
troubling increase in cases, but the number of outbreaks also 
continues to grow, and it is deeply disturbing.
    The reemergence of this highly contagious vaccine-
preventable disease poses a threat beyond the pockets of 
communities in which it arises. It is particularly dangerous to 
infants, children under the age of 5, those who are pregnant, 
and people with compromised immune systems.
    All these people are at higher risk of severe complications 
from measles. But what is particularly disconcerting is that 
this is a public health problem for which science has already 
provided a solution: a safe and effective vaccine. There is 
overwhelming confidence among researchers, public health 
officials, and parents in the MMR vaccine.
    Yet vaccine hesitancy and, to a lesser degree, vaccine 
access concerns are behind the growing number of measles cases 
in the United States since 2010.
    I know that we will discuss both of these issues and hear 
from our experts as to the Federal Government's responsibility 
in addressing both. But I would also like to hear from 
witnesses about one particular area of great concern to me, and 
that is the proliferation of disinformation about the safety 
and efficacy of the MMR vaccine.
    I am deeply troubled by the role digital media plays in 
perpetuating myths and fears regarding measles. It is 
undermining the facts on how to safely and effectively prevent 
measles and other vaccine-preventable diseases.
    For example, recent media reports found that users on 
YouTube and Facebook are steered towards antivaccination 
content due to the platform's algorithms.
    Both companies have said they are taking steps to address 
the promotion of conspiracy theories, but we must keep our eye 
on where this misinformation will pop up next, particularly 
when we know there is a preponderance of evidence that the MMR 
vaccine is safe and effective and that there are numerous 
measures in place to continue to monitor and assess its safety 
and the safety of other vaccines.
    I am deeply troubled that parents are being inundated with 
distortions and misinformation campaigns when they are going 
online to try to make informed decisions about their child's 
health.
    And I look forward to hearing from Dr. Messonnier--if I am 
pronouncing it right--and Dr. Fauci about what is driving the 
recent measles outbreak. I would also like to know what efforts 
are underway by the CDC and NIH to address this growing public 
health threat and where they still need additional support.
    So, hopefully, this will be a hearing where we try to get 
to the bottom of what is actually happening out there, and 
thank you for our witnesses.
    Thank you, Madam Chair. This is a very important hearing. 
Thank you.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    This committee has a long history of addressing public 
health concerns and infectious disease crises. Today, we are 
here to discuss the troubling increase in the number of measles 
cases here in the United States.
    This issue hits close to home for me. Just this past 
December, 33 cases of measles were confirmed in Ocean and 
Passaic counties of my home State of New Jersey.
    Fortunately, the outbreak in New Jersey is now over, but as 
of this morning, there have been 159 measles cases reported 
across the Nation already this year. And there are now six 
outbreaks--of three or more cases--in four States. Not only are 
we seeing a troubling increase in cases, but the number of 
outbreaks also continues to grow. This is all deeply 
disturbing.
    The reemergence of this highly contagious 
vaccinepreventable disease poses a threat beyond the pockets of 
communities in which it arises.
    It is particularly dangerous to infants, children under the 
age of 5, those who are pregnant, and people with compromised 
immune systems. All of these people are at higher risk of 
severe complications from the measles.
    What is particularly disconcerting, is that this is a 
public health problem for which science has already provided a 
solution: a safe and effective vaccine. There is overwhelming 
confidence among researchers, public health officials, and 
parents in the MMR vaccine.
    Yet vaccine hesitancy, and, to a lesser degree, vaccine 
access concerns are behind the growing number of measles cases 
in the U.S. since 2010.
    I know that we will discuss both of these issues and hear 
from our experts as to the Federal Government's responsibility 
in addressing both.
    I'd also like to hear from our witnesses about one 
particular area of great concern to me, and that is the 
proliferation of disinformation about the safety and efficacy 
of the MMR vaccine.
    I am deeply troubled by the role digital media plays in 
perpetuating myths and fears regarding measles. It is 
undermining the facts on how to safely and effectively prevent 
measles and other vaccine-preventable diseases.
    For example, recent media reports found that users on 
YouTube and Facebook are steered toward antivaccination content 
due to the platform's algorithms.
    Both companies have said they are taking steps to address 
the promotion of conspiracy theories, but we must keep our eye 
on where the misinformation will pop up next.
    Particularly when we know there is a preponderance of 
evidence that the MMR vaccine is safe and effective. And, that 
there are measures in place to continue to monitor and assess 
its safety and the safety of other vaccines.
    I am deeply troubled that parents are being inundated with 
distortions and misinformation campaigns when they are going 
online to try to make informed decisions about their child's 
health.
    I look forward to hearing from Dr. Messonnier and Dr. Fauci 
about what's driving the recent measles outbreaks. I'd also 
like to know what efforts are underway by the CDC and NIH to 
address this growing public health threat, and where they still 
need additional support.
    Thank you, and I yield back.

    Ms. DeGette. The gentleman yields back.
    The Chair now recognizes the ranking member of the full 
committee, Mr. Walden, for 5 minutes for the purposes of an 
opening statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Good morning, Madam Chair. Thank you for 
holding this hearing.
    The reemergence of vaccine-preventable diseases including 
measles coincided with the undervaccination as a major public 
health concern. World Health Organization last month called 
vaccine hesitancy one of the 10 biggest threats to global 
health, noting the shocking 30 percent increase in measles 
cases worldwide last year.
    In 2000, measles was considered to have been eliminated in 
the United States. Last year, the U.S. had its second most 
cases since 2000. The current measles outbreak showcases the 
problem of undervaccination.
    It is a problem that hits close to home for me since 65 
measles cases in the outbreak have mainly occurred in Clark 
County, Washington, a suburb of Portland, Oregon, with four in 
Multnomah County, Oregon, for a total of 69 confirmed measles 
cases.
    Measles exposure even reached my district with an infected 
person from Clark County visiting a trampoline park in Bend, 
Oregon. While there have been no confirmed cases resulting from 
that particular exposure, this highlights the reach of the 
measles outbreak.
    Unfortunately, the case information suggests the region 
near Portland has been an area of undervaccination. Most of 
these cases involve people who are not vaccinated and most of 
those infected were children between the ages of one and ten.
    County public health officials are confronted with 
directing hundreds of susceptible families who have been 
exposed to the virus at more than three dozen locations 
including a Portland Trailblazers basketball game, schools, 
churches, and stores such as Costco and Walmart.
    There are important reasons for getting the measles 
vaccine. Measles is a highly contagious infectious disease that 
spreads through coughing and sneezing. Health officials say the 
virus is so contagious that if an unvaccinated person walks 
through a room after someone with measles has left, there is a 
90 percent chance that an unvaccinated person will get that 
disease.
    This can be a very serious disease. Measles infection 
typically causes a high fever and rash. About one of four 
people who gets measles will be hospitalized.
    Infection can lead to ear infections, hearing loss and, in 
rare cases, brain swelling and even death. Measles vaccine is 
highly effective and may be one of the most effective vaccines 
around.
    Two doses are about 97 percent effective and since the 
introduction of the combination MMR vaccine there has been a 99 
percent reduction in the number of measles cases compared to 
the prevaccine era.
    It not only protects you, but others as well, particularly 
vulnerable infants who cannot be vaccinated. This year can help 
provide important information--this hearing--I am sorry--can 
help provide important information to address questions for 
some people about the safety of the vaccine as well as 
heightened awareness about the effectiveness of the vaccine and 
the importance of getting vaccinated.
    If we don't reverse the downward trend of vaccination we 
risk bringing back measles in full force.
    So I welcome both of our witnesses today to provide their 
expertise about the disease of measles and insights into the 
facts and value of measles vaccine.
    Dr. Nancy Messonnier, thank you for your service and your 
leadership in various senior capacities at the Centers for 
Disease Control and Prevention.
    Dr. Anthony Fauci, the director of National Institutes of 
Health Institute of Allergy and Infectious Diseases--sir, you 
need no introduction, having testified probably hundreds of 
times before our committee.
    However, on this occasion, I think you should be 
recognized, sir, for more than 50 years of public service, 
including your 35th anniversary year as director of the 
National Institute of Allergy and Infectious Diseases and for 
your achievements.
    [Applause.]
    You have made substantial contributions to HIV/AIDS 
research. You have helped develop therapies for formerly fatal 
diseases. With many honors, you have been awarded the Lasker 
Award and the Presidential Medal of Freedom.
    Chair DeGette, I really think we need to congratulate him. 
So we look forward to your testimony and to learning more in 
this committee about what we should do, going forward.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    Chair DeGette, thank you for holding this hearing. The 
reemergence of vaccine-preventable diseases, including measles, 
coinciding with undervaccination is a major public health 
concern. The World Health Organization last month called 
``vaccine hesitancy'' one of the 10 biggest threats to global 
health, noting the shocking 30 percent increase in measles 
cases worldwide last year. In 2000, measles was considered to 
have been eliminated in the United States. But last year, the 
U.S. had its second-most cases since 2000.
    The current measles outbreak showcases the problem of 
undervaccination.
    It's a problem that hits close to home for me since 65 
measles cases in this outbreak have mainly occurred in Clark 
County, Washington (a suburb of Portland, Oregon), with four in 
Multnomah County, Oregon, for a total of 69 confirmed cases of 
measles. The measles exposure even reached my district, with an 
infected person from Clark County visiting a trampoline park in 
Bend, Oregon. Though there have been no confirmed cases 
resulting from that particular exposure, this highlights the 
reach of the measles outbreak.
