[Senate Hearing 116-312]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 116-312
 
                          VACCINES SAVE LIVES:
                            WHAT IS DRIVING
                     PREVENTABLE DISEASE OUTBREAKS?

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                                   ON

     EXAMINING VACCINES, FOCUSING ON PREVENTABLE DISEASE OUTBREAKS

                               __________

                             MARCH 5, 2019

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
 
 
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
 
 
                                


        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                            ______                       


             U.S. GOVERNMENT PUBLISHING OFFICE 
 41-391 PDF            WASHINGTON : 2021 
         
        
        
        
          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming           PATTY MURRAY, Washington
RICHARD BURR, North Carolina       BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia            ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky                TAMMY BALDWIN, Wisconsin
SUSAN M. COLLINS, Maine            CHRISTOPHER S. MURPHY, Connecticut
BILL CASSIDY, M.D., Louisiana      ELIZABETH WARREN, Massachusetts
PAT ROBERTS, Kansas                TIM KAINE, Virginia
LISA MURKOWSKI, Alaska             MARGARET WOOD HASSAN, New 
TIM SCOTT, South Carolina          Hampshire
MITT ROMNEY, Utah                  TINA SMITH, Minnesota
MIKE BRAUN, Indiana                DOUG JONES, Alabama
JACKY ROSEN, Nevada
                                     
  
                                     
                                     
               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                  Evan Schatz, Minority Staff Director
              John Righter, Minority Deputy Staff Director
              
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         TUESDAY, MARCH 5, 2019

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State 
  of Washington, Opening statement...............................     3

                               Witnesses

Wiesman, John, DrPH, MPH, Secretary of Health, Washington State 
  Department of Health, Olympia, WA..............................     7
    Prepared statement...........................................     8
    Summary statement............................................    14
Omer, Saad B., MBBS, MPH, PhD, William H. Foege Professor of 
  Global Health, Professor of Epidemiology & Pediatrics, Emory 
  University, Atlanta, GA........................................    15
    Prepared statement...........................................    16
    Summary statement............................................    20
McCullers, Jonathan A., MD, Professor and Chair, Department of 
  Pediatrics, University of Tennessee Health Science Center, 
  Pediatrician-in-Chief, Le Bonheur Children's Hospital, Memphis, 
  TN.............................................................    21
    Prepared statement...........................................    23
    Summary statement............................................    25
Boyle, John G., President and CEO, Immune Deficiency Foundation, 
  Towson, MD.....................................................    26
    Prepared statement...........................................    28
    Summary statement............................................    29
Lindenberger, Ethan, Student, Norwalk High School, Norwalk, OH...    30
    Prepared statement...........................................    31

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Alexander, Hon. Lamar:
    The National Childhood Vaccine Injury Act of 1986, DHHS, May 
      4, 1988, report, Submitted for the Record..................    54
    The National Childhood Vaccine Injury Act of 1986, DHHS, July 
      21, 1989, report, Submitted for the Record.................   126
Murray, Hon. Patty:
    National Association of County & City Health Officials, 
      letter, Submitted for the Record...........................   178
Casey, Hon. Robert P., Jr.:
    Prepared statement, Submitted for the Record.................   181
Boyle, John G.:
    Recommendations for live viral and bacterial vaccines in 
      immunodeficient patients and their close contacts..........   182


                          VACCINES SAVE LIVES:

                            WHAT IS DRIVING

                     PREVENTABLE DISEASE OUTBREAKS?

                              ----------                              


                         Tuesday, March 5, 2019

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
Room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Isakson, Paul, 
Cassidy, Roberts, Scott, Braun, Murray, Casey, Baldwin, Murphy, 
Warren, Kaine, Hassan, and Smith.

                 OPENING STATEMENT OF SENATOR ALEXANDER

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order. Senator Murray 
and I will each have an opening statement, and then we will 
introduce our witnesses. After the witnesses' testimony, 
Senators will each have five minutes of questions.
    It was not long ago, when I was a boy, that I remember the 
terror in the hearts of parents that their children might 
contract polio. I had classmates who lived in iron lungs. The 
Majority Leader of the United States Senate, Mitch McConnell, 
contracted polio when he was very young. He has a poignant 
story about his mother, did not know what to do, but she took 
him to Warm Springs because that is where President Roosevelt 
went. And for a long period of time, when he was two or three 
years old, she massaged his legs several hours a day, which is 
hard to imagine if you remember toddlers. And that is why he is 
able to walk today. Thousands of others are not so lucky.
    Following the introduction of a vaccine in 1955, polio was 
eliminated in the United States in 1979, and since then, from 
every country in the world except three. Polio is just one of 
the diseases we have eradicated in the United States thanks to 
vaccine. Before the vaccine for measles was developed, up to 
four million Americans each year contracted the highly 
contagious, airborne virus. In 2000, the Centers for Disease 
Control and Prevention, CDC, declared measles eliminated from 
the United States. In the 1980s, smallpox was declared 
eradicated from the world by the CDC and the World Health 
Organization. These stories of polio and measles and smallpox 
are a remarkable demonstration of what modern medicine can 
accomplish in the lives of millions of people in our country 
and in the world.
    Four years ago, this Committee held a hearing on vaccines. 
That was following the 2014 outbreak of measles, the worst 
outbreak since the disease was declared eliminated in 2000. 
Even though 91 percent of Americans had been vaccinated for 
measles in 2017, according to the CDC we continue to see 
outbreaks of this preventable disease because there are pockets 
in the United States that have low vaccination rates. Last 
year, there were 372 cases of measles, the second highest 
number since 2000.
    So far this year, there have been 159 cases reported and 
outbreaks confirmed in Washington State, New York, Texas, and 
Illinois. We know some Americans are hesitant about vaccines, 
so today I want to stress the importance of vaccines. Not only 
has the Food and Drug Administration found them to be safe, but 
vaccines save lives. Vaccines have been so successful that 
until recently, Americans have lived without fear of getting 
measles, polio, or rubella. We have made significant strides in 
improving vaccination rates. In 2009, about 44 percent of 
Americans had received vaccines for seven preventable diseases, 
all of which I will now try to pronounce, diphtheria, tetanus, 
pertussis, polio, measles, mumps, and rubella, haemophilus, 
influenza type B, hepatitis B, chickenpox, and pneumococcal 
according to the CDC. Today, over 70 percent of Americans are 
vaccinated against all seven of these diseases.
    Vaccines protect not only those who have been vaccinated, 
but the larger community. This is called herd immunity. There 
is some young people who cannot be vaccinated. They are too 
young, or they have a weak immune system because of a genetic 
disorder, or they are taking medicine that compromises their 
immune system like cancer treatment. Vaccines protect those who 
cannot be vaccinated by preventing the spread of disease. 
However, low immunization rates can destroy a community's herd 
immunity. While the overall vaccination rate nationwide is high 
enough to create this herd immunity, certain areas, the pockets 
of the country where vaccination rates are low, are vulnerable 
to outbreaks.
    There is a lot of misleading and incorrect information 
about vaccines that circulates online throughout social media. 
Here is what I would like for parents in Tennessee to know--
parents in Washington, parents in Texas, everywhere in the 
country. Vaccines are approved by the Food and Drug 
Administration. They meet the Food and Drug Administration's 
gold standard of safety. The advisory committee on Immunization 
Practices makes recommendations on the use of vaccines in our 
country and annual child and adult vaccine schedules. This 
advisory committee is made up of medical doctors and public 
health professionals from medical schools, hospitals, and 
professional medical organizations from around the country. 
They are among the best our country has to offer. They have 
dedicated their lives to helping others. These recommendations 
are reviewed and approved by the CDC Director, and are 
available on the CDC website. There is nothing secret about any 
of these signs, and countless studies have shown that vaccines 
are safe.
    Internet fraudsters who claim that vaccines are not safe 
are preying on the unfounded fears and daily struggles of 
parents, and they are creating a public health hazard that is 
entirely preventable. It is important for those who have 
questions about vaccines, especially parents, to speak with a 
reputable health provider. As with many topics, just because 
you found it on the internet, does not mean that it is true. 
The science is sound. Vaccines save lives, the lives of those 
who receive vaccines and the lives of those who are too young 
or vulnerable to be immunized. Before I turn this over to 
Senator Murray, I want to add that the National Childhood 
Vaccine Injury Act of 1986 required the Department of Health 
and Human Services to submit a report to Congress within two 
years after the legislation was signed into law.
    The HELP Committee has received two reports from the 
Department submitted to Congress May 4th, 1988 and July 21, 
1989. I ask consent that the reports be submitted to the 
Committee record so they can be more accessible to the public.
    [The following information can be found on pages 54 and 126 
in Additional Material:]
    The Chairman. Senator Murray.

                  OPENING STATEMENT OF SENATOR MURRAY

    Senator Murray. Thank you very much, Mr. Chairman.
    As Washington State and several other states grapple with 
measles outbreaks, this issue cannot be more timely. I remember 
in 2000, when measles was officially eliminated from the United 
States, and what welcomed news that was for families across 
this country. And I remember the years of efforts that actually 
led to that victory.
    Before the vaccine was available, measles outbreaks used to 
spread through communities like wildfire. If you were old 
enough to drive, odds were, you had already had measles. But 
today, vaccines that protect against measles have been in use 
for over 50 years. Like other vaccines, we know the vaccine is 
safe, it is effective, and it saves lives. Which is why today a 
generation of students are starting College, almost none of 
whom had to worry about a measles outbreak at school. It also 
means a generation of new parents may not appreciate just how 
dangerous measles is.
    Before introduction of the measles vaccine and widespread 
vaccination, millions of people caught measles annually, 
meaning thousands were hospitalized, hundreds of people died, 
mostly children under 5 years old. But measles is not just 
deadly, it is also one of the world's most contagious diseases. 
It is easily transmitted through coughing and sneezing. It can 
linger in the air and on infected services for two hours. It is 
already contagious four days before an infected person develops 
a rash, and then another four days after. 9 out of 10 
unvaccinated people exposed to measles catch it. That is why 
the measles vaccine is so important in providing protection. 
Experts say, in order to establish herd immunity against 
measles, in order to prevent an outbreak from occurring within 
a community, at least 95 percent of people should be 
vaccinated. Meeting that threshold is crucial to protect people 
who are unable to get vaccinated, infants, those with certain 
medical conditions.
    Unfortunately, while the national vaccination rate remains 
high in communities across the country, we are falling behind. 
Vaccine coverage rates are declining in certain areas, 
contributing to the rise in preventable outbreaks like in Clark 
County, Washington, where public health officials continue to 
respond to a measles outbreak. The immunization rate among 
children in that community is less than 70 percent, far below 
what is needed to keep families safe. The result is a true 
public health emergency, over 70 confirmed cases and counting. 
And the majority of cases have affected children under 10 years 
old, who are unvaccinated. Each case is not just a concern for 
family members who are worried about their loved ones who are 
seriously sick, it is a threat to neighbors and communities 
left struggling to get an incredibly contagious disease under 
control. It is a terror for parents with newborns who cannot 
yet get vaccinated, and a strain on our public health system as 
hundreds of staff in Washington State are pulled from critical 
public health roles to respond to this crisis. And the Centers 
for Disease Control and Prevention stretches to support the 
response to outbreaks in Washington and several other states.
    Measles is not the only disease that deserves our attention 
amidst slipping vaccination rates. Diseases like the Chairman 
mentioned, mumps, pertussis, or whooping cough are also cause 
for concern. These outbreaks are a clear sign we have to do 
more to address vaccine hesitancy, and make sure parents have 
the facts they need to understand the science. Vaccines are 
safe, and effective, and life-saving. Parents across the 
country want to do what is best for their families to keep them 
safe, which is why they need to be armed with knowledge about 
the importance of vaccination. And why we need research into 
vaccine communication tools and strategies to help us better 
educate people to address vaccine hesitancy and build vaccine 
confidence.
    We also need to understand the roles social media and 
online misinformation play in spreading dangerous rumors and 
falsehoods, and we need to better prepare the full spectrum of 
health care providers, who are often the professionals people 
trust most, to counter vaccine hesitancy and promote 
vaccination. That is important not only for parents, but also 
for expectant parents who may already be deciding whether or 
not they plan to vaccinate, and for promoting adult vaccines 
and encouraging people to protect themselves and others 
throughout their lives.
    I look forward today to hearing from Dr. Wiesman about how 
Washington State is working now to get parents reliable 
information about the importance of vaccination. And from all 
of our witnesses who are here today about how the Federal 
Government and other partners can promote vaccines and prevent 
the spread of misinformation. And while we are now fighting 
multiple measles outbreaks, it is important we also educate 
people on the HPV vaccine's role in preventing sexually 
transmitted diseases and lowering cancer risks. The flu 
vaccine, particularly on the heels of one of the most deadly 
flu seasons in years, the whooping cough vaccine specially for 
those around infants who are particularly susceptible to the 
disease, and the value of other recommended vaccines.
    We also need to make sure we are approaching the public 
health challenges like this from a global perspective because 
we know diseases are not stopped by borders or walls or bans. 
They are stopped by doctors, and nurses, and vaccines, and 
public health awareness. And are stopped by strong investments 
in public health systems here at home and abroad. They say an 
ounce of prevention is worth a pound of cure. That is certainly 
the case here. A dose of MMR vaccine covering measles, mumps, 
and rubella is about $20, meanwhile Washington State has spent 
over $1 million already addressing the current measles 
outbreak. Investing in prevention is not just more effective in 
keeping our families and communities healthy, it is also more 
affordable as well. The vaccines for children program is 
another great example of this. Over 25 years now, it has helped 
kids in low-income families get shots at no cost. It has saved 
$1.6 trillion, prevented 380 million illnesses, and saved 
860,000 lives. That is more people than live in Seattle.
    I hope we can work together in a bipartisan way to build on 
programs like this with strong steps to help address public 
health crisis, and better yet, to prevent them from happening 
in the first place. And I am glad to have this opportunity to 
learn more about how we can do that, and to consider how to 
make sure people across the country understand that vaccines 
are safe and effective to keep their families and their 
community healthy.
    Mr. Chairman, I would ask that a letter from the National 
Association of County and City Health Officials be submitted 
for the record. It speaks to the important role of our local 
health departments across the country in responding to vaccine-
preventable disease outbreaks and other emergency health 
threats.
    The Chairman. So, ordered.
    [The following information can be found on page 178 in 
Additional Material:]
    The Chairman. Thank you, Senator Murray. We will now 
introduce our witnesses. Each one of you will have up to five 
minutes for questions and answers. I will ask the Senators, 
just try to keep questions and answers within the 5-minute 
period of time so everyone can have a chance to participate. 
Senator Murray will introduce the first witness.
    Senator Murray. Well, thank you again Mr. Chairman. From my 
home State of Washington, I am very pleased to introduce Dr. 
John Wiesman. Dr. Wiesman was appointed as Washington State's 
Secretary of Health back in 2013, and his service there is just 
the latest in a 22-year career working to keep our families and 
communities healthy. Throughout his career, he has worked at 
four different health departments, including Clark County 
Public Health in Vancouver, which is the current frontline of 
our measles outbreak in our state.
    Dr. Wiesman, I know some of my colleagues on the Committee 
will appreciate learning that before you came to my state to 
work in our public health system, you got your education in 
theirs, receiving your bachelor's degree in Wisconsin, your 
Masters in Connecticut, and your PhD in North Carolina. I am 
glad we have you now in Washington State, working to help keep 
our families safe and healthy, and respond to public health 
threats as we currently are. And I appreciate so much you 
coming all the way out here from our other Washington.
    The Chairman. Thank you, Senator Murray. Senator Isakson, 
will you introduce our second witness.
    Senator Isakson. Thank you very much, Chairman Alexander. I 
am very pleased to introduce to the Committee and everyone here 
today Dr. Saad Omer--and I believe that is the right 
pronunciation, is not?
    Dr. Omer. Close enough.
    Senator Isakson. Close enough, good. Well, mine is Isakson 
and I just want to make sure we got it right.
    [Laughter.]
    Senator Isakson. We are very delighted to have him here 
today as an expert on the subject we are discussing. Dr. Omer 
is a William H. Foege Professor of Global Health and Professor 
of Epidemiology and Pediatrics at Denver University School of 
Public Health and Medicine. Dr. Omer also works in the Emory 
Vaccine Center, making him a well-qualified witness for today's 
hearing.
    His research includes studies in the United States and 
internationally, including clinical and P.O. trials to estimate 
the efficacy of influenza, polio, measles, and other 
vaccinations. Dr. Omer has published approximately 250 papers 
in peer-reviewed journals and has served on several respected 
advisory committees and panels, including U.S. National Vaccine 
Advisory Committee. He has also mentored over 100 junior 
faculty members, clinical and research postdoctoral fellows, 
and PhD and other graduate students, playing an important role 
in ensuring that the pipeline of qualified scientists is well 
stocked in the United States of America. Dr. Omer, welcome to 
the Committee today. We are here for your expertise. We 
appreciate your testimony, and ``go Emory.''
    [Laughter.]
    The Chairman. Thank you, Senator Isakson.
    Third, we will hear from Dr. Jonathan McCullers. He is 
Chair of the Department of Pediatrics of the University of 
Tennessee Health Science Center. Services as Pediatrician and 
Chief at the remarkable Le Bonheur Children's Hospital in 
Memphis. Received his medical degree and completed his 
internship and residency at the University of Alabama at 
Birmingham. In 1999, he was named a St. Jude's scholar in the 
Physicians Scientist Development Program and joined the St. 
Jude's faculty in the Department of Infectious Diseases, where 
he spent 13 years managing a translational research lab 
studying influenza viruses and bacterial pneumonia. In 2012, he 
joined Le Bonheur. He has published more than 150 peer-reviewed 
articles.
    Fourth, John Boyle. He is President and CEO of the Immune 
Deficiency Foundation in Towson, Maryland, which is focused on 
meeting the needs of people with primary immunodeficiency 
disease. Prior to joining the foundation, he worked for the 
Children's National Medical Center and the Platelet Disorder 
Support Association. He received his Bachelor of Science from 
Boston University. A Master in nonprofit management from Notre 
Dame of Maryland University.
    Finally, we welcome Ethan Lindenberger. Mr. Lindenberger is 
currently a student at Norwalk High School in Norwalk, Ohio. He 
is here to share his experience seeking out information about 
vaccines and making decisions about whether or not to become 
vaccinated.
    Welcome again to all our witnesses.
    Dr. Wiesman, let us begin with you.
    Dr. Wiesman. Great.
    The Chairman. Dr. Wiesman, excuse me.