    Unfortunately, the case information suggests the region 
near Portland has been an area of undervaccination. Most of 
these cases involved people who were not vaccinated, and most 
of those infected were children between the ages of one and 10.
    County public health officials are confronted with 
directing hundreds of susceptible families who have been 
exposed to the virus at more than three dozen locations, 
including a Portland Trailblazers basketball game, schools, 
churches, and stores such as Costco and Walmart.
    There are important reasons for getting the measles 
vaccine. Measles is a highly contagious, infectious disease 
that spreads through coughing and sneezing. Health officials 
say the virus is so contagious that if an unvaccinated person 
walks through a room after someone with measles has left, there 
is a 90 percent chance that an unvaccinated person will get the 
disease. This can be a very serious disease. Measles infection 
typically causes a high fever and rash, and about one of four 
people who gets measles will be hospitalized. The infection can 
lead to ear infections, hearing loss, and in rarer cases, brain 
swelling and death.
    The measles vaccine is highly effective, and maybe one of 
the most effective vaccines around. Two doses are about 97 
percent effective. Since the introduction of the combination 
MMR vaccine, there has been a 99 percent reduction in the 
number of measles cases, compared to the prevaccine era. It not 
only protects you, but others as well, particularly vulnerable 
infants who cannot be vaccinated. This hearing can help provide 
important information to address questions for some people 
about the safety of the vaccine, as well heighten awareness 
about the effectiveness of the vaccine and the importance of 
getting vaccinated. If we don't reverse the downward trend of 
vaccination, we risk bringing back measles in full force.
    I welcome both of our witnesses to provide their expertise 
about the disease of measles, and insights into the facts and 
value of the measles vaccine. Dr. Nancy Messonnier, thank you 
for your service and your leadership in various senior 
positions at the Centers for Disease Control and Prevention. 
Dr. Anthony Fauci, the Director of the National Institutes of 
Health Institute of Allergy and Infectious Diseases, you need 
no introduction, having testified probably hundreds of times 
before this committee. However, on this occasion I think you 
should be recognized, sir, for your more than 50 years of 
public service, including your 35th anniversary year as 
Director of the National Institute of Allergy and Infectious 
Diseases, and your achievements. You have made substantial 
contributions to HIV/AIDS research, and you have developed 
therapies for formerly fatal diseases. Among many honors, you 
have been awarded the Lasker Award, and the Presidential Medal 
of Freedom. Chair DeGette, I think he deserves a bipartisan 
round of applause and our appreciation.
    We look forward to your testimony, and to learning how our 
committee can help support your efforts to protect public 
health.

    Mr. Walden. With that, I will yield the balance of my time 
to Dr. Burgess.
    Mr. Burgess. I thank the chairman for the recognition. In 
full disclosure, I am a measles survivor. I was of an age where 
the measles vaccine was not available.
    Even though I was very young when that happened, I still 
remember the clinical course with the measles of hard shaking 
chills, the muscle pain, and, of course, the rash that is 
pathognomonic of measles.
    I will tell you that we forget about some of the 
complications of measles. I took the liberty of printing out a 
couple of pages from Harrison's Principles of Internal 
Medicine.
    Let me just run through some of the highlights: laryngitis, 
croup, bronchitis, otitis media, ear infections, pneumonia both 
viral and secondary bacterial, fever, headache, drowsiness, 
coma, seizures. Ten percent of patients who have measles 
encephalitis do not survive. Transverse myelitis following 
measles has been reported, similar to polio. Gastrointestinal 
complications, hepatitis, appendicitis, ileocolitis, mesenteric 
adenitis.
    Other rare complications include myocarditis, 
glumerulonephritis, pulmonary nephritis, post-infection 
thrombocytopenia purpura. It is a serious illness. It is 
entirely vaccine preventable. I am grateful we are having the 
hearing today. I yield back.
    [The prepared statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    Thank you, Mr. Walden. This is an incredibly important 
hearing to hold as we are seeing measles outbreaks in different 
areas throughout the country. While the largest outbreaks have 
been in Oregon and Washington State, as of February 14th there 
are eight total confirmed cases in Texas in 2019, including one 
in my district in Denton. According to the Centers for Disease 
Control and Prevention, reported measles incidence decreased 87 
percent from 2000 to 2016, and the annual estimated measles 
deaths decreased 84 percent. What these statistics show us is 
that the vaccination program was safe and effective.
    It is frustrating to see a measles resurgence nearly 20 
years after measles was declared eliminated from the United 
States. I look forward to hearing from Dr. Fauci and Dr. 
Messonnier about how NIH and CDC have worked and will continue 
to work to protect our Nation's public health and prevent 
further spread of this terrible disease.

    Ms. DeGette. I thank the gentleman for yielding and, Mr. 
Walden, I really thank you for recognizing Dr. Fauci. He really 
is a true treasure, and we are always happy to see him.
    I am going to ask unanimous consent that Members' written 
opening statements be made part of the record.
    Without objection, so ordered.
    I also ask unanimous consent that Energy and Commerce 
members not on the Subcommittee on Oversight and Investigations 
be permitted to participate in today's hearing.
    Without objection, so ordered.
    I would now like to introduce our witnesses, who have 
already been introduced by a number of opening statements.
    Dr. Nancy Messonnier, who is with the National Center for 
Immunization and Respiratory Diseases at the CDC, and Dr. 
Anthony Fauci, the director of the National Institute for 
Allergy and Infectious Diseases at the National Institutes of 
Health.
    Both of you are aware, I know, that the committee is 
holding an investigative hearing and, as such, has had the 
practice of taking testimony under oath.
    So either of you have any objections to taking your 
testimony under oath?
    Let the record reflect the witnesses have responded no. The 
Chair then advises you that under the rules of the House and 
the rules of the committee you are entitled to be accompanied 
by counsel. Do you desire to be accompanied by counsel today?
    Let the record reflect the witnesses have answered no. If 
you would then, please rise and raise your right hand so you 
may be sworn in.
    [Witnesses sworn.]
    You may be seated. Let the record reflect that the 
witnesses have responded affirmatively, and you are now under 
oath and subject to the penalties set forth in Title 18 Section 
1001 of the U.S. Code.
    And the Chair will now recognize our witnesses for a 5-
minute summary of their written statements. As both of you 
know, there is a microphone and a series of lights in front of 
you.
    The light turns yellow when you have a minute left, and it 
turns red to indicate that your time has come to an end.
    So, Dr. Messonnier, I recognize you for your opening 
statement. Thank you.

STATEMENTS OF NANCY MESSONNIER, M.D., DIRECTOR, NATIONAL CENTER 
 FOR IMMUNIZATION AND RESPIRATORY DISEASE, CENTERS FOR DISEASE 
    CONTROL AND PREVENTION, DEPARTMENT OF HEALTH AND HUMAN 
SERVICES; ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE 
  OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL INSTITUTES OF 
        HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES

                 STATEMENT OF NANCY MESSONNIER

    Dr. Messonnier. Thank you.
    Good morning, Chair DeGette, Ranking Member Guthrie, and 
members of the committee. I am Dr. Nancy Messonnier. I am the 
director of the National Center for Immunization and 
Respiratory Diseases at CDC.
    Thank you for the opportunity to speak with you today. 
Outbreaks of measles have, once again, been prominent in the 
headlines. From January 1st to February 21st, 159 cases of 
measles have been confirmed in 10 States, including California, 
Colorado, Connecticut, Georgia, Illinois, Kentucky, New York, 
Oregon, Texas, and Washington.
    In 2018, 372 people with measles were reported from 25 
States and the District of Columbia. Most cases have been 
unvaccinated. Measles outbreaks have been and continue to be a 
constant threat to the health of the American people.
    While measles has been eliminated in the U.S. since 2000, 
measles is circulating in many parts of the world and 
importations remain a challenge.
    Unvaccinated U.S. residents traveling abroad are at risk 
for measles and returning unvaccinated U.S. residents and 
foreign visitors to the U.S. may develop measles and expose 
their families and communities.
    Nationally, we enjoy high measles vaccination coverage. 
However, there are pockets of people who are vaccine hesitant, 
who delay or even refuse to vaccinate themselves and their 
children.
    Outbreaks of measles occur when measles gets into these 
communities of unvaccinated people. Those choosing not to 
vaccinate tend to live near each other. Some of these are what 
we call close-knit communities, people who share common 
religious beliefs or racial ethnic background. Others are 
people who have strong personal belief against vaccination.
    In the past 5 years, there have been 26 measles outbreaks 
of more than five cases. Twelve of these were in close-knit 
communities including outbreaks in a Somali community in 
Minnesota in 2017 and orthodox Jewish communities in New York 
City and New York State in 2018.
    These 12 outbreaks account for 75 percent of cases over the 
past 5 years. Vaccine hesitancy is the result of a 
misunderstanding of the risk and seriousness of disease 
combined with misinformation regarding the safety and 
effectiveness of vaccines.
    However, the specific issues fueling hesitancy varies by 
community. Because vaccine hesitancy remains a highly localized 
issue, the strategy to address these issues need to be local 
with support from CDC. Strong immunization programs at the 
State and local levels are critical to understanding the 
specific issues and empowering local action.
    CDC also works to support State and local public health 
efforts through research to understand these reasons and 
develop targeted strategies to address hesitancy.
    In addition, a rapid response coordinated across local, 
State, and Federal jurisdictions is critical to control of 
outbreaks. The public health immunization infrastructure, the 
systems, and people is the backbone for such a response.
    Front line public health workers and clinicians across the 
country are following up on people potentially exposed to 
measles and recent outbreaks.
    A critical component of our immunization infrastructure is 
the Vaccines for Children program. Enacted in 1994 in response 
to a large measles outbreak, VFC is celebrating its 25 
anniversary.
    Because of VFC, we have seen significant decreases in the 
disparities in vaccination coverage that previously existed. I 
would like to acknowledge and thank Congress for the leadership 
they have shown in supporting VFC and providing us this 
national treasure.
    Our investments in the immunization program have been of 
great benefit to our children, our communities, and our 
country. Immunization continues to be one of the most cost-
effective public health interventions.
    Each dollar invested in the childhood immunization program 
earn $10 of societal savings and $3 in direct medical savings. 
Immunizing our children is the social norm with only 1 percent 
of children receiving no vaccines. Not only that, most parents 
continue to have confidence in the safety and effectiveness of 
vaccines.
    In many ways, however, we are a victim of our own success. 
Because of our success, fewer and fewer doctors and parents 
have witnessed the serious and sometimes life-threatening 
consequences of vaccine-preventable diseases, or VPDs.
    Because of our success, we live in a time when outbreaks of 
VPDs make headlines and are not just seen as a routine and 
sometimes tragic part of childhood.
    Because of our success, parents may wonder if vaccines are 
really necessary and they may believe that the risk of 
vaccinating infants or temporary discomfort a vaccine may cause 
outweighs the benefits of protecting them from VPDs.
    Our immunization system has risen to challenges in the 
past. CDC is committed to keeping measles and other VPDs from 
regaining a foothold in our country.
    Even very large outbreaks start with a single case. 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 
immunization partnership has achieved.
    Thank you.
    [The prepared statement of Dr. Messonnier follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Ms. DeGette. Thank you, Doctor.
    Dr. Fauci, you are now recognized for 5 minutes.

                 STATEMENT OF ANTHONY S. FAUCI

    Dr. Fauci. Thank you very much, Chairman DeGette, Ranking 
Member Guthrie, members of the committee. Thank you for giving 
me the opportunity to talk to you for a few minutes about the 
continued reemergence of vaccine-preventable disease, measles.
    As shown on this slide and as mentioned by several of you 
already, measles virus is one of the most contagious viruses 
that we know among the pathogens that confront mankind--as 
mentioned, that if an individual gets into a room with someone 
who has measles and that person is coughing and sneezing, 
there's about a 90 percent chance that that person---that is 
very unlike other diseases like influenza and other respiratory 
diseases when the hit rate, although it is high, is nothing 
approaching 90 percent.
    Also, we know a lot about the virus. It has been very well 
sequenced. That is important, because we can tell when the 
virus is reintroduced into our country from where it comes, 
such as the Israel insertion into the--into the Brooklyn among 
the Hasidic Jews. We knew that it had come from an individual 
from Israel.
    Importantly is the potential for eradication because a 
similar virus among animals was eradicated. I consider it 
really an irony that you have one of the most contagious 
viruses known to man juxtaposed against one of the most 
effective vaccines that we have and yet we don't do and have 
not done what could be done, namely, completely eliminate and 
eradicate this virus.
    You heard some of the--oops, I better go back one. Oops, it 
is just--it has got a life of its own. Go back a few. There you 
go.
    As was mentioned, prior to the vaccine era there were about 
3 million deaths each year. The decrease was dramatic. There 
were 21 million lives that were saved from vaccines between the 
year 2000 and 2017.
    But, as shown on the last bullet on this slide, there are 
110,000 deaths still today in the world, which means there is 
the danger of the reinsertion of measles from other countries 
and if we are not protected.
    Again, prevaccine measles in the United States 3 to 4 
million measles case and, as was mentioned by several of you, 
48,000 hospitalizations. Like Dr. Burgess, I remember very 
clearly the year that I got infected with measles. It was very 
uncomfortable and it was very scary because at that year I went 
back and looked at the statistics. There were 900,000 to a 
million cases in the United States that year.
    But look what the vaccine done. This is a very dramatic 
slide. As shown, it dramatically decreased it to the point of 
the year 2000 when we essentially eliminated.
    But let us take a look at some of the things that I 
mentioned about the disease itself. Fever, cough, rash, as was 
mentioned by Dr. Burgess--again, contagious from four days 
before the rash to four days after. So people are spreading 
measles before they really know that they actually have 
measles.
    We have a group of individuals who are particularly at risk 
for complications--infants and children, pregnant women, 
immunocompromised, and even adults. If you are not protected 
and you get infected, adults have a high incidence of 
complications.
    We have heard about the complications. They are not 
trivial. One out of ten with ear infections, which could lead 
to deafness; pneumonia in one out of 20 cases; encephalitis one 
in a thousand; a very rare occurrence called subacute 
sclerosing panencephalitis, which I will mention in a moment.
    I don't want to scare the audience here but this is an x-
ray of a child who was infected, developed pneumonia with 
bacterial complications. That x-ray, if it were normal, should 
look all dark where the lungs are. The light is what we call 
whiting out of the lungs, which very often leads to death.
    As I mentioned, subacute sclerosing panencephalitis is very 
rare, but it should be mentioned 7 to 10 years after an 
individual develops measles they can have a very devastating 
neurological syndrome--no known cure and is vaccine 
preventable.
    This is what it looks like. The brain on the right side has 
a lot of dark spaces where. That is where brain tissue should 
be. That is what happens when the brain gets damaged.
    And so this is the statistics that Dr. Messonnier and 
several of you mentioned about what is going on right now. This 
slide is really unacceptable. This is a totally vaccine-
preventable disease and when we see these kind of blips, this 
is not something to be taken lightly.
    So what we all should strive for that measles in the United 
States we need to get to zero.
    Thank you.
    [The prepared statement of Dr. Fauci follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
        
    Ms. DeGette. Thank you, Dr. Fauci.
    It is now time for Members to have the opportunity to ask 
questions. I will recognize myself for 5 minutes.
    Since we first announced we would be holding this hearing 
almost two weeks ago, more than 58 additional measles cases and 
an additional outbreak have been reported. Parents around the 
country are seeing headlines about these outbreaks.
    As, Dr. Fauci, you mentioned, it is so rare now that it 
actually does make headlines. But there is also a lot of noise 
out there on measles and vaccines and I think sometimes because 
we eliminated measles for a while parents now are unclear about 
how best to protect their children and families.
    Both of our witnesses are the two--two of the top public 
health officials in the country. And so I would like to ask 
each one of you what is the most important piece of advice you 
would give to parents around the country on how they can best 
protect their children and families from measles.
    Dr. Messonnier?
    Dr. Messonnier. Taking care of your health, eating well, 
exercising, getting enough sleep--those are all parts of a 
healthy lifestyle.
    But the only way to protect against measles is to get 
vaccinated. It is a safe and effective vaccine, and parents 
should go ahead and get vaccinated.
    If they have questions, they should talk to their doctor. 
Their doctor can provide them more information about measles, 
answer their questions, and reassure them to then go ahead and 
get vaccinated.
    Ms. DeGette. Dr. Fauci, do you have anything to add?
    Dr. Fauci. Yes. I think it is important to point out, 
obviously, ditto what everything that Dr. Messonnier said. But 
we should look upon it in two approaches. One, it is for the 
safety of your own child and the other is a responsibility to 
the community, because in your opening statement, Congressman 
DeGette, you mentioned this issue of herd immunity and we all 
have a responsibility to be part of that umbrella of herd 
immunity. And once it goes down below a certain percentage, 
then you have danger to the entire society.
    And something that is not fully appreciated is that we 
vaccinate children first time at 11 to 12 months, and then the 
boost at 4 to 6 years. Those infants are vulnerable to measles 
if they get exposed.
    So it is our responsibility to protect them and the only 
way you can protect those who are not old enough to yet get 
vaccinated or the immunosuppressed is to be part of that herd 
immunity.
    Ms. DeGette. Right. Now, Dr. Messonnier, you talked about 
the risks and benefits, and we have heard a lot from both of 
you about the benefits.
    What are the risks of the--and maybe, Dr. Fauci, you want 
to add into this, too--what are the risks inherent in the 
vaccine itself? I think that might be one reason why some 
parents are choosing not to vaccinate their children as they 
believe that the risks with the vaccine outweigh the benefits.
    Dr. Messonnier. I think you are exactly right and I think 
in the setting of not a lot of measles cases around parents 
weigh in their mind the risks and benefit and think they 
shouldn't vaccinate.
    The truth is this is an incredibly safe vaccine. We have a 
host of experience with it. The vaccine has been used for a 
really long time.
    We, in the United States, enjoy one of the most robust 
systems to monitor the safety of vaccines and that is why we 
can say with confidence that this is a safe vaccine. The most 
common side effects are a sore arm, which goes away pretty 
quickly.
    Ms. DeGette. And where can parents go to get factual 
information about vaccines?