  STATEMENT OF JOHN WIESMAN, DRPH, MPH, SECRETARY OF HEALTH, 
       WASHINGTON STATE DEPARTMENT OF HEALTH, OLYMPIA, WA

    Dr. Wiesman. Very good. That is good. Chairman Alexander, 
Ranking Member Murray, and distinguished Members of the 
Committee, thank you for the opportunity to discuss public 
health's work in protecting people from vaccine-preventable 
diseases.
    Vaccines are safe, effective, and the best protection we 
have against serious preventable diseases like measles. 
Vaccinating children in the United States has saved millions of 
lives, increased expectancy, and saved our society trillions of 
dollars. My admission as Washington's Secretary of Health is to 
protect and promote the health of all its people and ensure our 
public policy is based on best available science. I want to 
speak directly to the parents who have children with serious 
health issues, and who have been attending our hearings in 
Washington State and are watching this hearing today. I see 
your pain and your desire for answers to your children's health 
issues. Your mission to protect and promote the health of your 
children is one we share.
    While the science is clear that vaccines do not cause 
autism, we do need to better understand its causes. We need to 
develop together, affected families, scientists, and public 
health officials, research agendas to get the answers we need. 
State, territorial, and tribal, local public health agencies 
are on the front lines. In Washington State, we provide all 
recommended vaccines without charge to all children under the 
age of 19. We provide an electronic immunization information 
system for healthcare providers to track vaccine dose 
schedules, provide reminders when patients are overdue, and 
measure immunization rates. We help parents make informed 
decisions by sending them the information they need to keep 
children healthy and publish plain talk about childhood 
immunization. And we assist school nurses by giving them access 
to the electronic immunization records.
    As of yesterday, Washington State's measles outbreak had 71 
cases, plus 4 cases associated with our outbreak in Oregon and 
one in Georgia. Containing a measles outbreak takes a whole 
community response led by governmental public health. The 
moment a suspected case is reported, disease investigators 
interview that person to determine when they were infectious, 
who they were in close contact with, and what public spaces 
they visited. If still infectious, the health officer orders 
them to isolate themselves so they do not infect others, 
notifies the public--the community about the public places that 
they were in when they were infectious, and stands-up a call 
center to handle questions.
    We also reached out to individuals who were in close 
contact with the patient. If they are unvaccinated and without 
symptoms, we ask them to quarantine themselves for up to 21 
days. That is how long it can take to develop symptoms, and we 
monitor them so that we quickly know if they develop measles. 
If they show symptoms, we get them to a healthcare provider and 
obtain samples to test for measles. And if they have measles, 
we start the investigation process all over again. This is a 
staff and time intensive activity, and it is highly disruptive 
to people's lives. Responding to this preventable outbreak has 
cost over $1,000,000 million and required the work of more than 
200 individuals.
    What do we need from the Federal Government? First, we need 
sustained, predictable, and increased Federal funding. Congress 
must prioritize public health and support the Prevention and 
Public Health Fund. We are constantly reacting to crisis rather 
than working to prevent them. The association of state and 
territorial health officials in over 80 organizations are 
asking you to raise the CDC budget by 22 percent by FY2022. 
This will immediately bolster prevention services, save lives, 
and reduce health care cost.
    Second, our response to this outbreak has benefited greatly 
from the Pandemic and All-Hazards Preparedness Act, so thank 
you. The Public Health Emergency Preparedness Cooperative 
Agreement and the Hospital Preparedness Programs authorized by 
this law are currently funded $400 million below funding levels 
in the 2000s. More robust funding is needed, and I strongly 
urge you to quickly reauthorized PAHPA because many of the 
authorizations expired last year.
    Third, the 317 Immunization Program has been flat funded 
for 10 years. Without increased funding, we cannot afford to 
develop new ways to reach parents with immunization 
information, nor maintain our electronic immunization systems. 
Fourth, we need Federal leadership for a national vaccine 
campaign spearheaded by CDC in partnership with states that 
counter the anti-vaccine messages similar to successful Truth 
Tobacco Prevention campaign. We have lost much ground. Urgent 
action is necessary. Everyone has a right to live in a 
community free of vaccine-preventable diseases. To make this a 
reality, we must continue to invest in and strengthen our 
public health system.
    Thank you.
    [The statement of Dr. Wiesman follows:]
                   prepared statement of john wiesman
    Chairman Alexander, Ranking Member Murray, and distinguished 
Members of the Committee, thank you for the opportunity to appear 
before the Senate Committee on Health, Education, Labor and Pensions 
today to discuss an issue of significant importance to the lives of the 
American people--protecting people from vaccine-preventable diseases. 
State, territorial, tribal, and local public health agencies are on the 
front lines implementing vital public health programs, including 
immunization programs, and responding to a wide array of public health 
emergencies such as disease outbreaks.

    One of our objectives in public health is to share accurate, 
science-based information. To that end, allow me to say at the onset, 
vaccines are safe, effective, and the best protection we have against 
serious preventable diseases like measles. Vaccinating children in the 
United States has saved millions of lives, increased life expectancy, 
and saved trillions of dollars in societal costs. \1\ Yes, like any 
medication, vaccines have some minor side effects and can have rare 
serious complications. \2\ They can also eradicate diseases from our 
planet, like they did with smallpox and hopefully soon with polio. \3\, 
\4\ And in the United States, we have eliminated a number of vaccine 
preventable diseases. In 2000 we thought the United States had 
eliminated measles, but that is no longer the situation with the number 
of outbreaks we have had since then. \5\
---------------------------------------------------------------------------
    \1\  Whitney, C. G., Zhou, F., Singleton, J., & Schuchat, A. 
(2014). Benefits from immunization during the vaccines for children 
program era--United States, 1994-2013. MMWR 2014;63(16): 352-355.
    \2\  McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of 
Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary 
Recommendations of the Advisory Committee on Immunization Practices 
(ACIP). MMWR 2013; 62(RR04):1-34. Available at https://www.cdc.gov/
mmwr/preview/mmwrhtml/rr6204a1.htm
    \3\  https://www.who.int/csr/disease/smallpox/en/ (accessed March 
1, 2019)
    \4\  https://www.who.int/features/factfiles/polio/en/ (accessed 
March 1, 2019)
    \5\  Papania, M. J., Wallace, G. S., Rota, P. A., Icenogle, J. P., 
Fiebelkorn, A. P., Armstrong, G. L., ... & Hao, L. (2014). Elimination 
of endemic measles, rubella, and congenital rubella syndrome from the 
Western hemisphere: the US experience. JAMA pediatrics, 168(2), 148-
155.

    As secretary of health for Washington State, my mission is to 
protect and promote the lives of all the people in our state and when 
making public policy to ensure that it is based on the best science 
available to us. To that point, I want to speak directly to the parents 
who have children with autism and other serious health issues and who 
have been attending our hearings in Washington State and who are 
watching this hearing today. I see you and your children. I see your 
pain, your desire for answers to your children's health issues, your 
skepticism of government and the pharmaceutical industry, your mission 
to give your children the best life they can have and your desire to 
prevent other parents from the pain and suffering you and your children 
experience. Your mission to protect and promote the health of your 
children is a mission I share. And I know on this point, some of you 
will strongly disagree with me: the science demonstrates that autism is 
not caused by vaccines. But while the science on that is clear, we do 
need to better understand the causes of autism and other diseases 
better than we do today. We need to develop together--scientists, 
public health officials and affected families--research agendas to get 
the answers we all need. We need to create an environment where we can 
---------------------------------------------------------------------------
respectfully listen to each other and engage.

    Public health systems at every level are struggling due to chronic 
underfunding, increasing population size, and the emergence of new 
threats. We find ourselves constantly reacting to crises, rather than 
working to prevent them. It is therefore incumbent upon all of us at 
the federal, state, and local levels to provide the sustained, 
predictable, and increased resources necessary to focus on health 
promotion and disease prevention work as well as respond to emerging 
and reemerging diseases.
                            Measles Outbreak
    Currently, there are six ongoing but completely preventable measles 
outbreaks in the U.S., including one in Washington, three in New York, 
one in Texas and one in Illinois. \6\ Over the last 10 years, 
Washington State has had three measles outbreaks, one of which included 
the death of an immunocompromised person exposed to measles in a clinic 
waiting room. \7\ The current outbreak is larger and infecting people 
faster than those in recent history. Between the end of December 2018 
to March 1, 2019, Washington State has had 69 measles cases in our 
outbreak, plus four additional cases associated with our outbreak in 
Oregon and one in Georgia. Of the 69 Washington cases, 60 were 
unvaccinated, two had one dose of the measles vaccine and seven have an 
unverified immunization status. Two cases were hospitalized.
---------------------------------------------------------------------------
    \6\  https://www.cdc.gov/measles/ (accessed March 1, 2019)
    \7\  https://www.doh.wa.gov/Portals/1/Documents/5100/420-004-
CDAnnualReport2015.pdf (accessed March 1, 2019)

    In a global society with increased air travel, a disease outbreak 
in one part of the world can easily be transmitted to another by 
travelers. Our best protection against these preventable diseases is 
quite simple--vaccination. Currently, many countries in Europe are 
experiencing significant measles outbreaks. \8\ In this latest outbreak 
in Washington, we know that an individual traveled to Washington State 
from Europe who was already infected, but not yet symptomatic, with a 
wild strain of the measles virus circulating there. \9\ Fighting 
disease outside the U.S., as well as inside, promotes health security 
for everyone. Research shows every dollar invested in global 
immunization programs in the world's poorest countries saves $16. \10\ 
This is why we must fully fund the CDC and other health organizations 
to maintain disease-control activities globally.
---------------------------------------------------------------------------
    \8\  http://www.euro.who.int/en/media-centre/sections/press-
releases/2018/measles-cases-hit-record-high-in-the-european-region 
(accessed March 1, 2019)
    \9\  https://www.clark.wa.gov/public-health/measles-investigation 
(accessed March 1, 2019)
    \10\  Ozawa, S., Clark, S., Portnoy, A., Grewal, S., Brenzel, L., & 
Walker, D. G. (2016). Return on investment from childhood immunization 
in low-and middle-income countries, 2011-20. Health Affairs, 35(2), 
199-207.

    According to the CDC, measles can be serious for all age groups. 
However, children younger than five years of age and adults over 20 
years of age are more likely to suffer from measles complications. 
Common complications from the measles include ear infections, which can 
lead to permanent hearing loss, and diarrhea. However, some people may 
suffer from severe complications such as pneumonia and encephalitis. 
Finally, for every 1,000 people who get measles, one or two will die 
from it. \11\ Measles is so contagious that if one person has it, 9 out 
of 10 people of all ages around him or her will also become infected if 
they are not protected. \12\
---------------------------------------------------------------------------
    \11\  https://www.cdc.gov/measles/about/complications.html 
(accessed March 1, 2019)
    \12\  https://www.cdc.gov/measles/about/transmission.html (accessed 
March 1, 2019)

    Even though there is an effective vaccine, measles still caused 
110,000 measles deaths worldwide in 2017, mostly among children under 
five years of age. \13\ In 1963, prior to the United States measles 
vaccination program, three to four million people a year were estimated 
to get measles, resulting in 48,000 hospitalizations and 450 to 500 
measles deaths a year. \14\ From 1989 to 1991, a resurgence of measles 
in the United States resulted in more than 55,000 cases and 120 deaths. 
\15\ More than half of the children had not been vaccinated, even 
though they had seen a healthcare provider. In response, Congress 
created the Vaccine for Children program, which covers vaccines for 
those under 19 years of age on Medicaid, uninsured, underinsured, and 
American Indian/Alaskan Native. \16\ In addition, the Advisory 
Committee on Immunization practices recommended the second dose of MMR. 
\17\ We must continue the forward progress we have made protecting 
people from vaccine-preventable diseases.
---------------------------------------------------------------------------
    \13\  https://www.who.int/news-room/fact-sheets/detail/measles 
(accessed March 1, 2019).
    \14\  https://www.cdc.gov/measles/downloads/
measlesdataandstatsslideset.pdf (accessed March 1, 2019)
    \15\  https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html 
(accessed March 2, 2019)
    \16\  https://www.cdc.gov/vaccines/programs/vfc/about/ (accessed 
March 2, 2019)
    \17\  CDC. Measles prevention: recommendations of the Immunization 
Practices Advisory Committee (ACIP). MMWR 1989;38(No.S-9):1-18. 
Available at: https://www.cdc.gov/Mmwr/preview/mmwrhtml/00041753.htm
---------------------------------------------------------------------------
                         Vaccine Effectiveness
    The widespread use of measles vaccine led to a greater than 99 
percent reduction in measles cases compared with the pre-vaccine era. 
\18\ Two doses of the measles, mumps, and rubella (MMR) vaccination are 
97 percent effective against measles. \19\ And it is estimated 
worldwide that because of the measles vaccine, 20.5 million deaths were 
prevented between 2000 and 2016. \20\
---------------------------------------------------------------------------
    \18\  https://www.cdc.gov/measles/vaccination.html (accessed March 
1, 2019)
    \19\  https://www.cdc.gov/measles/hcp/index.html
    \20\  https://www.cdc.gov/measles/downloads/
measlesdataandstatsslideset.pdf (accessed March 1, 2019)

    It is important to note however, that some vaccines are not as 
effective as we would like. For example, according to the CDC the 
overall effectiveness of the 2017-2018 flu vaccine against both 
influenza A and B viruses was estimated to be 40 percent. This means 
the flu vaccine reduced a person's overall risk of having to seek 
medical care at a doctor's office for flu illness by 40 percent. \21\ 
While the effectiveness of the flu vaccine can vary, it is still the 
best protection against this annual illness, and was estimated to 
prevent about 110,000 flu hospitalizations, and 8,000 flu deaths during 
the 2017-18 season. \22\ A more effective vaccine would save even more 
lives. Similarly, protection from the current pertussis vaccine has 
been shown to wane during the five years after completion of the 5th 
childhood dose. \23\ As a nation, we must continue to invest in 
critical research and vaccine technology to improve vaccine 
development.
---------------------------------------------------------------------------
    \21\  https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm
    \22\  https://www.cdc.gov/flu/about/burden-averted/index.htm
    \23\  Cherry JD. The 112-year odyssey of pertussis and pertussis 
vaccines--mistakes made and implications for the future. JPIDS. 2019; 
XX(XX):1-8.
---------------------------------------------------------------------------
                     Consequence of Vaccine Success
    Due to the success of vaccines, fewer people have witnessed the 
complications and severity of vaccine preventable diseases. 
Unfortunately, this means that some parents may believe that 
vaccination is no longer necessary or that the minor or rarely severe 
complications from vaccines are somehow worse than getting the disease, 
resulting in some parents not vaccinating their children. Discredited 
and fraudulent research has been used as a basis to claim a link 
between MMR and autism. \24\ Moreover, public health officials 
throughout the country are gravely concerned about the latest 
misinformation originating from a well-organized and orchestrated anti-
vaccination movement.
---------------------------------------------------------------------------
    \24\  Eggertson, L. (2010). Lancet retracts 12-year-old article 
linking autism to MMR vaccines. Canadian Medical Association. Journal, 
182(4), E199.