    Dr. Messonnier. Yes, thank you. That is a really important 
question. As a parent myself I understand that there is lots of 
information out there and it is really hard to sort through it 
all and make sure that you are getting the correct choices for 
your children.
    CDC works really hard to make sure that we put out 
scientifically credible information. That is one of our core 
missions. But we also provide that information to health care 
providers.
    Parents say that the person they trust most to help them 
make health care decisions is still their health care provider 
and that is also true of patients that are hesitant to 
vaccinate.
    So parents should talk to their health care provider. They 
can help them sort through the sea of information out there to 
what is scientifically correct.
    Ms. DeGette. Dr. Fauci, do you have a sense of what parents 
can do to get accurate information about the risks and 
benefits?
    Dr. Fauci. Yes. I mean, I want to echo what Dr. Messonnier 
said. The CDC website is just really a cornucopia of important 
information. It is easily accessible. You go to cdc.gov. It 
says Search. Put measles in and all the things you really want 
to know about it are right there with references.
    Ms. DeGette. Great. OK. Thank you very much, both of you, 
for being with us today and clearing up some of these myths.
    I am now happy to recognize the ranking member, Mr. 
Guthrie, for purposes for asking questions for 5 minutes.
    Mr. Guthrie. Thank you very much, and again, thanks for the 
witnesses for being here. And this is important and I think 
every parent, regardless of what decisions they made on--want 
to make the best decision for their child. That is what 
people--and so we want to make sure the best information, the 
accurate information, so they can make the best decision for 
the child.
    This is particularly pertinent to me. One of my great 
friends growing up--I was born in 1964. He was born just a few 
months before me in 1963 and his mom had rubella. He was born 
without a hand--essentially, without a hand. And so I have 
always thought of measles and how devastating it can be.
    As a matter of fact, you can see him play baseball. He 
could throw the ball, have his glove on his hand, put his hand 
in and just amazing how he adapted to it. But it was something.
    So I remember later in life when I was a little older my 
mom telling how the--because she was six or seven months 
pregnant with me when he--when he was born and just the terror 
that went through our community and with women that were 
pregnant with their children at that time.
    So it has always been--so I just want to ask some questions 
and try to get information out, moving forward, and for both of 
you to answer. In your opinion as physicians and leaders in 
Federal public health agencies, should parents of unvaccinated 
children be more fearful of measles or the measles vaccine?
    Dr. Fauci. To me, it is a no doubt. That is really a no-
brainer. Clearly, if you look, and as I try to describe in my 
opening statement, the potential complications and even if you 
don't have complications, just the discomfort associated with 
the illness of measles far, far outweighs, as Dr. Messonnier 
said, of a very, very safe vaccine.
    So, to me, there is no doubt. I am a parent. I have three 
daughters. They were all vaccinated and the thing that I 
worried about was them, if I did not vaccinate them, getting 
measles if it came into the community. That would scare me, not 
the vaccine.
    Mr. Guthrie. Thank you.
    Dr. Messonnier. One thing I will add is that in the current 
outbreak in Clark County, Washington State, we have seen a huge 
upsurge in acceptance of vaccine and use of vaccine in the 
community.
    When faced with the real threat of measles, people--parents 
weigh that same equation and realize it is better to vaccinate. 
What we need to do is get those messages to parents before the 
measles outbreak hits.
    Vaccine is incredibly safe. Measles remains a risk 
throughout the country. Yes, it is a no-brainer.
    Mr. Guthrie. And your children are vaccinated?
    Dr. Messonnier. Of course my children were vaccinated.
    Mr. Guthrie. So for both of you, again, how many doses of 
MMR vaccine have been given in the U.S.? Millions or----
    Dr. Messonnier. I mean, millions of doses of MMR vaccine 
are given every year.
    Mr. Guthrie. And after more than 55 years of experience and 
hundreds of millions of doses, we estimate, what is the safety 
record of MMR vaccine?
    Dr. Messonnier. You are right. Millions of doses in the 
U.S., not to count also the multimillion of doses given 
globally, all tell us for certain that the safety record is 
good. It is an incredibly safe vaccine. Parents should be 
reassured that we know this vaccine is safe because of all this 
experience.
    Mr. Guthrie. Dr. Fauci?
    Dr. Fauci. Also, I think it is important about how some 
people can get confused because when you're in a certain area 
of childhood--so vaccines are recommended at around one year--
11 to 12 months--and then the boost at 4 to 6 years.
    During that period of time of childhood a lot of things 
happen to children. They get a lot of different diseases. 
Sometimes bad things happen. And if you were to look at that 
you can make an association and say, well, maybe that's due to 
the vaccine.
    But a number of studies over many, many years have shown 
the disassociation of that and, as Dr. Messonnier said, that 
when you go back and look at the strict safety of the vaccine 
it is extraordinarily safe.
    Mr. Guthrie. I want to look at some of the concerns. I have 
heard some parents claim that measles vaccine can cause brain 
inflammation--encephalitis. Is that true? Is that true?
    Dr. Fauci. Brain inflation encephalitis?
    Mr. Guthrie. Encephalitis. Can measles vaccine cause 
encephalitis--the vaccine?
    Dr. Fauci. The vaccine, no.
    Mr. Guthrie. There are no cases----
    [Disturbance in hearing room.]
    Dr. Messonnier. There is no----
    Dr. Fauci. Rare.
    Ms. DeGette. The Chair will remind all persons in the 
audience that manifestation of approval or disapproval of the 
proceedings is in violation of the rules of the House and its 
committees.
    The gentleman may proceed.
    Dr. Messonnier. In healthy children MMR vaccine does not 
cause brain swelling or encephalitis.
    Mr. Guthrie. So if a child wasn't healthy when they are 
vaccinated would----
    Dr. Messonnier. So there are rare instances of children 
with certain very specific underlying problems with their 
immune system and who the vaccine is contraindicated. One of 
the reasons it is contraindicated is in that very specific 
group of children there is a rare risk of brain swelling.
    Mr. Guthrie. Would a parent know if their child was in that 
category before they are----
    Dr. Messonnier. Certainly, and that is why a parent should 
talk to their doctor.
    Mr. Guthrie. OK. And then one more, because I had a couple 
of seconds with the questions. So another thing, that the 
people can self-medicate with Vitamin A to prevent measles and 
not do the vaccine. What is the validity of that, in your 
opinion?
    Dr. Fauci. Well, the history of Vitamin A and measles goes 
back to some very important and, I think, transforming studies 
that were done years ago in sub-Saharan Africa, is that with 
Vitamin A supplements and particularly in Vitamin A deficiency 
that children who get measles have a much more difficult 
course.
    So Vitamin A associated with measles can actually protect 
you against some of the toxic and adverse effects. Importantly, 
since in a country--a developed nation where you really don't 
have any issue with Vitamin A deficiency, that you don't really 
see that transforming effect.
    But some really good studies that were done years ago show 
that Vitamin A supplementation can be very helpful in 
preventing the complications of measles.
    Mr. Guthrie. It doesn't prevent onset of measles, if you 
are not immunized?
    Dr. Fauci. No. No.
    Mr. Guthrie. Is that what you are saying? I don't want to 
put words in your mouth.
    Dr. Fauci. It doesn't prevent--it doesn't prevent measles. 
But it is important in preventing some of the complications in 
societies in which Vitamin A deficiency might exist.
    Mr. Guthrie. Thank you. I appreciate your indulgence.
    Ms. DeGette. The gentleman yields back.
    The Chair now recognizes the gentlelady from Illinois, Ms. 
Schakowsky, for 5 minutes.
    Ms. Schakowsky. Dr. Messonnier and Dr. Fauci, if we could 
just once--maybe once again put on the record, yes or no. Is 
the highly contagious measles virus life-threatening--deadly? 
Yes or no.
    Dr. Messonnier. Yes.
    Dr. Fauci. The answer is yes. It rarely occurs. I mean, 
most children--myself, Mike Burgess----
    Ms. Schakowsky. Myself.
    Dr. Fauci [continuing]. Who developed measles--yourself and 
many people on the committee who got measles would recover 
completely. But you ask yourself, is there a potential to be 
deadly?
    History tells us unequivocally that's the case, because 
when you were talking about the measles vaccine before we 
vaccinated here in the United States in the early to mid-'60s, 
there were 400 to 500 deaths directly due to measles.
    Prior to the measles vaccine globally there were over a 
million--1 to 2 million--deaths in a year. So as Dr. Messonnier 
said in direct answer to your question, is it potentially 
deadly? Absolutely.
    Ms. Schakowsky. That is very important. Thank you.
    And that deeply should concern all of us and over the past 
two weeks a new outbreak has sprouted in my home State of 
Illinois with four confirmed cases in Champaign County, the 
home of the University of Illinois. It happens to be my alma 
mater.
    And I am trying to understand what has happened between 
2000 and 2019 and why we have fallen so far from the public 
health success stories when the CDC actually said that there--
we had eradicated in the United States measles in 2000.
    So, Dr. Messonnier, yes or no. Do you believe the primary 
cause of the spike in measles outbreak over the past few years 
is due to vaccine hesitancy and misinformation?
    Dr. Messonnier. Yes and no. I think vaccine hesitancy is a 
word that means many different things. Parents have questions 
about vaccines. They get those questions answered. That is what 
you should call hesitancy.
    So I do believe that parents' concerns about vaccine leads 
to undervaccination and most of the cases that we are seeing 
are in unvaccinated communities.
    However, if you look nationally at measles vaccination 
coverage, there are other things that are associated with low 
coverage. For example, living in a rural area versus an urban 
area. Rural areas have lower vaccine coverage with measles.
    Ms. Schakowsky. How would you account for that?
    Dr. Messonnier. Well, I think that there are other things 
besides the choice that are around access to care. For example, 
kids without health insurance have lower measles vaccination 
coverage.
    Ms. Schakowsky. So, generally, lack of access to care?
    Dr. Messonnier. In addition to parents making decisions not 
to vaccinate their kids, yes.
    Ms. Schakowsky. More than 50 percent of the current 
outbreak cases this year occurred in Clark County, Washington. 
In that region, only 81 percent of 1-to-5-year-old children and 
only 78 percent of 6-to-18-year-olds received the age-
appropriate measles, mumps, and rubella vaccine dosage. So it 
is really deeply troubling that it seems to cluster in certain 
places.
    Dr. Messonnier and Dr. Fauci, what do you believe would 
happen--let us say if only 78 percent of the entire U.S. 
population was vaccinated against the--against measles or, 
worse yet, what would happen if we stopped all measles 
vaccinations?
    Dr. Fauci. Well, measles, as I mentioned in my 
presentation, exists. There were 110,000 deaths in 2017. So 
measles is out there.
    Even though we, as a country, now have a high degree of 
vaccination, if we did what you are suggesting and essentially 
dropped it down to 70 percent, 50 percent, or even stopped, we 
would have an entirely susceptible population. We would be like 
countries prior to the vaccine era and that would be a 
catastrophe waiting to happen.
    So even if you go down to a certain level, if you look not 
only at the United States--we showed the figures of the United 
States--but right now there is a terrible outbreak going on in 
Madagascar. There have been 900 deaths so far in Madagascar.
    We are seeing that in other countries in which when you go 
below a certain level and that umbrella of herd immunity lifts, 
it truly is a catastrophe waiting to happen. So that is 
something that would be very scary to think about.
    Ms. Schakowsky. Let me just say as an organizer, I think 
part of it is a communications issue, an organizing issue, and 
we need to mobilize the public on this question. It is not just 
up to the two of you. We want to work with you but I think we 
need to get some organizers going.
    Thank you. I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
Texas, Dr. Burgess, for 5 minutes.
    Mr. Burgess. Thank you for the recognition.
    I learned something this morning. I always learn something 
on this committee. Mr. Guthrie asked a question about Vitamin A 
and, Dr. Fauci, thank you for your answer.
    I did not know that in Vitamin A deficient individuals 
perhaps there was going to be a harder course for the disease.
    I do feel obligated to mention that Vitamin A is not like 
Vitamin C. You may not take unlimited quantities of Vitamin A 
with impunity. It is a fat-soluble vitamin and it is stored in 
the body. So don't go out and hyperdose on Vitamin A because it 
will not accrue to your long-term benefit.
    So vaccines themselves are at the very heart of medical 
innovation and some my parallel the history of this country. 
Dr. Edward Jenner began his career and introduced the first 
vaccination in 1796, 20 years after our Declaration of 
Independence. So a long history of an association with 
vaccination.
    So the two of you work together on these issues. So can you 
perhaps tell us a little bit how you work together to prevent 
the reappearance of vaccine-preventable diseases, focused on 
measles this morning?
    Rubella--something I remember from my residency at Parkland 
Hospital. A congenital rubella syndrome in a child was 
devastating. These are illnesses that new generations of 
doctors don't see because of the effectiveness of the vaccine.
    Can you speak just briefly of how you--how your agencies 
interact and work together?
    Dr. Fauci. Well, as you know, Dr. Burgess, that the CDC and 
the NIH are within the Department of Health and Human Services. 
So we consider each other sister agencies, as it were, and the 
CDC has the major responsibility, as Dr. Messonnier will tell 
you, about the public health--the surveillance and the 
messages.
    We, as a research institution, try to fill in any of the 
gaps that occur from a research standpoint. What we are talking 
about today is really less of a research problem than it is an 
implementation problem.
    So how we help and work with our colleagues at the CDC is 
to continue to provide the evidence-based--the science-based 
evidence of why we need to implement a highly successful 
program that is, as we know, the vaccine program that we are 
talking about.
    Dr. Messonnier. No, I think this is an area where CDC does 
have the leadership role within HHS and our program is vast and 
diverse including all the operational pieces that it takes to 
deliver vaccines and, importantly, all the local partnerships 
that it takes to make the--to make the case for why vaccines 
are important.
    Communication is a hugely important part. Monitoring the 
effectiveness and safety of vaccines so that we can continue to 
assure the public that we know that the vaccines are working 
like we think they are.
    Mr. Burgess. And, Madam Chairman, I will just say that both 
of these--both NIH and CDC--where Members of Congress come 
visit it. I know it is a pain in the neck but you are always 
very good to receive us.
    Dr. Fauci, I try to come to the NIH once each congressional 
term and, Dr. Messonnier, I was at CDC--it is harder to get to 
Atlanta for me, but the--you have been very good about when I 
have come to make available information and personnel and it is 
very, very helpful in sort of setting the background for what 
you just described.
    Let me ask a question of either of you or both of you. The 
1999--the Public Health Service recommended removing 
thimerosal, the mercury-containing compound. My understanding 
is that childhood vaccinations now no longer contain thimerosal 
except for a select few--perhaps the multidose flu vaccine.
    Did the measles-mumps-rubella vaccine ever contain mercury 
or thimerosal? I need a verbal answer for the clerk.
    Dr. Fauci. No, it is preservative free.
    Dr. Messonnier. No, and you didn't ask this but I just 
would also point out this is an area where we work with FDA 
very closely since vaccine safety is their mandate.
    Mr. Burgess. Was there ever any evidence to suggest that 
mercury or thimerosal was unsafe? I guess that is a better 
question for the FDA but you all are experts--subject matter 
experts.
    Dr. Fauci. There is no evidence that it is unsafe.
    Dr. Messonnier. The thimerosal was removed from vaccines 
out of an abundance of caution at a time when there wasn't 
enough evidence. But evidence since then has been very 
conclusive.
    Mr. Burgess. Well, I thank you for that. I have some 
additional questions. I will submit those for the record.
    I yield back.
    Ms. DeGette. Thank you very much.
    The Chair now recognizes the chairman of the full 
committee, Mr. Pallone, for 5 minutes for questioning.
    Mr. Pallone. Thank you, Madam Chair.
    The elimination of measles in the United States in 2000 was 
a testament to science research and the public health system we 
have in place in this country. So it is disturbing to see the 
numbers on the current measles outbreaks and just how common 
these outbreaks are once again becoming in the United States.
    You know, I mean, I guess the CDC made the announcement 
based on the number of cases that had been eradicated. But even 
I myself, when I was doing my opening statement this morning, 
you know, my staff said oh, it is, you know, over in New Jersey 
and then we have a new outbreak.
    So, you know, I think there is reason to be concerned. So 
let me just say, Dr. Messonnier, is--what is the reason or the 
reason why we should be concerned that measles cases and 
outbreaks are increasing or may increase in the coming years, I 
mean, and do you agree that we should be concerned?
    Dr. Messonnier. Yes, we should certainly be concerned. So 
measles was identified as eliminated in the United States in 
2000 because there was no longer sustained transmission in the 
U.S.
    However, measles continues to circulate globally, which 
means unvaccinated U.S. travelers can be exposed to measles and 
bring it back home with them and folks in their families and 
their communities, if they are not protected by vaccine are at 
risk. Measles is so incredibly contagious that it can spread 
really quickly. So yes, we should be concerned.
    Mr. Pallone. All right.
    Now, given your answers, I am glad we are focusing on it 
today. But this threat, in my opinion, is amplified, 
unfortunately, by the spread of disinformation. There has been 
a significant--there has been significant reporting in the past 
few weeks regarding the use of digital media platforms to 
spread misinformation and fear about vaccinations.
    So let me go to Dr. Fauci. What role do you see the spread 
of disinformation online playing in the rise of these 
outbreaks?
    Dr. Fauci. I believe, Mr. Pallone, that it--that it plays 
an important role. It is not the only one but I believe it 
plays an important role and I think the classic example of that 
was the disinformation associated with the relationship between 
measles vaccination and autism, which back when it came out 
years ago there was a big concern that this was the case.
    When it was investigated it became clear that the data upon 
which those statements were made were false and fraudulent and 
the person who made them had his medical license revoked in 
England.
    And yet, as you know very well, the good news about the 
internet is that it spreads important information that is good, 
and the bad news about the internet is that when the bad 
information gets on there, it is tough to get it off.
    And yet people refer to things that have been proven to be 
false. So disinformation is really an important issue that we 
need to try and overcome by continuing to point people to what 
is evidence based and what is science based.
    So in so many respects, we don't--we shouldn't be 
criticizing people who get these information that is false 
because they may not know it is false. We need to try and 
continue to educate them to show them what the true evidence 
base is.
    But in direct answer to your question, that is an important 
problem--disinformation.
    Mr. Pallone. Now, do you think that the promotion of this 
inaccurate and fear-based messages--would you consider that in 
itself a threat to public health?