    In communities across Washington State and our nation, there are 
pockets of children who are not fully vaccinated or not vaccinated at 
all. This puts them at risk to contract measles and unintentionally 
spread it to others, especially since one is infectious with measles 
four days before the rash develops. It is absolutely paramount that 
public health and healthcare professionals across the nation join 
together to share the science about the safety and efficacy of vaccines 
---------------------------------------------------------------------------
with the public. And we must equip health care

    providers to be able to effectively answer the questions their 
patients may have about vaccines, as we do want parents with questions 
to engage their trusted health care provider. The health concerns that 
parents have over the risks of vaccination must be addressed with 
compassion, care, and evidence-based practice so that informed 
decisions can be made, and so that people can protect themselves and 
their loved ones from dangerous, vaccine-preventable disease.
                       Communications Challenges
    Public health and healthcare professionals face significant 
communications challenges with those who are uncertain about 
vaccinations because of fear, distrust, and/or misinformation. The 
increasing influence social media has over personal health decisions by 
promoting false information is alarming.

    Admittedly, public health officials must be smarter in using media 
of all types to share factual, credible information. We must call on 
social media companies such as Twitter, Facebook, and Google to use 
whatever mechanism they have available to stop promoting pseudoscience. 
And the problem isn't limited to social media, traditional media can 
spread this false information as well. As public health officials, we 
often partner with traditional media outlets to spread critical life-
saving information to the public. When traditional media invites and 
promotes celebrity spokespeople who question the validity of 
immunizations and remain blind to the body of scientific evidence, it 
makes our jobs all the more difficult, and frankly, puts the public's 
health at risk.

    Civic discourse on vaccinations must be improved. Individuals 
opposed to vaccinations are extremely well organized across the 
country. In Washington, State lawmakers who proposed legislation to 
remove the personal exemption from vaccination have received death 
threats and been stalked. A health care professional who recently 
testified in support of removing philosophical exemptions for school 
entry vaccination has been vilified on their health practice website 
and in nasty social media posts.

    For my part, I recently received an email from a parent who does 
not vaccinate their child concerning a social media post from my 
agency. Many of you have probably seen the post as it was going around 
many people's social media accounts during valentine's day. It's a 
cartoon of a school boy asking a school girl if she will be his 
valentine, and she asks if he has been vaccinated. While this social 
media post had one of our most shares ever and most likes, laughing 
faces, and angry faces, I have come to understand how this post just 
furthers the divide. I can do better, we all can do better. In fact, we 
must do better to focus on our mutual interest of keeping kids healthy.

    I completely agree with CDC Director Robert Redfield who said we 
need to change the hearts and minds of people in this country to not 
leave science on the shelf. \25\ Additional
---------------------------------------------------------------------------
    \25\ https://www.seattletimes.com/seattle-news/health/cdc-director-
federal-health-officials-stress-importance-of-measles-vaccinations/ 
(accessed March 1, 2019)

    federal funds should be provided to determine how best to 
communicate with vaccine hesitant parents and to counter the 
misinformation currently being spread.
                   Washington State's Vaccine Program
    Each year Washington State receives $105 million in federal funding 
and $66 million in state funding to support a comprehensive 
immunization system. Federal funding has a critical role in achieving 
national immunization coverage targets. It supports immunization system 
infrastructure and the purchase of vaccines for children who qualify 
and adults without health insurance. Our state supplements these 
federal funds to support health care providers and facilities, help 
parents make informed decisions, and partner with schools.

    During my tenure we've worked hard to keep communities protected, 
ensure stable funding for vaccines and build public/private 
partnerships to strengthen the immunization infrastructure. For 
example, we have increased the number of 13 to 17 year olds who started 
human papillomavirus (HPV) vaccination series from 46 percent in 2015 
to 61 percent 2018. This means that more youth in Washington are 
protected from the many cancers that HPV can cause.

    One of the biggest challenges with childhood immunization in 
Washington is the percentage of students out-of-compliance with state 
law because the parents have not submitted immunization documentation 
or exemption paperwork with the school. In the 2017-2018 school year, 
8.0 percent of kindergarten students lacked appropriate paperwork and 
were out-of-compliance. We believe this is largely because of the 
administrative burden on schools to staff this health work and track 
the paperwork from parents. To address this, we need to adequately fund 
school nurses. Our schools today are woefully understaffed with school 
nurses. This does not put our children first. Public health needs to 
partner with school nurses to ensure kids are vaccinated and keep our 
kids safe and healthy, especially during disease outbreaks. We are also 
working on health technology solutions to help school personnel easily 
access immunization records in our state immunization registry, which 
reduces duplicate data entry and allows for the easy use of report 
writing functions to track the immunization status of students.

    In addition, Washington is one of 17 states that allow parents to 
send their children to school and child care unvaccinated for personal 
or philosophical reasons. Two state lawmakers from Clark County have 
each introduced legislation designed to protect more children from 
vaccine preventable disease and increase the safety of these 
environments. One bill would eliminate the philosophical exemption for 
the MMR vaccine. The other would eliminate that exemption for all 
vaccines required for school or child care entry. This approach honors 
the responsibility we all have to protect each other. This proposed 
policy change is a good step forward and one I support. Vaccines are 
the best protection we have: they are safe, readily available, given 
without charge to all kids under 19 years of age in Washington State 
and proven to be effective. And I believe that parents want safe 
schools and childcare centers for all kids and those

    adults who serve them, including those who can't be vaccinated for 
medical reasons or who have lost their immunity due to serious medical 
conditions.
              Public Health Response to a Measles Outbreak
    In Washington, Governor Jay Inslee issued a Public Health Emergency 
Proclamation on January 25, 2019 to support the response efforts to our 
measles outbreak. \26\ This proclamation allowed mutual aid assistance 
through the Emergency Management Assistance Compact enabling the state 
to request public health responders from other states to support the 
outbreak response. North Dakota, Idaho, and Oregon provided staff to 
assist with the outbreak response.
---------------------------------------------------------------------------
    \26\  https://www.governor.wa.gov/news-media/inslee-declares-local-
public-health-emergency-after-identifying-outbreak-measles (accessed 
March 1, 2019)

    To date, this preventable outbreak has cost over $1 million and 
required the work of more than 200 individuals contributing over 10,000 
hours of work. These estimates do not take into account the health care 
costs of those ill, the cost to schools and businesses as they 
responded to the event, the cost to student learning for those 
unvaccinated children excluded from school, and to the lost 
productivity of their workers. In comparison, the cost of an MMR 
vaccine dose is about 20 dollars. \27\
---------------------------------------------------------------------------
    \27\  https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-
management/price-list/index.html (accessed March 1, 2019)
---------------------------------------------------------------------------
               Importance of Federal Funding and Programs
    Our response to this outbreak has benefited greatly from the 
Federal Government. The Pandemic and All Hazards Preparedness Act 
(PAHPA) authorities and funding over the years have allowed us to 
train, build, and maintain a strong Incident Management Team, which has 
ably led the response, and it has allowed us to develop strike teams to 
send into the response to carry out public health functions.

    The public health system is often invisible to most Americans when 
it is working well. It is when an emergency or a disaster or an 
outbreak strikes where the fragility and chronic underfunding of the 
public health system is laid bare. As just one example, in Washington, 
Clark County repurposed their home visiting nurses to address this 
outbreak. The day to day job of the home visiting nurses is to assist 
expectant and new mothers, many in high-risk situations, to help 
improve birth outcomes and raise healthy children. By redirecting their 
work, families are going without this critical service and increasing 
the risk for bad health outcomes. \28\
---------------------------------------------------------------------------
    \28\  https://www.columbian.com/news/2019/feb/25/nurse-family-
partnership-takes-on-intangible-costs-of-measles-outbreak/ (accessed 
March 2, 2019)

    In public health, we see the need to modernize. We do our best to 
make the most with the limited budgets we have. This is why federal 
funding is foundational for state, territorial, tribal and local health 
agencies to provide a comprehensive immunization system and emergency 
---------------------------------------------------------------------------
preparedness and response capability.

    In this case, federal funds from Section 317 of the Public Service 
Act are used to support the immunization grant program and provide 
vital resources to support our comprehensive system. Section 317 
funding provides support for our state to educate and inform the 
public, monitor vaccine effectiveness, account for the use of federal 
and state dollars, decrease ethnic and racial disparities, have strong 
outbreak investigation, improve tracking systems, and continue to 
provide the necessary support to health care professionals. Yet, the 
317 immunization grant program has been flat funded since 2009. Without 
increased funding, we cannot afford to develop new and innovative ways 
to increase immunization rates especially in light of the anti-vaccine 
movement. Research shows every dollar spent on childhood vaccines saves 
10 dollars, so this is a worthwhile investment. \29\ Additional funding 
would help address growing gaps in immunization coverage and strengthen 
the scientific foundation for vaccine policy decision making.
---------------------------------------------------------------------------
    \29\  Remy, Vanessa, York Zollner, and Ulrike Heckmann. 
``Vaccination: The cornerstone of an efficient healthcare system.'' 
Journal of market access & health policy 3.1 (2015): 27041.

    The Pandemic and All Hazards Preparedness Act (PAHPA) provides a 
framework and resources to support our emergency preparedness and 
response. Funds from the Public Health Emergency Preparedness 
Cooperative Agreement Program allows state health departments to build 
and strengthen our ability to respond to public health emergencies. 
Without this funding, state and local public health agencies would have 
been significantly delayed in identifying and containing this measles 
outbreak. This program is currently funded $400 million below funding 
levels in the 2000s. More robust funding would allow public health 
agencies to not have to reallocate resources from other vital public 
health programs to respond to urgent public health emergencies like 
measles outbreaks or other disasters. Despite this Committee's action 
to reauthorize the law last year, it has now lapsed; I ask you to move 
---------------------------------------------------------------------------
quickly to reauthorize PAHPA.

    The Prevention and Public Health Fund is the nation's first 
mandatory funding stream dedicated to improving our nation's public 
health system. The purpose of the fund was to supplement core public 
health programs with increased investment in disease prevention, yet it 
has primarily been used to backfill the funding of core public health 
programs. Currently 47 percent of the 317 immunization program is 
funded by the Prevention and Public Health Fund. Research shows every 
dollar invested in community-based prevention saves $5. \30\
---------------------------------------------------------------------------
    \30\  Prevention for a Healthier America: Investments in Disease 
Prevention Yield Significant Savings, Stronger Communities, Trust for 
America's Health, 2009.

    I'm here to make clear the threat of these vaccine preventable 
illnesses, so we can respond together to restore health to the very 
part of our system responsible for prevention. One immediate response 
Congress can take is to raise the budget of the Centers for Disease 
Control and Prevention by 22 percent by 2022, as requested by the 
Association of State and Territorial Health Officials and over 80 other 
organizations. \31\ Doing so will immediately begin to save lives, 
promote optimal health for all, bolster our prevention services and 
reduce healthcare costs.
---------------------------------------------------------------------------
    \31\  http://www.astho.org/Advocacy-Materials/22-by-22/ (accessed 
March 1, 2019)
---------------------------------------------------------------------------
                               Conclusion
    Vaccines are a testament to human ingenuity to ward off morbidity 
and mortality. Vaccines activate the natural human immunity system. The 
science is clear that vaccines are safe and effective. Vaccines can 
eradicate diseases. Vaccine programs are one of public health's 
greatest accomplishments. They are under great threat and we need to 
reverse course.

    I thank you for holding this hearing and increasing awareness about 
the importance of vaccines and public health. Everyone has a right to 
live in a community free of vaccine-preventable disease. We must 
continue to invest in and strengthen our public health system.
                                 ______
                                 
                  [summary statement of john wiesman]
    Vaccines are safe, effective, and the best protection we have 
against serious preventable diseases like measles. Vaccinating children 
in the U.S. has saved millions of lives, increased life expectancy, and 
saved trillions of dollars in societal costs. \1\ Yes, like any 
medication, vaccines have some minor side effects and can have rare 
serious complications, but they do not cause autism. \2\, \3\ They can 
also eradicate diseases from our planet, like they did with smallpox 
and hopefully soon with polio. \4\,\5\
---------------------------------------------------------------------------
    \1\  Whitney, C. G., Zhou, F., Singleton, J., & Schuchat, A. 
(2014). Benefits from immunization during the vaccines for children 
program era--United States, 1994--2013. MMWR 2014;63(16): 352-355.
    \2\  McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of 
Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary 
Recommendations of the Advisory Committee on Immunization Practices 
(ACIP). MMWR 2013; 62(RR04):1-34. Available at https://www.cdc.gov/
mmwr/preview/mmwrhtml/rr6204a1.htm
    \3\  Eggertson, L. (2010). Lancet retracts 12-year-old article 
linking autism to MMR vaccines. Canadian Medical Association. Journal, 
182(4), E199.
    \4\  https://www.who.int/csr/disease/smallpox/en/ (accessed March 
1, 2019)
    \5\  https://www.who.int/features/factfiles/polio/en/ (accessed 
March 1, 2019)

    There are six ongoing but preventable measles outbreaks in the 
U.S., one in Washington, three in New York, one in Texas, and one in 
Illinois. \6\ Washington's outbreak has cost over $1 million compared 
to the $20 cost of an MMR vaccine dose. \7\
---------------------------------------------------------------------------
    \6\  https://www.cdc.gov/measles/ (accessed March 1, 2019)
    \7\ https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-
management/price-list/index.html (accessed March 1, 2019)

    Due to the success of vaccines, fewer people have witnessed the 
complications and severity of vaccine preventable diseases. Therefore, 
some parents may believe that vaccination is no longer necessary or 
that the minor or rarely severe complications from vaccines are somehow 
worse than getting the disease, resulting in some parents not 
vaccinating their children. Moreover, a well-organized and orchestrated 
---------------------------------------------------------------------------
anti-vaccination movement is a threat to the public's health.

    Section 317 funding provides immunization program support for 
states and it has been flat funded since 2009, despite the threats 
noted above. We need increased funding to develop new ways to increase 
immunization rates. Currently 47 percent of the 317 immunization 
program is funded by the Prevention and Public Health Fund, a fund that 
was intended to add prevention capacity, not backfill.

    The Pandemic and All Hazards Preparedness Act (PAHPA) provides 
essential support for response efforts, but it is currently funded $400 
million below funding levels in the 2000s. More robust funding is 
needed to respond to urgent public health emergencies. And I ask you to 
quickly reauthorize PAHPA.

    One immediate response Congress can take is to support public 
health is to raise the budget of the Centers for Disease Control and 
Prevention by 22 percent by 2022, as requested by the Association of 
State and Territorial Health Officials and over 80 other organizations. 
\8\ Doing so will immediately begin to save lives, promote optimal 
health for all, bolster our prevention services, and reduce healthcare 
costs.
---------------------------------------------------------------------------
    \8\  http://www.astho.org/Advocacy-Materials/22-by-22/ (accessed 
March 1, 2019)
---------------------------------------------------------------------------
                                 ______
                                 
    The Chairman. Thank you, Mr. Wiesman.
    Dr. Omer.