    Dr. Fauci. Yes, of course. I think the spread of false 
information that leads people into poor choices, even though 
they are well meaning in their choice, it is a poor choice, 
based on information. I think that is a major contribution to 
the problem that we are discussing.
    Mr. Pallone. I mean, part of the problem is, you know, is 
this 30 seconds. In other words, you know, people will listen 
to the news or watch the internet and they will hear, as you 
say, that somehow vaccinations lead to autism and they will 
hear that and then, you know, they won't hear what comes later 
that says that that is false because that is more complicated, 
you know. I mean, it is just the nature of it.
    Look, the main thing I wanted to say because we are--you 
know, I only have 5 minutes--is that you keep stressing the 
science and that we have to follow the science and protect the 
public health based on what the science tells us, and I think 
that is what's so crucial here, and that is the one thing that, 
you know, we have and that, you know, CDC and National 
Institutes of Health are providing for us, is the science-based 
information and we have to rely on it and get that out.
    So thank you so much. Thank you both. Thank you, Madam 
Chair.
    Ms. DeGette. The gentleman yields back.
    The Chair will once again remind the persons in the 
audience that manifestation of approval or disapproval of 
proceedings is in violation of the rules of the House and the 
committees, and if these violations continue then we will 
notify the Sergeant at Arms, who will have you removed.
    So I would appreciate cooperation of everyone so we can 
hear the witnesses and so we can hear the Members' questioning.
    And with that, I will now recognize the gentlelady from 
Indiana, Mrs. Brooks, for 5 minutes for her questioning.
    Mrs. Brooks. Thank you, Madam Chairwoman.
    Dr. Fauci, I would like to focus--and actually both of you, 
Dr. Messonnier and Dr. Fauci--I would like to talk a little bit 
about U.S. biodefense.
    And Congresswoman Eshoo and I led the Pandemic All-Hazard 
Preparedness Act bill, which we have gotten passed through the 
House once again, and I think what a lot of people in the 
country don't fully appreciate is the importance of a 
biodefense and defending our country, whether it is for 
national security reasons or with respect to public health 
threats.
    Is undervaccination to U.S. biodefense and how does--how do 
vaccinations play into the protection of our country and what 
does biodefense mean?
    Dr. Fauci?
    Dr. Fauci. Yes. Thank you for that question. That is a very 
good question because we have been involved in biodefense for 
quite a while. The effort really galvanized at 9/11 when we had 
the anthrax attack and we put a consideration amount of 
resources into developing countermeasures in the parts of 
vaccines, therapeutics, diagnostics, against what were 
classically agents that were used in bioterror.
    When we analyzed our approach back in 2001, 2002, and 2003 
it became clear that it really is all a part of emerging and 
reemerging infections--those that naturally emerge as new 
infections, like we saw with AIDS and SARS. Those that----
    Mrs. Brooks. Zika?
    Dr. Fauci. Yes, Zika.
    Mrs. Brooks. Ebola?
    Dr. Fauci. But those that--those are reemerging so there 
are brand new infections. There are reemerging infections and 
we would consider as part of the big problem and the link that 
I think you are referring to, and I totally agree with you, 
that if you have a vaccine-preventable disease but you still 
let that disease go unchecked because of lack of vaccination, 
that is all part of the problem of not adequately addressing 
reemerging infectious disease.
    Measles in an old disease. Right now what we are seeing on 
the charts that we showed is the reemergence of a vaccine-
preventable disease, which to me falls under that broad 
category that you are referring to.
    Mrs. Brooks. And I--and I appreciate you giving us the 
numbers. We were at 159 as of February 21st. The numbers might 
be slightly higher. But that--those numbers are dramatic for 
only two months of the new year.
    How is it--and both of you have talked about the importance 
of eradicating it entirely with a concerted global public 
health effort because you have got 900 people who have died in 
Madagascar, and I know while people here in this country may 
not think that people in Madagascar can infect our country, why 
do we believe it is possible to eradicate a disease like 
measles? Why do we think it is even possible?
    Dr. Messonnier? Dr. Fauci?
    Dr. Fauci. So I have been saying that it is a--the vaccine 
is extraordinarily effective. We have eliminated--the 
agricultural industry has eliminated a closely related virus 
among animals called rinderpest. So it is, essentially, the 
same virus only the animal version of it.
    So when you have a highly effective, and I want to 
underscore that because measles is one of the most effective 
vaccines that we have of any vaccine, that a massive public 
health effort could lead to eradication because we don't have 
an animal vector.
    We don't have an intermediate host. We don't have a vector 
that transmits it. It is just person-to-person 
transmissibility.
    So, theoretically, we could eradicate it. The problem 
between eradication and elimination, if you eliminate it like 
we did in this country in 2000, as long as there is measles 
somewhere you always have the threat of it reemerging if you 
let down the umbrella of her immunity.
    Mrs. Brooks. And so, Dr. Messonnier, helping other 
countries with vaccine implementation would be helpful to our 
country. Is that correct?
    Dr. Messonnier. That is right. I mean, control of measles 
around the world is a priority for CDC and there are a whole 
variety of efforts towards that.
    I do think it is important, though, Dr. Fauci is correct 
about Madagascar. But I think Americans don't realize that in 
2018 there were also outbreaks in England, France, Italy, and 
Greece. American travelers going abroad need to think about 
their immunization status, not just when they are going to 
countries like Madagascar but even going to Europe.
    Mrs. Brooks. Thank you. I yield back my time.
    Ms. DeGette. The Chair now recognizes the gentleman from 
California, Dr. Ruiz, for 5 minutes.
    Mr. Ruiz. Thank you very much for being here again. My 
questions are going to be in line of two separate topics, which 
are interrelated as well.
    One is the disparities that we see in the vaccination rates 
and two is the coordination between your agencies and the 
State, Federal, nonprofit in dealing with communications and 
the outreach.
    So, Dr. Messonnier, you said that one of the biggest 
challenges is access to these vaccines and so we see 
disparities in low income, uninsured, underinsured populations 
in getting the vaccine.
    The Affordable Care Act made it a mandatory coverage for 
private health insurance through the essential health benefits 
to provide these vaccines.
    If we eliminate or repeal these essential health benefits 
and allow insurance companies to not cover these vaccines, 
would that--would that worse the problem of access to these 
vaccines?
    Dr. Messonnier. So thanks for the opportunity to talk about 
this. In fact, the vaccines for Children's Program provides a 
safety net. Vaccines----
    Mr. Ruiz. So if the private--if the private health 
insurance were no longer required to provide vaccines, would 
that decrease perhaps the vaccination rate?
    Dr. Messonnier. So right now the issue is not in private 
insurance. All insurance companies provide vaccines free of 
charge.
    Mr. Ruiz. Of course. So the Affordable Care Act right now 
makes it mandatory to provide. It is part of the essential 
health benefit. So if they repeal that essential health benefit 
and they are no longer required to provide it, they can choose 
not to provide, which then makes it difficult to get access to 
the care.
    Medicaid is also a good program that gives low-income 
children and other families the ability to get the vaccination, 
along with the programs that you administer as well.
    So if we repeal those, then we are going to make the 
problem worse by not having those vaccinations available. Can 
you speak, broadly, to the coordination role that CDC plays and 
how that is important for responding to outbreaks?
    Dr. Messonnier. Sure. The backbone of our response to 
outbreaks is the State, local, Federal, community interaction 
around immunizations. I think Clark County is a perfect 
example.
    The health departments, certainly, at the local level was 
the first to respond. These outbreaks can be quickly 
overwhelming because every case has potentially hundreds and 
thousands of contacts that need to be tracked down.
    The county quickly got overwhelmed. They came to the State 
asking for support and then the State came to CDC. CDC already 
has folks embedded in the health department and we work closely 
with them every day. But they asked for more support and we had 
boots on the ground right away.
    Mr. Ruiz. Would--Dr. Fauci, when it comes to the measles 
cases or other vaccine-preventable diseases, are there 
particular challenges to mobilizing and promoting a cohesive 
preparedness message or communications plan within communities 
at a national level?
    Dr. Fauci. At a national level, the communication I think 
from the CDC is quite good. I mean, if you look at the messages 
that come out from the CDC--and I could let Nancy speak about 
this better than I--but the beauty about what the CDC does is 
that they work very, very closely with the State and local 
health authorities. I mean, that is a very, very important 
partnership.
    So you have the Federal level with a very important message 
that gets disseminated through the State and local health 
authorities.
    Mr. Ruiz. And what is the coordination with the Indian 
Health Service in reaching out to rural and reservations?
    Dr. Messonnier. Yes. It is a close partnership and has been 
for a long time. The immunization community--again, State, 
local, Federal community--is very closely aligned and works 
really closely together.
    We understand that a lot of these issues are local. So 
while CDC provides scientifically credible information, it is 
often most effective for folks in the community to be the ones 
conveying that information.
    Mr. Ruiz. Are you talking more about the programs that you 
offer to low-income and uninsured, underinsured and how do you 
get to those communities that are very underinsured?
    Dr. Messonnier. I mean, the vaccine for Children's Program 
has provided that safety net for a number of years and it is 
one of the reasons we have enjoyed such good control of measles 
and other vaccine-preventable diseases.
    This data that suggests that there are some communities 
that are not taking advantage of that program is concerning and 
we are working closely with our local and State partners to 
understand the drivers.
    I am not sure the issues are the same everywhere. We really 
need to understand what the local issues are and then figure 
out how to solve them.