  STATEMENT OF SAAD B. OMER, MBBS, MPH, PHD, WILLIAM H. FOEGE 
   PROFESSOR OF GLOBAL HEALTH, PROFESSOR OF EPISTEMOLOGY AND 
           PEDIATRICS, EMORY UNIVERSITY, ATLANTA, GA

    Dr. Omer. Thanks for the opportunity for me to talk about 
vaccines in this forum.
    Elimination of endemic measles transmission from the U.S. 
in 2000 is a significant public success. Since then, most of 
the cases have occurred through U.S. travelers going outside 
and bringing it back. While recent measles outbreaks have been 
contained, the frequency and size of these outbreaks have been 
particularly alarming for those of us who follow these trends. 
The rest of this testimony will be focused on answering some of 
the salient questions that have been coming up.
    The first question is, why haven't we seen a national level 
outbreak in the U.S.? And we cannot take this for granted. 
Countries with similar development status like Germany, France, 
and Italy specifically more recently, have had national level 
outbreaks. And it is not a coincidence that we have not seen 
similar national outbreaks, and there are several reasons for 
it. First of all, our laws, school level mandates, work. And 
they work by changing the balance of convenience.
    In most states, they work by changing the balance of 
convenience for vaccination compared to non-vaccination by 
having physician counseling, or by having parents go through a 
video that talks about vaccines and the benefits of vaccines, 
etc. And the third thing is, in our country, medical societies 
like the American Academy of Pediatrics and the Infectious 
Disease Society of America have been very prominent in vaccine 
advocacy, and it is important because it is based on the fact 
that physicians are the most trusted source of vaccine 
information.
    We have talked about the role measles has played--vaccine 
refusal has played in these outbreaks, and I will just give a 
few numbers. For example, more than half of the cases since the 
elimination have been unvaccinated, and approximately 70 
percent of them--of unvaccinated due to vaccine refusal are 
non-medical exemptions. So, there is a contribution of vaccine 
refusal in our epidemiology of measles. And vaccine mandates 
have been an effective tool in changing that balance of 
convenience that I was talking about. But that is a state level 
issue. I will focus on some of the things the Federal 
Government can do.
    In my written testimony, I have provided a few more details 
on that specific issue and I would be happy to answer 
questions. So, there are a few things the Federal Government 
can do. First, consider making vaccine counseling reimbursable. 
And I have worked on vaccine research in multiple countries, in 
multiple states in the U.S. There are a lot of local factors 
that are specific, but there is one constant, vaccine 
providers--health care providers, specifically physicians, are 
the most trusted source of vaccine information even amongst 
those who are a little bit skeptical of vaccines. So, we need 
to use that tool more effectively.
    On the practical side, physicians do not have the time to 
properly counsel patients using evidence-based approaches, and 
part of the reason, not all of the reason, is the fact that 
this is not reimbursable. So, physicians lose money on this 
kind of important public health education. We should as a 
country, the second point is, invest in high-quality vaccine 
acceptance and communications research. And I often say that if 
you do not accept half-baked vaccine development science--and 
we do not. The FDA goes through evaluation of the science from 
trials and basic sciences, etc. We should not be accepting of 
half-baked vaccine communication and behavioral science. And we 
have precedent in this country. For example, NIH's cancer 
prevention initiatives are a gold standard in these kinds of 
interventions and evidence-based communications strategy.
    NIAID, national institute for immunology--I am sorry, 
national institute for infection and allergy, has--they have 
had very effective intervention development in the area of HIV, 
AIDS behavior. So, we have that precedent in this country, and 
we need to invest in actual research. And before we develop 
evidence, while we develop evidence, there is an existing 
blueprint of interventions that the National Vaccine Advisory 
committee put together, and unfortunately not all of its 
interventions and its recommendations have been implemented. So 
that is ready to be implemented.
    CDC plays this important role in fighting these fires, 
working with state and local health departments, which is 
somewhat unique in the developed world and we need to support 
their mission. And we should continue to prioritize vaccine 
safety research, and I would want to thank you for bipartisan 
and consistent support for vaccines because that matters. And 
that shows that there is broad societal support for vaccines, 
and those of us who work to protect children from these 
infectious diseases really appreciate that.
    [The statement of Dr. Omer follows:]
                   prepared statement of saad b. omer
    I am Saad B. Omer, the William H. Foege Professor of Global Health 
and Professor of Epidemiology & Pediatrics at Emory University, Schools 
of Public Health and Medicine. I have served on several scientific and 
public health advisory committees including the National Vaccine 
Advisory Committee and the Public Health Committee of the Infectious 
Diseases Society of America. My research has focused on vaccines--
including clinical/field trials, vaccine safety studies, and studies of 
interventions to increase vaccine acceptance.

    I want to thank the Committee for the opportunity to share my 
perspective on vaccine preventable diseases, the current epidemiology 
of measles, and the importance of vaccines. In my testimony, I will 
attempt to answer a few salient questions on this topic. My statement 
substantially draws from my previous writings and research.
       Should we be concerned about the recent measles outbreaks?
    The elimination of endemic transmission of measles from the United 
States in 2000 is considered a significant public health success. Since 
then, measles has mostly occurred as outbreaks--either because of 
imported cases (mostly from U.S. travelers returning home with the 
infection) or among those who come in contact with these cases.

    Are the recent cases and outbreaks sporadic, or are we on the verge 
of the return of widespread measles? While recent measles outbreaks 
have been contained, the frequency and size of these outbreaks is 
alarming. For example, according to a CDC study, the annual median 
number of cases and outbreaks more than doubled during 2009-2014 
compared to the earlier post-elimination years (Fiebelkorn et. al.; J 
Pediatric Infect Dis Soc.; 2017). This trend has continued since the 
publication of the CDC study. A return of widespread measles is not 
inevitable, but to ensure we prevent it, we need to seriously address 
causes of non-vaccination including vaccine refusal.

    Notably, each year there are children not vaccinated against 
measles. These nonimmunized children join the ranks of all other 
susceptible children from years past, increasing the population of 
susceptible people. With the slow and steady accumulation of people who 
haven't been immunized, we may only be delaying a large measles 
outbreak. In fact, in an epidemiological study my research 
collaborators and I published in 2016, we estimated that 1 in 8 
children younger than 18 are susceptible to measles (Bednarczyk, 
Orenstein, & Omer; American J. Epi, 2016).

    Importantly, we found that the rate of protection against measles 
is hovering dangerously close to the ``herd immunity threshold''--
computed as the proportion of people who need to be immune to prevent 
outbreaks. Similar findings have been subsequently reported by other 
researchers, highlighting the need for interventions to improve measles 
vaccination rates. If vaccine refusal is left unchecked, more people 
will be susceptible to this disease, leading to larger outbreaks and 
possibly resumption of sustained transmission.
 Why haven't we seen a national level measles outbreak in recent years?
    A national outbreak, or an outright national-level measles 
resurgence, would not be out of the ordinary for a Western country. In 
recent years, there have been several large sustained outbreaks in 
Europe. In Italy, for example, approximately 5,000 measles cases were 
reported from February 2017 to January 2018. Similarly, large national-
level outbreaks have occurred in Britain, Germany, and France. In 2008, 
the World Health Organization reported approximately 60,000 measles 
cases from countries included in its European region. While most 
European countries, including Britain, have been certified as having 
eliminated measles, the disease is still considered endemic in Italy, 
Germany, and France.

    It's not just luck that the United States hasn't seen a similar 
resurgence. There are many things the United States does right in 
vaccine policy, compared to Europe. For example, the United States has 
a tapestry of school-entry vaccine requirements that work. These 
requirements, based in state laws, have contributed to maintaining high 
immunization rates and keeping rates of vaccine noncompliance low. In 
the U.S., the Centers for Disease Control and Prevention (CDC) 
aggressively monitors and responds to emerging outbreaks--an 
epidemiological firefighting function it performs with state and local 
health departments. In Europe, on the other hand, the effectiveness of 
public health agencies is uneven. The European Centre for Disease 
Prevention Control, a much smaller and newer agency compared to the 
American CDC, lacks the resources and mandate to perform a similar 
function. U.S. professional medical societies such as the American 
Academy of Pediatrics and the Infectious Diseases Society of America 
have been at the forefront of vaccine advocacy--leveraging the fact 
that physicians are the most trusted source of vaccine information.

    But while a national measles resurgence in the United States has 
been so far kept at bay, we cannot be complacent. With the steady 
accumulation of susceptible individuals in our communities, efforts are 
required at the national, state, and local level to ensure that this 
dangerous disease does not return in full force.
       What is the role of vaccine refusal in measles outbreaks?
    In a 2016 paper, my colleagues and I evaluated the association 
between vaccine delay, refusal, or exemption and the epidemiology of 
measles in the United States (Phadke et al.; JAMA, 2016). We found that 
since the elimination of measles from the United States in 2000, more 
than half (56.8 percent) of measles cases had no history of measles 
vaccination. Among the unvaccinated, age-eligible measles cases for 
whom the reason for non-vaccination was available, 70.6 percent had a 
nonmedical exemption to vaccination.

    One tool epidemiologists use to chart the temporal course of 
outbreaks is the epidemic curve in which the daily cases of a disease 
are plotted against time. In the 2016 paper, we created a cumulative 
epidemic curve comprising of all measles outbreaks since 2000 for which 
relevant data were available. According to this cumulative epidemic 
curve, unvaccinated individuals made up a greater proportion of measles 
cases in early parts of epidemics--meaning that unvaccinated people 
provided the tinder to start the fires of these epidemics.

    In an earlier national study, the risk of measles among children 
with vaccine exemptions was 35 times that of the vaccinated population 
(Salmon et.al; JAMA, 1999). Equally importantly, higher rates of 
vaccine exemption in a community are associated with greater measles 
incidence in that community, among both the exempt and nonexempt 
population. One reason for ongoing outbreaks is the epidemiological 
phenomenon of clustering of susceptible individuals--which happens when 
a group of unvaccinated individuals in a specific area grows large 
enough to render protection from overall high immunization rates less 
effective.
        Is vaccine refusal the only reason for recent outbreaks?
    While vaccine refusal is an important risk factor for vaccine 
preventable disease outbreaks, it is not the only reason why these 
outbreaks occur. For example, CDC reported insurance status is an 
important factor in non-vaccination (Hill et al.; MMWR; 2018). 
Similarly, while vaccine refusal plays a role, waning immunity is an 
important cause of decline in pertussis (whooping cough) vaccine 
effectiveness and subsequent outbreaks (Klein et al.; NEJM; 2012).
  Are vaccine mandates a useful policy option for controlling vaccine-
                         preventable diseases?
    State laws in the United States mandate that every child entering 
kindergarten either provide proof of being immunized or file for an 
exemption. All 50 states allow for medical exemptions from mandated 
vaccinations. Eighteen states allow religious and personal belief 
exemptions, 30 states permit religious exemptions only, and 3 states 
only allow medical exemptions. Mandates have played a key role in 
keeping disease rates low. Because vaccination and exemption laws are 
established at the state level, there is substantial variation in 
immunization requirements, types of nonmedical exemptions offered (i.e. 
personal belief exemption vs. only religious exemption), ease of 
obtaining an exemption, and enforcement of immunization legislation 
across the United States (Omer et al.; NEJM; 2009).

    The amount of administrative effort needed to complete the 
exemption process varies by state. Vaccine laws in the U.S. work by 
changing the balance of convenience in favor of vaccination and away 
from non-vaccination. Ease of obtaining a nonmedical exemption has been 
shown to be associated with state vaccine exemption rates--and, more 
importantly, higher rates of vaccine-preventable diseases. In a 2006 
study published in The Journal of the American Medical Association, for 
example, we documented that states with easy procedures for granting 
nonmedical exemptions had higher rates of vaccine refusal and 
approximately 50 percent higher rates of whooping cough (Omer et al.; 
JAMA; 2006). The association between ease of exemption and vaccine 
refusal rates has been consistent in our subsequent studies as well 
Omer et al.; NEJM, 2012 & Omer et al.; Open Forum Infect Dis.; 2017).

    The policy option of eliminating all nonmedical exemptions is being 
discussed in a few states. However, the evidence on the impact of this 
option is nuanced and evolving. Until recently, West Virginia and 
Mississippi were the only two states that did not allow any nonmedical 
exemptions. These states have traditionally had some of the highest 
immunization rates in the country. California recently eliminated 
nonmedical exemptions. The initial results from this policy change 
(through California law SB277) are nuanced. In addition to the 
implementation of this law, there was a state-level administrative 
initiative to correctly apply ``conditional entrance'' requirements--a 
category meant for children who had started but not completed their 
vaccine schedule or had temporary medical exemptions. Prior to the 
enforcement initiative, this category was inconsistently applied and, 
sometimes, misused. While there has been an increase in the percentage 
of California kindergartners entering school fully vaccinated, publicly 
available data suggest that this increase may by mostly due to the pre-
SB277 education- and enforcement-based effort to correctly apply the 
conditional entrance requirements. Importantly, there is evidence of an 
emerging replacement effect as a result of increase in children being 
not up-to-date for vaccines due to other categories e.g. through 
increase in medical exemptions.

    Irrespective of emerging evidence from California, states have 
other policy options short of eliminating all nonmedical exemptions. 
For example, states can tweak their rules to make sure parents are as 
informed as possible by adding a legally mandated physician counseling 
requirement for those seeking exemptions. This approach has been 
effective in reducing nonmedical exemptions (Omer et al.; Pediatrics; 
2018). Moreover, states can reconfigure their immunization requirements 
to tilt the balance of convenience in favor of vaccination (Omer et 
al.; NEJM; 2019).
 Vaccine mandates are implemented at the state level. Can the federal 
    government do anything about vaccine acceptance and controlling 
                               outbreaks?
    I believe the federal government has a substantial role to play in 
increasing vaccine acceptance. While vaccine mandates are a state-level 
issue, there are many policy options within the purview of the federal 
government. I will highlight a few of them:

          1. Consider making vaccine counseling reimbursable:
        Several factors associated with vaccine acceptance vary by 
        location and demographics. But there is one constant: 
        healthcare providers, particularly physicians, are the most 
        trusted source of vaccine information--even among those who 
        refuse vaccines (e.g. Freed et al.; Pediatrics; 2011). A strong 
        physician recommendation for vaccines is an extremely useful 
        tool for immunization acceptance. However, having an effective 
        conversation with vaccine hesitant parents requires time and 
        effort. Unfortunately, the time spent on vaccine hesitant 
        patients is not billable--further dis-incentivizing physicians 
        from having this difficult but useful conversation.

          2. Invest in vaccine acceptance/communication research:
        While vaccine communication and acceptance interventions are an 
        active area of research, a lot more needs to be done. In recent 
        years, several promising leads have emerged--many from 
        federally funded research. For example, research on 
        ``presumptive communication'' leverages power of verbal 
        defaults-based ``nudges'' for framing vaccine conversations 
        Opel & Omer; JAMA Pediatr.; 2015). Similarly, motivational 
        interviewing--a well-established counseling technique that has 
        been evaluated to increase vaccine acceptance--works through 
        people's internal motivation for desirable health behavior 
        (Dempsey et al.; JAMA Pediatr.; 2018). In my research group, 
        multi-tiered practice-provider-patient based interventions (the 
        so called P3 model) have shown promise. However, current 
        vaccine acceptance research is sporadic and a focused, high 
        priority research program is needed. Fortunately, there are 
        examples of similar high priority behavioral and communication 
        research that can be emulated. These examples and potential 
        templates include National Cancer Institute's Behavioral 
        Research Program--a comprehensive program of research to 
        increase the breadth, depth, and quality of behavioral research 
        in cancer prevention and control. Given its role as the 
        nation's premier biomedical and behavioral health research 
        agency, it would be natural for NIH to have a leading role in 
        guiding these investments.

          3. Implement the National Vaccine Advisory Committee's 
        recommendations:
        While there is need for new research, there are existing 
        approaches that can increase confidence in and acceptance of 
        vaccines. Fortunately, an evidence-based blueprint exists in 
        the form of recommendations published in 2015 by the National 
        Vaccine Advisory Committee, an independent committee charged 
        with the advising the Department of Health and Human Services 
        (NVAC; Public Health Rep.; 2015). These recommendations focus 
        on evidence-based strategies for increasing confidence in 
        vaccines. Unfortunately, these recommendations have not been 
        fully implemented.

          4. Support CDC's mission of controlling measles outbreaks:
        As I mentioned earlier, CDC--in collaboration with state and 
        local health departments--plays an important role in 
        controlling outbreaks of vaccine preventable diseases such as 
        measles. Responding to these outbreaks is costly and time and 
        labor-intensive. Ensuring that CDC continues to have adequate 
        resources will help with maintaining adequate outbreak response 
        capabilities in the face of increasing outbreaks.