    Mr. Ruiz. I agree. I think that local communication plans 
is very important and herd immunity is also very important as 
well.
    Thank you. I yield back my time.
    Ms. DeGette. The Chair now recognizes the gentleman from 
South Carolina, Mr. Duncan, for 5 minutes.
    Mr. Duncan. Thank you, Madam Chair.
    When I travel I carry a yellow card with me in addition to 
my passport to have a record of all the shots that I have 
taken--immunizations--and as a father of three sons, when my 
sons entered kindergarten and grade school we had to provide an 
immunization record for them and I would argue that they 
probably would not have been able to attend public schools in 
South Carolina without certain immunizations and vaccinations.
    We had a hearing last week about unaccompanied children and 
child separation at the border, et cetera, and one point I made 
then is that, you know, we don't know the vaccination history 
of a lot of the children that show up at our border and we have 
a porous southern border and there are children and other 
individuals that come into this country that we don't know 
about--that aren't apprehended, they don't go through a normal 
port of entry--and what we are seeing is a rise of certain 
diseases--not necessarily measles but diseases in this country 
that we had beaten back over the years.
    And so I think it is alarming from a subject of vaccination 
and immunization when we see those diseases rising, and one of 
the world's measles outbreaks right now is happening Brazil 
where people fleeing a completely broken country of Venezuela 
are spreading measles.
    And Madam Chair, I would like to submit for the record an 
NPR article, ``Collapse Of Health System Sends Venezuelans 
Fleeing To Brazil For Basic Meds,'' and I will submit that for 
the record.
    [The information appears at the conclusion of the hearing.]
    They have been in an unvaccinated population because of the 
collapse of the failed socialist state in Venezuela, where 
there should be an instructive example for some of us in this 
committee room of the lack of that sort of medical treatment of 
vaccinations.
    I would note that the humanitarian aid that countries like 
the U.S. are trying to send to Venezuela is being burned on 
bridges by the Maduro regime instead of actually being used to 
help his own people.
    This includes vaccinations like the ones we are discussing 
today. There were measles vaccinations that were burned on the 
bridges as part of the relief effort to Venezuela.
    So now the CDC tells us that the first dose of MMR vaccine 
provides 93 percent of coverage against measles. The second 
dose increases that number to 97 percent.
    We also know from reports here in the U.S. and around the 
globe that some kids have faced adverse reactions to this 
powerful and life-giving immunization.
    Therefore, my question for each of you on the panel is 
this. Considering the prodigious advances in technology and 
medical research that our Nation has discovered since around 
the 1960s when the MMR vaccine was first introduced, how can we 
now further increase the efficiency of the MMR vaccine to fight 
measles while at the same time work to limit the adverse 
reactions that some children have had after receiving the MMR 
shot?
    And I ask both of you that.
    Dr. Messonnier. This is a great example of a vaccine that 
is so good, so effective, and so safe that we haven't tinkered 
with it. I think that while there are many challenges in 
immunizations, the effectiveness and safety of measles vaccine 
isn't one of them.
    The measles vaccine has mostly stayed the same because of 
the high effectiveness and the long track record of safety.
    Mr. Duncan. Dr. Fauci?
    Dr. Fauci. There was--I totally agree with Dr. Messonnier. 
You know, as a person who has been involved with developing 
vaccines for a long time you really don't get much better than 
97 percent. That is really good.
    So the thing that you, I believe, were alluding to when the 
Edmonston strain came out in 1963 it was highly effective and 
not serious--any serious adverse events. But there was a 
percentage of fevers that were associated with an occasional 
rash. That was improved in 1965 to develop another strain.
    And then since 1968 what was--a strain that is now being 
used in Attenuvax it is called is one, as Dr. Messonnier has 
said, that not only maintains the 97 percent effectiveness but 
it is very, very free of serious toxicities.
    Mr. Duncan. And I agree. I mean, I think these strains are 
adaptive. We see that in the flu virus where we can only 
anticipate what the virus is going to look like this year. 
Sometimes it adapts or sometimes it changes and the vaccine for 
the flu isn't quite the right flu vaccine for the year and we 
see an increase.
    So I want to continue to raise awareness that we need to 
make sure as asylum seekers come to this country whether they 
are coming along our southern border or whether folks are 
immigrating to the Nation from other places that we make sure 
that those countries have the right immunization schedules and 
vaccinations for the children and the adults because, 
ultimately, when they come to this country and live amongst us 
they may not have the same vaccinations and immunizations that 
we experience in this country and we may see measles today and 
maybe something else in the future.
    And with that, I yield back.
    Ms. DeGette. The gentleman yields back.
    The gentleman from Texas has a unanimous consent request.
    Mr. Burgess. Thank you, Madam Chair. I have a unanimous 
consent request to place into the record a letter from Dr. 
Peter Hotez from Children's Hospital in Houston.
    Ms. DeGette. Without objection, that letter shall be placed 
into the record, and also without objection the NPR article 
that the gentleman from South Carolina requested be put in the 
record will be placed in the record.
    [The information appears at the conclusion of the hearing.]
    The Chair now recognizes the gentlelady from Florida, Ms. 
Castor, for 5 minutes.
    Ms. Castor. Thank you, Madam Chair. Thank you very much for 
being here today.
    I want to get a little more specific on Dr. Ruiz's 
questions on disparities. You said, Dr. Messonnier, that 
disparities exist when it comes to the MMR vaccine. What do 
those disparities look like and how do they break down by 
demographics?
    Dr. Messonnier. Thank you.
    So, you know, there is always the national picture and then 
the local picture. Nationally, I can tell you that there are 
certain groups that have lower risks of MMR vaccination, 
although overall everybody and generally nationally has high 
rates. But there are low rates of MMR in those of lower 
socioeconomic status, those without insurance, and those who 
live in rural areas as opposed to urban areas.
    The specific drivers, though, locally may be different and 
that is why we really have to work closely at the State and 
local level to understand at a community level what that is. Is 
that access, is it misinformation, and how can we resolve the 
issues?
    Ms. Castor. How about by location?
    Dr. Messonnier. Oh. So there are States in the U.S. that 
have higher vaccination coverage than others. But I would also 
say that, if you talk to any State health department, what you 
find is that even within the State there are differences at a 
community, local, county, school level.
    I think one real advancement in using the data that is 
available is that some States have actually put that data 
online and so you can go to a website and look, for example, at 
a State and see at a county level and at a school level what 
immunization coverage is. It is really powerful information for 
parents to understand what is going on in their communities.
    Ms. Castor. What is the biggest source of the reemergence 
by demographic?
    Dr. Messonnier. So I think it is an interesting question. 
The groups that I was talking about with lower vaccination 
coverage are a concern because it is a failure of our safety 
net.
    But most of the disease and certainly the large outbreaks 
we are seeing in this country are actually not associated with 
those. It is associated with groups of people like close-knit 
communities that are undervaccinated and clustering together.
    Ms. Castor. Because I--and that was my impression and I was 
a little confused by the last line of questioning that the 
alarm should be over immigration and asylum seekers.
    Do you have a comment on that? Dr. Fauci?
    Dr. Fauci. Well, I think what Dr. Messonnier said is 
absolutely correct. If you look at the known outbreak, so if 
you take the outbreak in the Williamsburg section of Brooklyn 
in New York City and in Rockland County it was a relatively 
closed group who had a rate of vaccination that was below the 
level of a good herd immunity.
    A person from Israel, understandably, came over legally as 
a visitor into the community and then you had a massive 
outbreak in New York. The Somali community in Minnesota, the 
same thing happened.
    You had a group there who had a lower rate that went below 
the cutoff point for herd immunity. Some immigrant came in as 
one of the members of the community. It was a relatively closed 
community and that is what you have.
    So I think when you talk about outbreaks, it really 
transcends some of the demographic issues that you were talking 
about about lower income or rural versus urban. It really is in 
a closed community that we are seeing it.
    Ms. Castor. With lower vaccination rates. So that is----
    Dr. Fauci. Right. Exactly. It is all lower vaccination 
rates.
    Ms. Castor. So it is pretty remarkable. We really are 
fortunate that we have such a safe and effective measles 
vaccine. I mean, these statistics are fairly remarkable. 
Prevaccine, 2.6 million deaths each year.
    After the vaccine was introduced in 1963 a dramatic 
decrease. Dr. Fauci, you say from 2000 to 2017 over 21 million 
deaths have been prevented, and it used to be that most 
children were--acquired measles by age 15 but thanks to all of 
the great work by scientists and public health agencies like 
you all, as a result, we were able to practically eliminate 
this.
    But despite this breakthrough, the millions of lives it has 
saved, there is still so much misinformation about the vaccine. 
Today, you all, leading health experts, help us clarify some of 
this.
    Dr. Fauci, looking at the science, what do we know about 
the--again, I don't think we can say this often enough because 
of the misinformation--how safe and effective is the measles 
vaccine--the MMR vaccine--and how would you compare it to other 
vaccines?
    Dr. Fauci. Well, let us talk about efficacy first. It is, 
clearly, one of if not the most effective vaccine that we have. 
As Dr. Messonnier said, you really can't get much better than 
that.
    That is the reason why we don't want to tinker with its 
efficacy. Ninety-seven percent is really, really good. And as 
both of us have said many times, it is a very safe vaccine--
over millions and millions and millions of doses that have been 
given. It is a very, very safe vaccine.