          5. Continue to prioritize vaccine safety research:
        Over the years, the U.S. has developed a robust vaccine safety 
        research infrastructure. CDC's Vaccine Safety Datalink system 
        utilizes data from 9 HMOs from across the country to conduct 
        active epidemiologic surveillance for vaccine safety. The 
        Vaccine Adverse Events Reporting System maintained by the CDC 
        and the FDA captures spontaneous reports of potential vaccine 
        side effects. The FDA's Sentinel is the largest system 
        available in the U.S. for vaccines adverse event surveillance. 
        Similarly, the FDA's pre-licensure and post licensure safety 
        review of vaccines is useful in ensuring vaccine safety. 
        Continued support for these vaccine safety initiatives is not 
        just useful for ensuring confidence in vaccines but, more 
        importantly, it's the right thing to do. However, it is 
        important that assessment of vaccine safety continues to be 
        science-based.

          6. Maintain bipartisan and vociferous support for vaccines:
        This committee has previously expressed strong support for 
        vaccines--through statements supporting vaccines. Such 
        statements matter. They indicate broad social support for 
        vaccines and signal to the so-called fence sitters that 
        vaccination is the social norm. As someone who has spent his 
        professional life ensuring children and adults are protected 
        from infectious diseases, I personally thank you for these 
        statements.
          We have a history of bipartisan action for vaccines
    In the aftermath of the last measles resurgence in the United 
States in 1989-1991, there was a remarkably bipartisan effort to 
address the main cause of that resurgence: vaccine access. President 
Bill Clinton and congressional Republicans and Democrats came together 
to establish the Vaccines for Children program to remove affordability 
as a barrier to vaccination. This program was effective in addressing 
inequities in immunization coverage. Preventing the next potential 
resurgence of measles will require a similar broad-based response.

    Acknowledgements and disclosures: I want to acknowledge the work by 
members of my research group and collaborators on some of the research 
and synthesis I shared. Part of the content in this testimony has 
previously appeared in peer-reviewed publications and op-eds (e.g. my 
February 11 Washington Post op-ed with my colleague Bob Bednarczyk). I 
have received funding for my research from federal agencies (e.g. NIH, 
CDC, AHRQ), international public health agencies (the World Health 
Organization, Gavi-the vaccine alliance), and philanthropic foundations 
(e.g. the Bill & Melinda Gates Foundation, Thrasher Research Fund). I 
do not receive funding from vaccine manufacturers.
                                 ______
                                 
                  [summary statement of saad b. omer]
    Elimination of endemic transmission of measles from the United 
States in 2000 is a significant public health success. Since then, 
measles has mostly occurred either because of imported cases (mostly 
from U.S. travelers returning home) or among their contacts. While 
recent measles outbreaks have been contained, the frequency and size of 
these outbreaks is alarming. For example, according to a CDC study, the 
annual median number of cases and outbreaks more than doubled during 
2009--2014 compared to 2000--2008.

    Why haven't we seen a national level measles outbreak in recent 
years?

          Because school-entry vaccine requirements keep rates 
        of vaccine noncompliance low.

          CDC aggressively responds to emerging outbreaks--an 
        epidemiological firefighting function it performs with state 
        and local health departments.

          Medical societies such as the American Academy of 
        Pediatrics and the Infectious Diseases Society of America have 
        been at the forefront of vaccine advocacy.

    What is the role of vaccine refusal in measles outbreaks?

          Since the measles elimination, more than half of 
        measles cases had no history of measles vaccination.

          Among the unvaccinated, age-eligible measles cases 
        for whom a reason was available, 70.6 percent had a nonmedical 
        exemption to vaccination.

          Unvaccinated individuals make up a greater proportion 
        of measles cases in early parts of epidemics--indicating that 
        unvaccinated people often provide the tinder to start the fires 
        of these epidemics.

          Vaccine refusal is not the only reason for non-
        vaccination e.g. insurance status is an important factor.

    Are vaccine mandates a useful policy option for controlling 
vaccine-preventable diseases?

          Most state-based vaccine mandates in the U.S. work by 
        changing the balance of convenience in favor of vaccination and 
        away from non-vaccination.

          Ease of obtaining a nonmedical exemption is 
        associated with higher state-level vaccine exemption rates and 
        higher rates of vaccine-preventable diseases.

          States have a range of policy options vis-`-vis 
        mandates--ranging from eliminating nonmedical exemption to 
        adding requirements such as legally mandated physician 
        counseling.

    Vaccine mandates are implemented at the state level. Can the 
federal government do anything about vaccine acceptance and controlling 
outbreaks?

    There are many policy options within the purview of the federal 
government; these options include:

           1. Consider making vaccine counseling reimbursable.

           2. Invest in vaccine acceptance/communication research.

           3. Implement recommendations from National Vaccine Advisory 
        Committee's vaccine confidence report.

           4. Support CDC's mission of controlling measles outbreaks.

           5. Continue to prioritize vaccine safety research.

           6. Maintain bipartisan and vociferous support for vaccines.

    We have a history of bipartisan action for vaccines

    In the aftermath of the last measles resurgence in the United 
States in 1989--1991, there was a remarkably bipartisan effort to 
address the main cause of that resurgence: vaccine access. Republicans 
and Democrats came together to establish the Vaccines for Children 
program to remove affordability as a barrier to vaccination. This 
program was effective in addressing many inequities in immunization 
coverage. Preventing the next potential resurgence of measles will 
require a similar broad-based response.
                                 ______
                                 
    The Chairman. Thank you, Dr. Omer.
    Dr. McCullers, welcome.

 STATEMENT OF JONATHAN A. MCCULLERS, MD, PROFESSOR AND CHAIR, 
   DEPARTMENT OF PEDIATRICS, UNIVERSITY OF TENNESSEE HEALTH 
  SCIENCE CENTER, PEDIATRICS-IN-CHIEF, LE BONHEUR CHILDREN'S 
                     HOSPITAL, MEMPHIS, TN

    Dr. McCullers. Thank you.
    Good morning Chairman Alexander, Ranking Member Murray, 
other Members of the Committee. My name is John McCullers. I am 
the Chair of Pediatrics at the University of Tennessee and the 
Pediatrician-in-Chief at Le Bonheur Children's Hospital in 
Memphis. As someone who has devoted his career to the child 
health sphere, I truly believe there is no more precious 
resource than our children, and they should be protected by all 
means available to us. They really are the future of this 
Nation.
    The Childhood Vaccination Program in the United States has 
proven to be one of the most powerful public health 
achievements in our history. In the first half of the 20th 
century there were more than 1 million infections and more than 
10,000 deaths every year in this country from diseases which 
are now preventable by childhood vaccines. Measles alone costs 
more than a half-million illnesses every year. Measles is a 
highly contagious viral respiratory disease characterized by 
fever, cough, sore throat, and a rash. It is a very dangerous 
disease. About 1 in 1,000 infected persons develop 
encephalitis, an infection of the brain. 1 in 1,000 develop 
severe pneumonia, and about half of those with those severe 
complications die. There is no specific treatment for measles, 
so vaccination is the only means of preventing these outcomes.
    With the introduction of a safe and effective vaccine for 
measles in 1963 and improved public health efforts to see that 
nearly every child received it, new cases of measles arising in 
the United States were entirely eliminated by the year 2000. 
Unfortunately, the issues of vaccine opposition and vaccine 
hesitancy are now impairing our ability to effectively ensure 
coverage aided by state laws that make it easier to avoid 
vaccination. The last decade has brought numerous outbreaks to 
the United States, including several that are ongoing at 
present. These outbreaks are strongly linked to vaccine 
refusal, and in particular, to clustering of unvaccinated 
individuals in specific communities or regions.
    This problem is not limited to the United States, however. 
Countries worldwide are dealing with similar outbreaks. As a 
single example for the Committee, there was zero cases of 
measles in Brazil in 2017, but more than 10,000 cases occurred 
on a countrywide level in 2018, when infected travelers brought 
measles into that country. The vaccine against measles is very 
safe and very effective. One dose provides complete protection 
in about 93 percent of individuals, while a second dose raises 
that level of protection to 97 percent. Very few side effects 
occur. About 1 in 10 children experience fever for 1 to 2 days 
after vaccination. And about 1 in 3,000 to 1 in 4,000 have a 
simple seizure associated with fever with no lasting effects. 
Allergic reactions are very rare and typically very mild.
    When compared to the outcomes of the disease itself, it is 
easy to see why doctors and public health officials universally 
recommend on time and complete vaccination. Unfortunately, 
vaccine refusal is high and getting worse in many states. This 
issue is complicated by the variety of state policies regarding 
exemption from vaccination and the methods of counseling about 
vaccines. The rate of parents claiming non-medical exemptions 
is about 2.5 times higher in states that allow both religious 
and philosophical objection. Evidence seeing that multiple 
pathways for exemption really worsens this problem. Social 
media is now driving a new phenomena somewhat distinct from 
vaccine opposition termed vaccine hesitancy. When parents get 
much of their information about health care issues such as 
vaccines from the internet or from social media platforms such 
as Twitter and Facebook, reading uninformed opinions in the 
absence of accurate information can lead to really 
understandable concern and confusion in these parents. They may 
be hesitant to get their children vaccinated without being 
provided with more information.
    The role of the pediatrician is very important therefore 
with these families. We must do a better job of communicating 
at many levels, but particularly at the point of contact at the 
well-child visit when vaccination should take place. About half 
of the time when counseled appropriate, parents with vaccine 
hesitancy will agree to have their children vaccinated on time. 
And the other half, little seems to help at that stage. The 
solution must be earlier either in the form of policy or 
broader educational efforts.
    In closing, I would like to thank the Committee for 
addressing this important issue. Vaccine refusal is one of the 
growing public health threats of our time. If we continue to 
allow non-medical exemptions to vaccination, the rates of 
vaccine will continue to fall, more outbreaks will undoubtedly 
follow. As a leader at a children's hospital, I have a unique 
perspective on this. These children's hospitals are regional 
and sometimes national resources. Le Bonheur Children's 
Hospital sits in the corner of Tennessee next to Arkansas and 
Mississippi. These three states all have very different 
policies for granting exemptions to vaccines, which creates a 
tremendous problem for us and a threat to the children we 
serve, many of whom are too young to be vaccinated or 
immunocompromised, and more prone to severe diseases.
    I urge the Committee to consider solutions that will both 
harmonize public health policy in this area and will also 
protect children as they grow up to become the next generation.
    Thank you.
    [The statement of Dr. McCullers follows:]
              prepared statement of jonathan a. mccullers
    Good Morning Chairman Alexander, Ranking Member Murray, other 
Members of the Committee, and interested parties. I am Dr. Jon 
McCullers, the Chair of the Department of Pediatrics at the University 
of Tennessee Health Science Center and the Pediatrician-in-Chief at Le 
Bonheur Children's Hospital in Memphis. As someone who has devoted his 
career to the child health sphere, I firmly believe that there is no 
more precious resource than our children, and that they should be 
protected by all means available to us. They truly are the future of 
this nation. As the lead pediatrician for one of our nation's top 
Children's Hospitals, I feel it is my duty and privilege to advocate on 
behalf of children everywhere. The declining rates of childhood 
vaccination in this nation and, indeed, worldwide, now prove to be a 
threat to this future.

    The childhood vaccination program of the United States has proven 
to be one of the most powerful public health achievements in our 
history. In the first half of the 20th century, there were more than 1 
million infections and more than 10,000 deaths every year from diseases 
which are now preventable by childhood vaccines. To put that into 
perspective in the current day, without childhood vaccines the States 
of Tennessee and Washington would be dealing with between 24,000 and 
37,000 vaccine preventable diseases in an average year, and between 250 
and 275 children would die, most of them under the age of 5. Measles 
alone caused more than a half million illnesses every year in the first 
half of the last century, and between 450 and 500 children died 
annually. Measles is a viral respiratory disease, characterized by 
fever, cough, sore throat, and a rash. It is a very dangerous disease--
about 1 in a thousand infected persons develop encephalitis, an 
infection of the brain, 1 in a thousand develop severe pneumonia, and 
about half of those with these severe complications die. Measles is 
also highly contagious - while some individuals infected with some 
severe infectious agents like influenza only infect 1-2 other persons 
on average, a person infected with measles infects 20-30 other people 
on average if they are unvaccinated. There is no specific treatment for 
measles, so vaccination is the only means of preventing these outcomes. 
With the introduction of a safe and effective vaccine for measles in 
1963 and improved public health efforts to see that nearly every child 
received it, new cases of measles arising in the United States were 
entirely eliminated by the year 2000. 2006 saw our lowest case number 
with only 55 illnesses, all imported from other countries, and no 
deaths.

    Unfortunately, the issues of vaccine opposition and vaccine 
hesitancy are now impairing our ability to effectively insure 
appropriate vaccine coverage, aided by state laws that make it easier 
to avoid vaccination. The last decade has brought numerous outbreaks in 
the United States, including several that are ongoing at present. These 
outbreaks are strongly linked to vaccine refusal, and in particular to 
clustering of unvaccinated individuals in specific communities or 
regions. Cases are introduced from unvaccinated individuals traveling 
here from other countries, and spread rapidly through communities with 
vaccination rates under the level needed for herd immunity. 372 persons 
contracted measles during 17 different outbreaks in the United States 
in 2018, and 159 have been infected in the first 7 weeks of 2019. This 
problem is not limited to the US . . . many countries worldwide are 
dealing with similar outbreaks. As a single example, there were 0 cases 
of measles in Brazil in 2017, but more than 10,000 cases occurred in 
2018 when infected travelers brought measles into that country.

    The vaccine against measles is very safe and very effective. One 
dose provides complete protection in about 93 percent of individuals, 
while a second dose raises that level of protection to 97 percent. Very 
few side effects occur. About 1 in 10 children experience fever for 1-2 
days, and about 1 in 3000 to 1 in 4000 have a simple seizure associated 
with fever with no lasting effects. Allergic reactions are very rare 
and typically very mild. No reactions or adverse effects of a more 
severe nature have been associated with the vaccine, despite extensive 
use, monitoring, and study for many decades. When compared to the 
outcomes of the disease itself, it is easy to see why doctors and 
public health officials universally recommend on time and complete 
vaccination.

    Unfortunately, vaccine refusal is high and getting worse in many 
states. This issue is complicated by the variety of state based 
policies regarding exemption from vaccination and the methods of 
counseling about vaccines. Three states currently only allow medical 
exemptions from vaccination--California, Mississippi, and West 
Virginia. These states all have vaccination rates for measles at the 
age of school entry at 97 percent or better--above the 96 percent level 
needed for herd immunity. Thirty states allow for religious exemptions 
to vaccines, and 17 allow both religious and personal exemption. The 
rate of parents claiming non-medical exemptions to vaccines is 2.5 
times higher in states that allow both religious and philosophical 
exemptions compared to religious exemptions alone--evidence that 
allowing multiple pathways to exemption worsens this problem. Of the 5 
states that have less than 91 percent vaccination rates, Colorado, 
Idaho, Indiana, Kansas, and Washington, three allow both types of 
exemption. Although some states such as Tennessee have reasonable rates 
currently (97 percent) while allowing religious exemptions only, the 
rate of non-medical exemptions has nearly tripled under this policy in 
the past decade, and it can be predicted that this will continue to 
rise. California is an illustrative case . . . that state allowed both 
types of exemptions earlier in the decade, but non-medical exemptions 
rose to 3.3 percent in 2013, the overall level of vaccination dropped 
below the level needed for herd immunity, and the state experienced a 
large outbreak of measles in 2014-2015 with spread of the disease in 
Disneyland the park theme parks. California subsequently eliminated 
non-medical exemptions and the vaccination rate has returned to 97 
percent. The American Academy of Pediatrics has suggested that the 
practice of delaying or spacing out childhood vaccines contributed to 
that outbreak.

    Opposition to vaccines began in England in the early 19th century 
after introduction of Jenner's cowpox vaccine for the dangerous disease 
smallpox. People objected on religious grounds and due to the 
irrational fear of becoming a cow. Opposition in the United States 
became common in the 1850s, resulting in lawsuits against states that 
mandated vaccination, culminating in a Supreme Court opinion in 1905 
that found in favor of states' right to enforce mandatory vaccination 
as a public health tool. Although the concept of vaccination opposition 
is not new, the rise in frequency and ease of rapid international 
travel has made it much more dangerous today than it was a century ago 
when vaccine refusers may have been isolated from others. The reasons 
for refusing vaccination have historically been very heterogenous. In 
1998 the Wakefield Hoax unified many vaccine refusers by providing a 
single platform for them using a false narrative--that childhood 
vaccines caused unsuspected, long term medical problems that had been 
missed by scientists. In response, a great deal of scientific work was 
done to prove that there is no link between vaccines and conditions 
such as autism. The Institute of Medicine has now declared that the 
evidence is thorough and convincing on this point. The anti-vaccination 
movement at this time, therefore, no longer has a platform or any 
credibility and has returned to a more heterogeneous group of 
objections.

    In the present day, however, social media and the amplification of 
minor theories through rapid and diffuse channels of communication, 
coupled with instant reinforcement in the absence of authoritative 
opinions, is now driving a new phenomenon somewhat distinct from 
vaccine opposition, termed vaccine hesitancy. When parents get much of 
their information from the internet or social media platforms such as 
twitter and Facebook, reading these fringe ideas in the absence of 
accurate information can lead to understandable concern and confusion. 
These parents may thus be hesitant to get their children vaccinated 
without more information. The role of the pediatrician is very 
important with these families--we must do a better job of communicating 
at many levels, but particularly at the point of contact in the well 
child visit when vaccination should take place. Half of the time when 
counseled appropriately, those with vaccine hesitancy will agree to 
have their children vaccinated on time. In the other half, little seems 
to help at that stage, so the solution must be earlier, in the form of 
policy or broader educational efforts.

    In closing, I would like to thank the Committee for addressing this 
important issue. Vaccine refusal is one of the growing public health 
threats of our time. If we continue to allow non-medical exemptions to 
vaccination, rates of vaccination will continue to fall and more 
outbreaks will undoubtedly follow. As a leader at a Children's 
Hospital, I have a unique perspective on this, as Children's Hospitals 
are regional and sometime national resources. Le Bonheur Children's 
Hospital sits in the corner of Tennessee next to Arkansas and 
Mississippi, and serves a large number of children from 7 different 
states as well as providing high level specialty care for select 
diseases to children across the United States. Tennessee, Arkansas, and 
Mississippi all have different policies for granting exemptions to 
vaccines, which creates a tremendous problem to us and a threat to the 
children we serve, many of whom are too young to be vaccinated or are 
immunocompromised and more prone to severe diseases. I urge the 
Committee to consider solutions that will both harmonize public health 
policy in this area and will also protect children as they grow up to 
become the next generation.
                                 ______
                                 
              [summary statement of jonathan a. mccullers]
    Good Morning Chairman Alexander, Ranking Member Murray, and other 
Members of the Committee. I am Dr. Jon McCullers, the Chair of the 
Department of Pediatrics at the University of Tennessee Health Science 
Center and the Pediatrician-in-Chief at Le Bonheur Children's Hospital 
in Memphis. As someone who has devoted his career to the child health 
sphere, I firmly believe that there is no more precious resource than 
our children, and that they should be protected by all means available 
to us. They truly are the future of this nation. The declining rates of 
childhood vaccination in this nation and, indeed, worldwide, now prove 
to be a threat to this future.

    The childhood vaccination program of the United States has proven 
to be one of the most powerful public health achievements in our 
history. In the first half of the 20th century, there were more than 1 
million infections and more than 10,000 deaths every year from diseases 
which are now preventable by childhood vaccines. Measles alone caused 
more than a half million illnesses every year in the first half of the 
last century, and between 450 and 500 children died annually. Measles 
is a highly contagious viral respiratory disease, characterized by 
fever, cough, sore throat, and a rash. It is a very dangerous disease - 
about 1 in a thousand infected persons develop encephalitis, an 
infection of the brain, 1 in a thousand develop severe pneumonia, and 
about half of those with these severe complications die. There is no 
specific treatment for measles, so vaccination is the only means of 
preventing these outcomes. With the introduction of a safe and 
effective vaccine for measles in 1963 and improved public health 
efforts to see that nearly every child received it, new cases of 
measles arising in the United States were entirely eliminated by the 
year 2000.

    Unfortunately, the issues of vaccine opposition and vaccine 
hesitancy are now impairing our ability to effectively insure 
appropriate vaccine coverage, aided by State laws that make it easier 
to avoid vaccination. The last decade has brought numerous outbreaks in 
the United States, including several that are ongoing at present. These 
outbreaks are strongly linked to vaccine refusal, and in particular to 
clustering of unvaccinated individuals in specific communities or 
regions. Cases are introduced from unvaccinated individuals traveling 
here from other countries, and spread rapidly through communities with 
vaccination rates under the level needed for herd immunity. This 
problem is not limited to the United States - countries worldwide are 
dealing with similar outbreaks. As a single example, there were 0 cases 
of measles in Brazil in 2017, but more than 10,000 cases occurred in 
2018 when infected travelers brought measles into that country.

    The vaccine against measles is very safe and very effective. One 
dose provides complete protection in about 93 percent of individuals, 
while a second dose raises that level of protection to 97 percent. Very 
few side effects occur. About 1 in 10 children experience fever for 1-2 
days, and about 1 in 3000 to 1 in 4000 have a simple seizure associated 
with fever with no lasting effects. Allergic reactions are very rare 
and typically very mild. When compared to the outcomes of the disease 
itself, it is easy to see why doctors and public health officials 
universally recommend on time and complete vaccination.

    Unfortunately, vaccine refusal is high and getting worse in many 
states. This issue is complicated by the variety of state based 
policies regarding exemption from vaccination and the methods of 
counseling about vaccines. Three states currently only allow medical 
exemptions from vaccination, while 30 states allow for religious 
exemptions to vaccines, and 17 allow both religious and personal 
exemption. The rate of parents claiming non-medical exemptions to 
vaccines is 2.5 times higher in states that allow both religious and 
philosophical exemptions compared to religious exemptions alone - 
evidence that allowing multiple pathways to exemption worsens this 
problem. California is an illustrative case . . . that state allowed 
both types of exemptions earlier in the decade, but non-medical 
exemptions rose, the overall level of vaccination dropped below the 
level needed for herd immunity, and the state experienced a large 
outbreak of measles in 2014-2015 with spread of the disease in 
Disneyland the park theme parks. California subsequently eliminated 
non-medical exemptions and the vaccination rate has returned to 97 
percent.

    Social media is now driving a new phenomenon somewhat distinct from 
vaccine opposition, termed vaccine hesitancy. When parents get much of 
their information from the internet or social media platforms such as 
twitter and Facebook, reading fringe ideas in the absence of accurate 
information can lead to understandable concern and confusion. These 
parents may thus be hesitant to get their children vaccinated without 
more information. The role of the pediatrician is very important with 
these families - we must do a better job of communicating at many 
levels, but particularly at the point of contact in the well child 
visit when vaccination should take place. Half of the time when 
counseled appropriately, those with vaccine hesitancy will agree to 
have their children vaccinated on time. In the other half, little seems 
to help at that stage, so the solution must be earlier, in the form of 
policy or broader educational efforts.

    In closing, I would like to thank the Committee for addressing this 
important issue. Vaccine refusal is one of the growing public health 
threats of our time. If we continue to allow non-medical exemptions to 
vaccination, rates of vaccination will continue to fall and more 
outbreaks will undoubtedly follow. As a leader at a Children's 
Hospital, I have a unique perspective on this, as Children's Hospitals 
are regional and sometime national resources. Le Bonheur Children's 
Hospital sits in the corner of Tennessee next to Arkansas and 
Mississippi. These three states all have very different policies for 
granting exemptions to vaccines, which creates a tremendous problem to 
us and a threat to the children we serve, many of whom are too young to 
be vaccinated or are immunocompromised and more prone to severe 
diseases. I urge the Committee to consider solutions that will both 
harmonize public health policy in this area and will also protect 
children as they grow up to become the next generation.
                                 ______
                                 
    The Chairman. Thank you, Dr. McCullers.
    Mr. Boyle, welcome.

     STATEMENT OF JOHN G. BOYLE, PRESIDENT AND CEO, IMMUNE 
               DEFICIENCY FOUNDATION, TOWSON, MD

    Mr. Boyle. Chairman Alexander, Ranking Member Murray, and 
Members of the Committee, thank you for inviting me here to 
testify in the importance of herd immunity, or community 
immunity as we like to say, for vaccine-preventable diseases.
    My name is John Boyle and I am the President and CEO of 
Immune Deficiency Foundation, a not for profit patient 
organization that represents people with primary 
immunodeficiency disease or PI. Primary immunodeficiency 
diseases are a group of more than 350 rare and chronic 
disorders in which parts of the body's immune system are either 
missing or functioning improperly.
    There is an estimated 250,000 people diagnosed PI in the 
U.S. alone. That is about 1 and 1,200 of your constituents. 
These disorders are caused by genetic defects and are not 
contagious. Now there is a variety between the different forms 
of PI, but one thing unites all of us, we are immunocompromised 
meaning that we are potentially vulnerable to even common 
viruses and bacteria. Now, I have a form of PI known as X-
linked agammaglobulinemia or XLA. I was diagnosed with it when 
I was six months old, when a respiratory infection nearly 
killed me. In short, I do not produce antibodies, but I am able 
to be here with you today because I receive weekly infusions of 
antibiotics from other people through a blood plasma product 
called immunoglobulin or IG. These infusions give me back some 
of what I am missing, but I am still susceptible to infections.
    Now, because I was diagnosed early and I receive IG 
therapy, my health is better than most others with PI. However, 
a simple cold can wreak havoc with me or many other members of 
our community. We are incredibly vulnerable to communicable 
illnesses. Now for some members of our community, infections 
are truly a life-and-death matter. I think all of you probably 
remember David Vetter, affectionally known as the boy in the 
plastic bubble, who was born with severe combined immune 
deficiency or SCID. Children diagnosed with SCID, XLA, or any 
other form of PI face multiple challenges with simple everyday 
pathogens. Exposing these children to something as severe as 
measles could be life-threatening. Parents and communities 
where vaccine use is being questioned are afraid to send their 
children outside. They are afraid because they know the 
history, the science, and the math, and they know the stakes. 
If people stop vaccinating, the safety net of community 
immunity will fall, and their children will be among the first 
casualties.
    Now, of course, this does not just affect children, it 
affects adults too. While there is now newborn screening for 
SCID, most members of our community go years or even decades 
with serious or recurrent infections without knowing that they 
have a compromised immune system. I am particularly concerned 
for the health of this segment of our community, the 
undiagnosed. If community immunity fails, they do not even know 
that they need to take precautions. Those of us who know that 
we have PI do what we can to avoid exposure to infections. But 
the undiagnosed lack this basic knowledge and are even more at 
risk. Now the reason that all of us are so dependent on 
community immunity in the PI community is that vaccines do not 
work with most of us who have forms of PI. Our systems either 
do not remember the pathogens, or we physically cannot create 
the antibodies.
    A further complication is that there are some vaccines that 
are actually dangerous to us, live vaccines. As a result, those 
in the field of immunology have studied this issue thoroughly 
to produce evidence-based guidelines to best safeguard those of 
us with PI. An article that I shared with the Committee 
discusses the issue surrounding which vaccines are either 
indicated or not, but it also addresses the growing neglect of 
societal adherence to routine vaccinations, what we are here 
talking about today. It states how important it is for family 
members and then those around patients with immunodeficiencies 
to receive all available standard immunizations in order to 
protect the family member who has PI.
    Now in closing let me say this, my life along with the 
lives of hundreds of thousands of others who are 
immunocompromised depend on community immunity. We depend on 
vaccines. I understand from the concern that some new parents 
have, particularly given the misinformation on social media. 
But that fear cannot override the facts.
    History has shown us that vaccines work. Science has shown 
us that vaccines are necessary. And mathematics has shown us 
that the odds of children having a healthy life are magnitudes 
greater if they have had their vaccines. The current decline in 
vaccine usage is literally bringing back plagues of the past. 
All those of us who are immunocompromised will suffer first and 
suffer more. The loss of community immunity is a threat to all 
of us.
    We need to band together to dispel the myths, combat 
misinformation campaigns, and help ensure that measles and 
other vaccine-preventable diseases are once again put in their 
place, in history books and not in our communities.
    Thank you.
    [The statement of Mr. Boyle follows:]
                  prepared statement of john g. boyle
    Chairman Alexander, Ranking Member Murray, and Members of the 
Committee:

    Thank you for inviting me to testify on the importance of herd 
immunity for vaccine preventable diseases.

    My name is John G. Boyle, and I am the President and CEO of the 
Immune Deficiency Foundation. IDF is a not-for-profit patient 
organization representing people with primary immunodeficiency 
diseases, or PI.

    Primary immunodeficiency diseases are a group of more than 350 
rare, chronic disorders in which part of the body's immune system is 
missing or does not function properly. There are an estimated 250,000 
people diagnosed with a form of PI in the U.S. alone. That's 
approximately 1 in 1,200 of your constituents.

    These disorders are caused by genetic defects and are not 
contagious. Many are first recognized shortly after birth or in early 
childhood, but many more are not diagnosed until much later in life.

    There is some variety between the different forms of PI, but one 
thing unites all of us: we are immunocompromised, meaning that we are 
potentially vulnerable to even the most common viruses and bacteria. We 
all struggle, to varying degrees, with recurring infections and 
persistent illnesses even when treatments are available that lessen the 
impact of our diagnoses.

    I have a form of PI known as X--Linked Agammaglobulinemia, or XLA. 
I was diagnosed with it when I was six months old after a respiratory 
infection nearly killed me. In short, I don't produce antibodies. I'm 
able to be with you today because I receive weekly infusions of 
antibodies from other people through a blood plasma product called 
immunoglobulin, or Ig.

    These infusions give me back some of what I'm missing, but I'm 
still very susceptible to infections.

    Because I was diagnosed early and receive Ig therapy, my day-to-day 
health is better than many others with PI. However, a simple cold can 
wreak havoc with the lives of many members of our community. Without a 
fully-functioning immune system, we're incredibly vulnerable to 
communicable illnesses.

    For some members of our community, infections are unquestionably a 
life and death matter. I suspect that all of you recall David Vetter, 
affectionately known as the ``boy in the bubble,'' who was born with 
Severe Combined Immunodeficiency or SCID, one of the most severe forms 
of PI. Infants born with SCID are missing vital portions of their 
immune system, and their survival is based on receiving a bone-marrow 
transplant or gene therapy in their first few months of life.

    Children diagnosed with SCID, XLA, or any other form of PI face 
multiple challenges with simple, everyday pathogens. Children with PI 
regularly fall ill and miss school because of Rhinovirus and other 
diseases that are not that serious to most people. Exposing these 
children to something as severe as measles could be life threatening. 
Parents who live in communities where vaccine use is being questioned 
have shared that they are afraid to send their child to school--even 
when their child is not sick and should be able to participate.

    They're afraid because they understand the science, the math, and 
the history. They know the stakes: if people stop vaccinating and the 
safety net of ``community immunity'' fails, their children will be 
among the first casualties.

    As a father, I gravitate to talking about children first. But this 
issue affects adults too. While there is now newborn screening for SCID 
in all 50 states, most members of our community go years or even 
decades dealing with serious and recurrent infections without knowing 
they have a compromised immune system. Because of this, we know there 
are many people living with PI who are undiagnosed. I am particularly 
concerned for the health of this segment of our community, the 
undiagnosed. If community immunity fails, they do not know that they 
need to take precautions. Those of us who know we have PI do what we 
can to avoid exposure to infections. But the undiagnosed lack this 
basic knowledge and are even more at-risk.

    The reason that all of us, young and old, diagnosed or undiagnosed 
are so dependent on community immunity is that vaccines do not work for 
most of us with PI. The basic concept of a vaccine is to expose the 
body's immune system to an inert version of a pathogen so it can 
``remember'' that pathogen and make antibodies when necessary. This 
does not work with us because our systems either don't remember the 
pathogens or we physically can't create the antibodies.

    A further complication is that being immunocompromised as we are 
there are some vaccines that could actually be dangerous to us, 
particularly ``live'' vaccines. As a result, those in the field of 
immunology have studied this issue thoroughly to produce evidence-based 
guidelines to best safeguard those with PI.

    In 2014, the IDF Medical Advisory Committee published an article in 
The Journal of Allergy and Clinical Immunology called ``Recommendations 
for live viral and bacterial vaccines in immunodeficient patients and 
their close contacts,'' to help clarify which vaccines can be given to 
patients with PI. While the primary purpose of the article was to 
provide clarity about which vaccines were either indicated or 
contraindicated for people with various PI diagnoses, it also addressed 
the growing neglect of societal adherence to routine vaccinations, a 
topic particularly relevant to this morning's discussion. I would like 
to submit the full copy of this article for the committee report.