    Ms. Castor. Thank you very much. I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
New York, Mr. Tonko. I was trying to figure out the order. New 
York. Mr. Tonko, for 5 minutes.
    Mr. Tonko. Thank you, Chairwoman DeGette.
    Promoting healthy families in communities is possible 
thanks to the dissemination of science-informed health 
information directly to patients and health providers play a 
critical role as the most trusted source of health information 
for people and, certainly, parents.
    However, ensuring that patients receive accurate 
information has grown complicated in the digital age. In fact, 
according to the Pew Research Center, seven in ten adults in 
the United States look online for health information, and even 
when they are not searching for information online, content 
finds them.
    I know you spoke a bit about this with Chairman Pallone. I 
went to delve a little more deeply. Recently, the Guardian 
reported that antivaccination content is being recommended to 
users on a range of digital media platforms proliferating 
misleading information, testimonies, and advertisements on 
mediums used to explore news-related topics.
    So, Dr. Messonnier, what do the data and examples of recent 
measles outbreaks tell us concerning the impact of 
disinformation on public health and in these communities?
    Dr. Messonnier. Yes. I am certainly really concerned about 
the misinformation. But I also understand how complicated it is 
for parents that are inundated with information and aren't sure 
what information to trust.
    All our research continues to show that among all groups of 
parents of all ages of children they still trust their own 
health care provider most. So most parents are hearing this 
information and then going to their health care provider to 
help them sort it through and most parents in the U.S. are 
still going on to get their kids vaccinated.
    Mr. Tonko. Thank you.
    And Dr. Fauci, what guidance do you have to assist patients 
in discerning fake information from science-based information?
    Dr. Fauci. What we try and do is to steer them towards the 
well-established scientific literature as opposed to claims 
that are just made in a almost haphazard way.
    I mean, that is one of the problems, that if a person makes 
a claim it gets onto the internet and, understandably, people--
parents, in particular--have a difficulty discerning what is 
false equivalency. Like someone says this and then the other 
one says that and they say, I don't know who to believe.
    But if you delve deep into it and you look at some of the 
published work from organizations like the CDC and other 
organizations you will see that that is based on very strict 
science and that is what we hope we can get them to understand.
    Mr. Tonko. Thank you, Doctor.
    In response to the spotlight on the monetization of 
misinformation about vaccines, are there ways in which 
platforms are being manipulated to promote antivaccination 
messaging? Some companies have announced new policies. For 
instance, Facebook says it is working on its algorithms to 
prevent antivaccination content from being recommended to 
users.
    Pinterest has decided to remove all vaccination-related 
posts and searches, even accurate information, and YouTube just 
recently announced that it would prevent channels that promote 
antivaccination content from running advertising.
    Dr. Fauci, do you think these actions are a step in the 
right direction to ensure parents and families have access to 
science-based factual health information?
    Dr. Fauci. Obviously, it is a very sensitive subject 
because it then gets in that borderline between the--you know, 
essentially, crushing of information that might actually be 
useful information.
    However, having said that, I do think that a close look and 
scrutiny at something that is egregiously incorrect has some 
merits of taking a careful look as to whether one--you want to 
be participating in the dissemination of that.
    Always being careful about not wanting to essentially 
curtail freedom of expression, you still want to make sure you 
don't do something that is so clearly hazardous to the health 
of individuals.
    Mr. Tonko. I appreciate that.
    And, Dr. Messonnier, as the agency charged with protecting 
our national public health, what efforts are underway at CDC to 
counter the online proliferation of antivaccination 
disinformation?
    Dr. Messonnier. As a science-based agency, CDC really 
focuses on making sure that we get scientifically credible 
information available to the folks at the front lines that need 
it every day.
    In order to do that, we do scan social media to see what 
issues are arising and what questions are emerging to make sure 
that we can then gather the scientifically appropriate answers 
and get that to our partners on the front lines so that they 
can talk to patients about that information.
    Mr. Tonko. Thank you. I appreciate both of you testifying 
today and with that, Madam Chairwoman, I yield back.
    Ms. DeGette. The gentleman yields back.
    The Chair now recognizes the gentlelady from New Hampshire, 
Ms. Kuster, for 5 minutes.
    Ms. Kuster. Thank you, Madam Chair, and thank you to our 
witnesses for being with us and to all the caring families that 
are here with us today as well.
    Thanks to the introduction of the MMR vaccine, 56 years ago 
the vast majority of families in the United States have never 
had to experience firsthand.
    Perhaps the fact that measles is so rare now has 
contributed to the misunderstandings about the disease itself, 
its potential severity, and the threats posed by the outbreaks, 
and you both testified to us today about how measles poses a 
public health threat and we have evidence ongoing right now as 
these pockets are--the contagious nature of the disease is 
being demonstrated in these communities with low vaccination 
rates.
    We have been fortunate in New Hampshire to have very high 
vaccination rates and thus we have not experienced--and I 
should knock on wood--an outbreak of measles in the Granite 
State.
    But recently we have a new threat and that is an outbreak 
of hepatitis A. Hepatitis A is not currently a required vaccine 
in New Hampshire, though it is in 13 States.
    I would love to ask you, are you concerned about that the 
continued distrust of vaccines like the MMR or hepatitis B will 
detract from efforts to vaccinate for future maladies and in 
particular, in this case, hepatitis A and how concerned should 
we be in terms of protecting my constituents from outbreaks of 
new pathogens including hepatitis A?
    Dr. Messonnier. Yes. I think that is a great point. You 
know, in the equation that a parent has in terms of what they 
believe is the risk of disease and the safety and effectiveness 
of vaccine, if they don't see the disease as a clear and 
present danger sometimes they don't vaccinate.
    When I try to talk to families and parents about 
immunization, I don't want to scare them into getting measles 
vaccine. I want to increase their faith in the U.S. 
immunization program and in the immunizations that are part of 
it so they don't just get measles vaccine. They get all of the 
recommended vaccines.
    Ms. Kuster. And could you comment? For something like 
hepatitis A that's not required as a vaccine in most States how 
do we get to the point where we would have herd immunity--where 
people would be safe from this public health threat, and how do 
we go about educating the community of what the risks are to 
individual families with hepatitis A?
    Dr. Messonnier. I am sorry to say that I am not enough of 
an expert in the hepatitis A vaccine to answer that. But we 
will certainly get----
    Ms. Kuster. Could you answer just generally about herd 
immunity, not using hepatitis A per se but just the concept of 
getting us to the place where most people in the community are 
safe from a particular pathogen or contagious disease?
    Dr. Messonnier. So the concept of herd immunity is that by 
vaccinating an individual you don't just prevent them from 
getting disease but you also prevent them from transmitting it 
to others.
    And what that means is that in a community individuals who, 
for example, can't get the vaccine because they are too young 
or they have some kind of illness that prevents it are still 
protected by the question of protection provided by their 
community. It is a really important concept and it is why we as 
a society need to take care of those most vulnerable children.
    Dr. Fauci. Hepatitis A is a bit different than measles, as 
we all know, for a number of reasons is that if you look at the 
level of herd immunity that you would need with measles, it is 
really 92, 93 to 95 percent.
    Ms. Kuster. It is quite high.
    Dr. Fauci. It is much less so--it is much less so with 
hepatitis. Hepatitis A is something you want to avoid. You can 
avoid it. It is a really good vaccine, and it is a safe 
vaccine.
    It tends, unlike measles, which is essentially an equal 
opportunity microbe, in that it is, as we have seen the 
outbreaks of hepatitis A they are very much more skewed towards 
homeless individuals, individuals who are in a situation where 
hygienic issues are a problem. We have seen outbreaks in 
different cities throughout Nevada and Las Vegas and other 
places.
    So it is a preventable disease and, as Dr. Messonnier said, 
we would encourage people to embrace the entire vaccination 
program because we have vaccines that are preventing diseases 
that were problems years ago.
    Ms. Kuster. Well, thank you for your work. We appreciate 
it, and certainly as a mother I appreciate keeping my own 
family safe. Thank you. I yield back.
    Ms. DeGette. I thank the gentlelady. The ranking member has 
some final comments.
    Mr. Guthrie. So I just want to close and thank the 
witnesses for coming, and I have discussed this with several 
people back home, and I just want to reiterate what I said. I 
know there are a lot of parents in the room here today.
    There is not a parent I have talked to that whatever 
decisions they are making are making it--what they believe in 
the love and the best interests of their child.
    And so I think it is important that we do have the science, 
the CDC, the NIH, and people with your credentials and 
reputations to present this evidence, and hopefully people have 
the opportunity to see it and to read it because I--like I 
said, there is not anyone that I have ever talked to that may 
have a different opinion from me that the opinion wasn't formed 
in what they thought was for the love and interest of their 
child.
    So we appreciate people being here today. Thank you.
    Ms. DeGette. I want to thank the witnesses for their 
participation in this hearing and I want to remind Members 
that, pursuant to committee rules, they have 10 business days 
to submit additional questions for the record to be answered by 
witnesses who have appeared before the subcommittee.
    I ask that witnesses agree to respond promptly to any such 
questions should you receive any and, again, thank you for 
giving us your science-based testimony today. We appreciate it.
    And with that, this subcommittee is adjourned.
    [Whereupon, at 11:34 a.m., the committee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
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