    The authors clearly recommend, ``Education about the critical need 
for maintenance of herd immunity (community immunity) in the population 
at large.'' In essence, community immunity offers valuable protection 
to patients with PI who are unable to mount protective antibody 
responses. It is particularly important for family members of patients 
with T and B cell immunodeficiencies, such as Common Variable Immune 
Deficiency (or CVID), SCID, and XLA to receive all of the available 
standard immunizations in order to protect their family member with 
these types of PI. I will note that any person with PI should consult a 
healthcare provider, particularly an immunologist, to discuss whether 
there should be any adjustments to the specifics of their vaccination 
care plan depending on their diagnosis. Of course, consulting a 
healthcare provider is what everyone should do when it comes to 
discussing vaccine-related questions. They can answer your questions, 
and--I hope--allay concerns and put things into perspective.

    In closing, let me say this: my life, along with the lives of 
hundreds of thousands of others who are immunocompromised depend upon 
herd immunity. We depend on vaccines. I understand the concern that 
some new parents have particularly given the misinformation on social 
media, but that fear can't override facts. History has shown us that 
vaccines work. Science has shown us that vaccines are necessary. And 
mathematics has shown that the odds of children having a healthy life 
are magnitudes greater if they've had their vaccines.

    The current decline in vaccine usage is literally bringing back 
plagues of the past. While those of us who are immunocompromised will 
suffer first and suffer more--the loss of community immunity is a 
threat to us all. We need to band together to dispel myths, combat 
misinformation campaigns, and help ensure that measles and other 
vaccine-preventable diseases are once again put in their place--in 
history books, not in our communities.

    I thank you for inviting me to testify, and I look forward to any 
questions you may have.
                                 ______
                                 
                  [summary statement of john g. boyle]
    For someone with any one of these disorders--particularly those who 
are untreated--what may be a modest cold or virus for most people could 
be a serious or even fatal condition. Severe infections, such as the 
measles, pose even more risk for immune compromised people, and 
community immunity represents the best way to effectively prevent what 
could be a life-threatening situation. People with PIs are unable to 
mount adequate protective antibody responses to infections so most 
people with these conditions cannot get vaccines themselves.

    As outbreaks of vaccine-preventable diseases have increased over 
the years, the PI community has grown concerned. When the safety net of 
community immunity fails:

          Parents of children with PI are concerned about 
        sending their children to school where they have no protection 
        from contagious diseases, even when they are otherwise healthy 
        enough to participate.

          Many people, including adults, who have not yet been 
        diagnosed with a PI, are at high risk because they do not know 
        to take precautions to avoid infections.

    The lives of hundreds of thousands of individuals who are 
immunocompromised depend on herd immunity--they depend on their 
community being vaccinated. When people opt to not immunize--absent 
sound medical information or other compelling reasons--it creates a 
dangerous situation that is particularly harmful for individuals with 
primary immunodeficiency and to others with compromised immune systems.
    The Chairman. Thank you, Mr. Boyle.
    Mr. Lindenberger, welcome.

STATEMENT OF ETHAN LINDENBERGER, STUDENT, NORWALK HIGH SCHOOL, 
                          NORWALK, OH

    Mr. Lindenberger. Thank you, Chairman Alexander, Senator 
Murray, and distinguished Committee Members for the opportunity 
to speak today.
    Good morning everyone. As was stated, my is Ethan 
Lindenberger and I am a senior Norwalk High School, and my 
mother is an anti-vax advocate that believes vaccines cause 
autism, brain damage, and do not benefit the health and safety 
of society despite the fact such opinions have been debunked 
numerous times by the scientific community. I lived my entire 
life without numerous vaccines against diseases such as 
measles, chickenpox, or even polio. However, in December 2018, 
I began catching up on my missed immunizations, despite my 
mother's disapproval, eventually leading to this story and 
being able to speak here today. And I am very happy for that, 
so thank you.
    Now, to understand why I have come here and what I really 
want to talk about, I have to talk about my home life and my 
upbringing. I grew up understanding my mother's believes that 
vaccines are dangerous, and she would speak openly about these 
views. Both online and in person, she would voice her concerns, 
and these beliefs were met with strong criticism.
    Over the course of my life seeds of doubt were planted and 
questions arose because of the backlash my mother would 
receive, but over time that really did not lead anywhere. Now 
it is important to understand that as I approached high school 
and began to critically think for myself, I saw that the 
information in defense of vaccines outweighed the concerns 
heavily. I began leading debate clubs at my school and pursuing 
truth above all else, and I realized one certain quality to 
debates and to conversations in general when it comes to 
controversial discussions, which is that there seems to always 
be two sides to a discussion. There always seems to be a 
counterclaim or rebuttal and always something to strike back 
with in terms of debate. Though this may seem true in all 
instances, this is not true for the vaccine debate, and I 
approached my mother with this concern that she was incorrect.
    I approached my mother numerous times trying to explain 
that vaccines are safe and that my family should be vaccinated. 
Approaching even with articles in the CDC explicitly claiming 
that ideas that vaccine cause autism and extremely dangerous 
consequences were incorrect. In one such instance where I 
approached my mother with information from the CDC that claims 
vaccines do not cause autism, she responded with, that is what 
they want you to think. Skepticism and worry were taking the 
forefront in terms of information. Now, conversations like 
these reaffirmed that evidence in defense of vaccines was, at 
least on an anecdotal level, much greater than the deeply 
rooted misinformation my mother interacted with. And that is 
what I want to focus on today.
    To combat preventable disease outbreaks, information is, in 
my mind, the forefront of this matter. My mother would turn to 
anti-vaccine groups online and on social media, looking for her 
evidence in defense, rather than health officials and through 
credible sources. This may seem to be in malice because of the 
dangers that not vaccinating imposes, but this is not the case. 
My mother came, in the sense of loving her children and being 
concerned. This misinformation spreads and that is not 
necessarily justifiable, but I carry this knowledge with me 
that it was with respect and love that I disagreed with my 
mother. And with the information she provided, I continued to 
try and explain that it was misinformed. Ideas that, again 
vaccine cause autism, brain damage, and also that the measles 
outbreak is of no concern to the society and to America, were 
ideas that were pushed by these sources that she would go to. 
And for certain individuals and organizations that spread this 
misinformation, they instill fear into the public for their own 
gain selfishly and do so knowing that their information is 
incorrect.
    For my mother, her love, affection, and care as a parent 
was used to push an agenda to create a false distress. And 
these sources, which spread misinformation, should be the 
primary concern of the American people. Although change is 
already in place, more strides can be done. Almost 80 percent 
of people according to Pew Research Center, turn to the 
internet for health related questions. I further explained some 
more statistics and evidence in my written testimony. Now, in 
terms of what I would like to walkway with today and kind of 
finalize with, although my mother would turn to very 
illegitimate sources and sources that did not have peer-
reviewed evidence or information, I quickly saw that the 
evidence and claims for myself were not accurate. And because 
of that and because of my health care professionals I was able 
to speak with and the information provided to me, I was able to 
make a clear, concise, and scientific decision.
    Approaching this issue with the concern of education and 
addressing misinformation properly can cause change, as it did 
for me. Now, although the debate around vaccines is not 
necessarily centered on information and concerns for health and 
safety, this is why education is important, and also 
misinformation is so dangerous.
    Thank you.
    [The statement of Mr. Lindenberger follows:]
                prepared statement of ethan lindenberger
    Thank you Chairman Alexander, Senator Murray, and distinguished 
Committee Members for the opportunity to speak today.

    Good morning, everyone. My name is Ethan Lindenberger and I am a 
senior at Norwalk High School. My mother is an anti-vaccine advocate 
that believes vaccines cause autism, brain damage, and do not benefit 
the health and safety of society despite the fact such opinions have 
been debunked numerous times by the scientific community. I went my 
entire life without vaccinations against diseases such as measles, 
chicken pox, or even polio. However, in December of 2018, I began 
catching up on my missed immunizations despite my mother's disapproval, 
eventually leading to an international story centered around my 
decisions and public disagreement with my mother's views.

    To understand why I am here and how I have come to this point, I 
first must share some details about my upbringing and household. I grew 
up understanding that my mother believed vaccines are dangerous, as she 
would speak openly about her views both online and in person. These 
beliefs were met with strong criticism, and over the course of my life 
seeds of doubt were planted and questions arose because of the backlash 
my mother received when sharing her views on vaccines.

    These questions and doubts were minor and never led to a serious 
realization of how misinformed my mother was. As these thoughts grew, I 
continued to attend high school and remained undecided in my opinion of 
vaccinations for many years. At my high school, I ran a debate club and 
learned about the importance of finding credible information both 
through my own pursuits in leading this club and through the fantastic 
teachers at Norwalk.

    This is important to understand, as learning to find credible 
research and information is fundamental to finding truth in a world of 
misleading facts and false views. Through leading my debate club, I saw 
there are almost universally two or more sides to every discussion. To 
every claim there is a counterclaim, and to every statement there was 
always a rebuttal. Though this may seem to be true in all instances, 
the scientific studies and evidence that analyze the benefits and risk 
of vaccinations are separate from this truth. In its essence, there is 
no debate. Vaccinations are proven to be a medical miracle, stopping 
the spread of numerous diseases and therefore saving countless lives.

    I remember speaking with my mother about vaccines, and at one point 
in our discussion she claimed a link existed between vaccines and 
autism. In response, I presented evidence from the CDC which claimed 
directly in large bold letters, ``There is no link between vaccines and 
autism.'' Within the same article from the CDC on their official 
website, extensive evidence and studies from the institute of medicine 
(IOM) were cited. Most would assume when confronted with such strong 
proof, there would be serious consideration that your views are 
incorrect. This was not the case for my mother, as her only response 
was, ``that's what they want you to think.''

    This is only one example amongst a myriad of conversations where 
such evidence was disregarded and ignored. And this response is 
representative of the entire discussion around vaccines, where one side 
is based in scientific evidence and truth while the other is based in 
skepticism and falsities.

    Conversations like these were what reaffirmed the evidence in 
defense of vaccinations and proved to me, at least on an anecdotal 
level, that anti-vaccine beliefs are deeply rooted in misinformation. 
Despite this, a necessary clarification must be made when discussing 
this misinformation: anti-vaccine individuals do not root their 
opinions in malice, but rather a true concern for themselves and other 
people. Although it may not seem to be true because of the serious 
implications of choosing not to vaccinate, the entire anti-vaccine 
movement has gained so much traction because of this fear and concern 
that vaccines are dangerous.

    According to a study analyzing the views and beliefs of the dangers 
imposed by vaccinations by the Pew research center on February 5th, 
2017, ``About half (52 percent) of parents with children ages 0 to 4 
say the risk of side effects is low, while 43 percent say it is medium 
or high. By contrast, seven-in-ten adults with no minor-age children 
(70 percent) rate the risk of side effects from the [MMR] vaccine as 
low.'' That means that nearly 20 percent of Americans which previously 
believed vaccines posed a low risk for children of a young age begin to 
raise concerns once they have a child. Such is the case for my mother.

    This does not justify spreading misinformation, and I carried this 
knowledge with me as I pursued vaccinations without my mother's 
approval. Her beliefs were not true, and propagating these lies is 
dangerous. However, it is not necessarily ill-natured. This was the 
foundation for the respectful disagreement between us as I publicly 
expressed concerns for her misinformed beliefs.

    I speak here today to first express this concept, that anti-vaccine 
parents and individuals are in no way evil. With that said, I will 
state that certain individuals and organizations which spread 
misinformation and instill fear into the public for their own gain 
selfishly put countless people at risk. If one agrees that vaccines are 
safe and substantially benefit the health and safety of the public, 
you'd see the anti-vaccine leaders and proponents of misinformation 
which knowingly lie to the American people are the real issue. Using 
the love, affection, and care of a parent for their children to push an 
agenda and create false distress is shameful. The sources which spread 
misinformation should be the primary concern of the American people.

    Change is already taking place, as the largest source of 
misinformation comes from private social media platforms. In a 2011 
study by the pew research center, 80 percent of Americans turn to the 
internet for health related questions. This is dangerous due to the 
sources which spread misinformation online, and the surprising 
influence they hold. The Atlantic examined vaccine related posts on the 
social media platform Facebook from 2016--2019. In their article, they 
found that ``Just seven anti-vax pages generated nearly 20 percent of 
the top 10,000 vaccination posts in this time period.'' This echo-
chamber that a handful of sources generate create the majority of anti-
vaccine information on these platforms, and with my mother it continues 
to influence her views along with countless Americans.

    My mother would turn to some of the cited sources in this article 
by The Atlantic, using their information as a basis for her views. This 
was problematic, as with a quick inspection of the claims and evidence 
of these sites their intentions are revealed. Information is not 
properly cited, and data is skewed to create false claims. In one video 
published by the website ``stopmandatoryvaccines.com'' (which was 
listed as one of the top contributors of anti-vaccine information by 
the Atlantic), the measles outbreak was made out to be a unfounded 
panic created by big pharmaceutical companies and meant to push 
legislative agendas. Del Bigtree, a celebrity in the anti-vaccine 
movement, spoke with ``Dr. Bob Sears.'' My mom and I sat down, watching 
this video so she could prove her beliefs were not unfounded.

    In this video, Dr. Bob Sears claims that in the past 15 years there 
hasn't been a single death to the measles. In contrast, 449 people have 
had fatal reactions to the MMR vaccine. This completely ignores that if 
the measles disease was left to its own devices, it could cause an 
incomparable amount of deaths. The World Health Organization (W.H.O) 
estimates that ``During 2000-2017, measles vaccination prevented an 
estimated 21.1 million deaths making measles vaccine one of the best 
buys in public health.'' I bring this up to show how in my own personal 
life this misinformation reached my family. Not only that, it led to 
the people I care about being put at risk.

    In school, I was pulled out of class every year and told that if I 
did not receive my shots, I wouldn't be able to attend my high school. 
But, every year, I was opted out of these immunizations and, because of 
current legislation, I was allowed to attend a public high school 
despite placing my classmates in danger of contracting multiple 
preventable diseases.

    The debate around vaccinations is not centered around information, 
but instead concerns on the health and safety of society. We must 
distinguish the difference between a personal view and a medical 
concern, a safety concern, and the dangers of such rhetoric. The 
information leading people to fear for their children, for themselves, 
and for their families is causing outbreaks of preventable diseases. 
Therefore, combating this information while also working towards 
legislative changes may help protect our nation from needless deaths. 
My story highlights this misinformation and how it spreads. Between 
social media platforms, to using a parent's love as a tool, these lies 
cause people to distrust in vaccination, furthering the impact of a 
preventable disease outbreak and even contributing to the cause of 
diseases spreading. This needs to change and I only hope my story 
contributes to such advancements.
                                 ______
                                 
    The Chairman. Thank you, Mr. Lindenberger. And thank you 
for coming from Ohio to let us hear what you have to say. Now 
we will begin 5-minute round of questions. I would--if many 
Senators interested, I would ask the Senators to keep the 
combination of questions and answers within five minutes. Dr. 
McCullers, you are a Pediatrician-in-Chief at one of our 
country's leading children's hospital, so your business is to 
talk every day during your career with lots of parents about 
their children. So, what do you say to parents, to a parent who 
comes to you in Memphis and said, I have heard on the internet 
or I have read that vaccines cause autism and I do not want my 
child to be vaccinated? What do you say to that parent?
    Dr. McCullers. Well, what we find when we look at this is 
that parents really have a very complex set of issues that they 
are concerned about. That is one of them but there is a lot of 
other things that they think about and that they bring to us. 
So, it is not one issue that we have to talk about, it is many, 
many issues.
    The Chairman. But what--I want to focus on autism. What if 
they say that to you?
    Dr. McCullers. This was a concern that was raised about 20 
years ago when there was a fraudulent paper published linking 
vaccines to autism.
    The Chairman. That paper was published in the United 
Kingdom, correct?
    Dr. McCullers. It was published in the United Kingdom----
    The Chairman. In a respected journal, is that correct?
    Dr. McCullers. It was a respected journal. It was a 
physician who published it, and he was, unfortunately, paid by 
a set of attorneys more than #400,000 to falsify information 
because they were suing the government of England against 
vaccines. So, this was found to be wrong. It was retracted. He 
lost his medical license----
    The Chairman. What did the journal do about it?
    Dr. McCullers. The journal retracted the paper and said it 
no longer is valid.
    The Chairman. Have there been other papers or journals that 
agreed with that physician's----
    Dr. McCullers. There have not been that agreed with that 
position. There has been numerous scientific research done in 
the interim that have shown the opposite, that these vaccines 
are not linked. And the Institute of Medicine here in the 
United States, our highest authority on these sorts of issues, 
has declared that they are--it is a uniformly, basically, a 
closed issue now.
    The Chairman. As you talk with parents, so is that 
persuasive with a mother who is concerned about her child and 
who has heard that vaccines cause autism?
    Dr. McCullers. I think if there is a rapport with the 
physician and a mutual respect, they are both for the opinion 
of the parent but then also for the position of the physician, 
you can say things like that and say the evidence is clear, I 
believe this, you should do this, and they will trust that 
information.
    The Chairman. In your opinion, there is no evidence, 
reputable evidence, that vaccines cause autism?
    Dr. McCullers. There is absolutely no evidence at this time 
that vaccines cause autism.
    The Chairman. Dr. Omer, do you agree with that?
    Dr. Omer. Absolutely.
    The Chairman. Dr. Wiesman, do you agree with that?
    Dr. Wiesman. I do.
    The Chairman. Mr. Boyle, do you agree with that?
    Mr. Boyle. I do.
    The Chairman. Mr. Lindenberger?
    Mr. Lindenberger. I do.
    The Chairman. Dr. Wiesman, what about state exemptions? You 
are a state public health officer and as a former Governor, I 
generally have a biased toward Washington not telling states 
what to do on many on----
    [Laughter.]
    The Chairman. With Washington, DC not telling states what 
to do. Senator Murray is correcting me here. So, what advice do 
you have about state exemptions and the effect on the concern 
we see today in pockets of measles across the country?
    Dr. Wiesman. I think as we heard earlier that the choice to 
sort of make exemptions more difficult to get, to be sort of as 
burdensome as sort of not getting the vaccine, is incredibly 
important. In Washington State, as you know, we have two bills 
right now that are looking to remove the personal exemptions 
from vaccine for school entry and for childcare entry. I think 
that is one of the tools that we have and that we should be 
using for this. I will also say in Washington State another 
problem we have is that about 8 percent of our kids are out of 
compliance with school records so that we do not even know if 
they are vaccinated or would like exemptions. And we have to 
tackle that problem as well, which really is a resource issue 
for schools and public health.
    The Chairman. I am going to stay within my time. Senator 
Murray.
    Senator Murray. Thank you very much. Dr. Wiesman, I really 
appreciate everything you and your state and local colleagues 
are doing on the frontlines of this measles outbreak in 
Washington State confirming and managing the cases, tracing 
potential contacts, identify exposures sights, crafting 
community messages. There is a lot going on, but it is really 
scary to imagine how much worse this outbreak would be if not 
for all the tireless work of so many public health officials on 
the ground. But we all hope we are able to not just respond to 
outbreaks, but also focus on preventing them in the first 
place. And I want to ask you, how have initiatives like the 
public-private partnership Vax Northwest and your department's 
proactive communication with parents of young children helped 
in building confidence?
    Dr. Wiesman. Great, thanks. Yes, we do believe that the 
child profile mailings that go out to parents, to kids up to 
age 6, they go out at points in time that are appropriate to 
the development of the child, are incredibly important. It is a 
trusted source of information, not just on vaccines, but on 
childhood development. And it is that relationship that we 
build with parents through that mailing that I think is 
incredibly important.
    When I go out to the public and I see a new parent, I will 
often ask them, hey, do you get this little mailing from the 
health department? And they say, I do, we love, it is great 
information. So, I think that trusted source is really 
important. The public-private partnership that we have with Vax 
Northwest is actually a research initiative to try and best 
understand how we actually address vaccine hesitancy. There 
have been two studies done. One looking with health care 
providers on how to best train them around communication with 
their patients. Unfortunately, that work did not find that it 
made a difference in terms of addressing vaccine hesitancy nor 
necessarily health care providers efficacy around feeling 
confident in those conversations. The other piece was one with 
parents and parents who were interested in vaccine advocacy, 
training them on how to have conversations with parents, how to 
share information at PTA meetings, etc. And that did find that 
it increased parents' knowledge of vaccines and reduced their 
hesitancy.
    Senator Murray. Okay, thank you. And, Dr. Omer, as 
vaccination rates in some areas drop to low levels, we need to 
keep each other safe. Your research on vaccine hesitancy and 
likewise is really critical. And we know that some parents are 
making decisions about whether or not to vaccinate before they 
even have their child. I wanted to ask you, what are the 
implications of some of these early decisions and what have you 
learned about the key factors that lead some parents to 
hesitate to vaccinate?
    Dr. Omer. Thank you for the question. And you rightly 
pointing out that a lot of this--that there is evidence to 
suggest that a lot of parents are making the decisions on 
vaccines before the baby is born. After the baby is born, it is 
like a fast moving train, and parents go through this extended 
jet-lag. And so, before that, there is a lot of discussion 
happening, etc. And there are several reasons for this. The 
first one is, the big picture reason is that vaccines are a 
victim of their own success, and as the rate of vaccine 
preventable diseases go down, because of vaccines, successive 
cohorts of parents see and hear about real or perceived adverse 
events and not the disease. And what happens is that mental 
calculus changes. And in that milieu, there are several that 
interact with several local factors, and in the U.S. for 
example, due to that sort of change in the disease rates, which 
is a good thing, we have less appreciation of vaccines 
susceptibility and severity and more questions about vaccine 
safety.
    Senator Murray. Because we do not see it.
    Dr. Omer. In that context, focusing on not just childhood 
but before the baby is born, we are working for example, our 
group is doing a randomized controlled trial in collaboration 
with University of Colorado and John's Hopkins, where we are--
you now and this is due to an investment, due to funding from 
the National Institute for Allergy and Infectious Diseases, 
where we are looking at bringing together the best evidence and 
packaging it and seeing if that has an impact in not just 
maternal vaccination, but this intervention being performed in 
pregnancy, leading to childhood vaccination rates increase. And 
so, the initial results from them are promising, but to come 
back to the idea that we need to continue to invest in the best 
science for vaccine behavior and communication as we do for 
vaccine safety and vaccine efficacy.
    Senator Murray. Okay, thank you very much.
    The Chairman. Thank you, Senator Murray. Senator Isakson.
    Senator Isakson. Thank you, Chairman Alexander. Thank you 
all for your testimony. Mr. Lindenberger, what year in school 
are you?
    Mr. Lindenberger. I am a senior in high school.
    Senator Isakson. When did you start doing the investigation 
and research on vaccination?
    Mr. Lindenberger. From my mother specifically, I mean she 
would vocalize her views on vaccines throughout my entire life 
and it was a slow progression to start to see evidence as I 
would see people, I suppose, trying to counterclaim with her 
and argue online. I would see that she would have this backlash 
as she would share information. So, on Facebook, she shared a 
video and people would be like that is incorrect, this is 
false. And so, as a child that intrigued me that people 
disagreed with my mom and I started to look into it over the 
course of multiple years.
    Senator Isakson. That is the second time you have used 
online in your answer. I want to ask, does your mother get most 
of her information online?
    Mr. Lindenberger. From what she has presented, yes. Either 
through Facebook or through sites that use the social media 
platforms, like Facebook--mainly Facebook, I mean.
    Senator Isakson. Where do you get most of your information?
    Mr. Lindenberger. From not Facebook. I mean, from CDC, the 
World Health Organization, scientific journals, and also cited 
information from those organizations like the Institute of 
Medicine. I try my best also to look at credited sources.
    Senator Isakson. I would love to be guest at Thanksgiving 
dinner at your house. That would be----
    [Laughter.]
    Senator Isakson. It would be a heck of a discussion 
everybody would have. I know that. Dr. Omer, thank you for 
being here and thanks for the work that Emory does. Emory does 
a phenomenal job in infectious disease and all kinds of things 
like that. What currently--are there any things on the horizon 
that would join this group of people, that we might want to 
immunize for later on?
    Dr. Omer. There are several exciting developments, and one 
of the big gaps in vaccine has been the fact that there is a 
gap of vulnerability between the baby is born and when we start 
vaccinating them. And that is due to immunological reasons. And 
one of the most exciting developments in this area is the area 
of maternal immunization where you vaccinate mom. And I had the 
privilege of being involved in some of those trials, etc. to 
protect not just the mother but the baby as well. So, there are 
vaccines against the respiratory syncytial virus, which is the 
biggest cause of viral pneumonia in the world on the horizon. 
So, there is a variety of vaccines being developed. There is a 
vaccine that is being developed against group B streptococcus, 
etc. So, there are several vaccines on the horizon. The field 
is expanding.
    Senator Isakson. Now would those vaccinations take place in 
the mother before the baby is delivered?
    Dr. Omer. Yes.
    Senator Isakson. It transfers to the baby during the course 
of gestation?
    Dr. Omer. Exactly. And our first trial had a name of 
``mother's gift'' ages ago, and I think it is an appropriate 
name for this kind of first strategy where maternal antibodies 
protect the baby.
    Senator Isakson. You know, I have been to Africa with CDC a 
number of times and seen your work, the work in the field that 
they do. I do not know of any organization that does more for 
health care in other countries that CDC does. How much do you 
use CDC as a resource in your work at Emory?
    Dr. Omer. A lot. The CDC is a national treasure. And the 
firefighting function that I talked about they perform with the 
state and local health department is somewhat unique. For 
example, the European CDC is relatively new and has a very 
narrow mandate. And people who have looked at the effectiveness 
of national public agencies in Europe, have clearly come out 
with the understanding that our CDC is very strong. And I am 
not trying to put down any other country's public agencies, 
because they are trying their best, but the kind of investments 
that have gone into building this cooperative framework of the 
CDC being the premier technical public agency but working 
closely with the state and local health department has served 
us really well, including in this area.
    Senator Isakson. I do not think you are putting them down 
at all. In fact, to tell you the truth, it is the world's 
health care center, the CDC, and we are lucky to have it in the 
United States of America, but the world considers it their 
health center. And they are doing better job--CDC is doing a 
better job incubating CDCs in other countries now to replicate 
what they do in countries that are more developed and populated 
so----
    Dr. Omer. Absolutely.
    Senator Isakson. They are a great resource, great help, and 
a great service. And I thank all of you for being here today 
and Mr. Lindenberger, do not forgot that I will come to your 
Thanksgiving dinner one day and just meet you and your mom.
    [Laughter.]
    Senator Isakson. Thank you, Mr. Chairman, or Madam 
Chairman.
    Senator Murray. [Presiding] Senator Baldwin.
    Senator Baldwin. Thank you. In 2015, this Committee held a 
similar hearing to discuss the resurgence of vaccine-
preventable diseases in response to a multi-state measles 
outbreak. Our Nation's vaccination program has saved lives by 
preventing and reducing the outbreak of vaccine preventable 
diseases like measles, which has one of the most effective 
vaccines. So, I am troubled that we are here again facing 
another preventable outbreak in several states that has 
similarly been exacerbated by a surge of misinformation 
surrounding vaccine safety. I believe we must do a better job 
to prioritize investments in cutting edge science and public 
education surrounding vaccine safety. Younger children and 
those with compromised immune systems have a higher risk of 
measles complications. And with the breath of misinformation 
proliferating in the media and online about the science behind 
vaccines Dr. Wiesman,
    Dr.--is it Omer?
    Dr. Omer. Yes.
    Senator Baldwin. Dr. Omer, what role do state health 
departments play in our main community leaders like school 
officials and providers with accurate information and 
scientific resources on vaccine safety? And as a follow-on, 
what can Congress do to improve the public health education, so 
we do not see another preventable outbreak in the future?
    Dr. Wiesman. Thank you for that question. Yes, so states 
and local health departments really are the leaders in 
communities around these health strategies to engage their 
communities around vaccine information. They help provide the 
health education. They work with the school systems. They work 
with health care providers to make sure that health care 
providers have the information they need. It really takes a 
sort of coordinated effort.
    Honestly, that system is crumbling. The sort of resources 
that are going into prevention in our state, local, tribal, and 
territorial health agencies has been decreasing. And we are 
really not up to the task. For example, I had a call with CDC a 
number of months ago. State health officials, we do this every 
two weeks, and CDC was on the call talking about a hepatitis A 
outbreak that is occurring throughout the country in many 
communities. They are encouraging us to do proactive 
vaccination campaigns with homeless and injection drug users, 
which is where this is being seen. I do not have the resources. 
I asked my staff, what would a plan look like? It would 
probably cost us $5 million. I do not have those resources. I 
do not have the staff that are there. That is very, very 
concerning to me. And, I forgot your second question, but----
    Senator Baldwin. How can Congress help? So, I am thinking--
--
    Dr. Wiesman. I sort of helped answer that right there.
    Senator Baldwin. That is right. That is right.
    Dr. Wiesman. Including, I think, in research around how do 
we--the social research around how is it we communicate with 
folks about vaccines, and then have a national campaign. We 
really need to get on this.
    Dr. Omer. Just to add to that, in addition to research, 
investment in high quality research, I think Congress can work 
on making vaccine counseling reimbursable. So that is a 
specific tool that physicians can use at the periphery, at the 
frontlines of these conversations that are happening every day. 
Then sort of take the blueprint that I mentioned that is 
already there, that was developed by the National Vaccine 
Advisory committee, that has very specific science-based 
recommendations to have that kind of implementation out there.
    To continue to support CDC's mission of this controlling 
outbreaks, etc. That should not be taken for granted. And the 
last thing in this stream of specific things is, continue to 
prioritize the vaccines safety research enterprise that we 
have, which is not just a template for this country, but 
everywhere else as well. So, having a robust vaccine safety 
system is not only a tool to maintain confidence in vaccines, 
but it is just the right thing to do. So, these are some of the 
specific things Congress and the Federal Government can do.
    Senator Baldwin. Thank you. I have only a few seconds left. 
I am going to ask a question. Maybe if we run out of time, you 
can submit information for the record. But I follow of course 
some of the advancements that happen in my state and some of 
the interesting things that are happening.
    Since 2007, a company called FluGen in Madison, Wisconsin 
has been working to develop a more effective flu vaccine based 
on technology that was discovered and invented at the 
University of Wisconsin. As we have heard today, highly 
effective vaccines have played a critical role in advancing 
public health around the world, and I think there is more that 
we could do to support the development of better vaccines to 
protect individuals from an illness that results in literally 
thousands of deaths each year. Mr. Boyle, can you describe why 
it is important for Congress to continue to support this 
medical research that advances the development of more 
effective vaccines for common illnesses like the flu, and 
specifically for vulnerable populations?
    Mr. Boyle. Sure, let me try. One of the challenges that I 
see when I even think about my colleagues and friends who 
sometimes struggle with whether to get the flu vaccine is basic 
issues of fears of things like needles. They do not want to get 
a shot. They are scared of that. For that reason, I know that 
things like the flu-mist and others are attractive, the problem 
is within our community a live virus, such as that has been 
used in the past, is a problem.
    We are a little bit torn in that we want something to be 
easy and efficacious and something that is going to be widely 
adopted, but at the same time we have to be concerned about 
those who are especially undiagnosed. So, there is a little bit 
of a balance there and further investigation to help understand 
what new technologies could be made to reduce the burden of 
getting a vaccine, be it for the flu or anything more 
communicable, would be phenomenal. At the same time, we will 
have to work with the CDC and others in order to balance out 
the needs of those who are actually going to be affected by 
that negatively. But we are all in it together.
    The continued conversation and exploration is important, 
and our community and other immunocompromised communities would 
I think be delighted to be part of these conversations.
    Senator Baldwin. Thank you.
    Senator Cassidy. [Presiding] Dr. Paul.
    Senator Paul. Thank you. Thank you for your testimony. For 
much of modern history, science and freedom have lived in 
relative harmony. Traditionally as medical discoveries came 
about like the smallpox, or polio vaccine, antisepsis or 
antibiotics, the results were so overwhelming that overtime the 
vast majority of the public accepted these advances 
voluntarily.
    In fact, innovations like the smallpox vaccine had to 
overcome initially great public prejudice. Dr. Zabdiel Boylston 
learned about the Middle Eastern technique from his servant for 
the famous Pastor Cotton Mather. His first patient was actually 
his son, an incredibly brave choice. The consensus of the 
medical community though was entirely opposed to him at the 
time. The vaccine was a live vaccine, and as Dr. Boylston 
learned about 1 and 50 of those inoculated would die from the 
vaccine. And yet, the death rate from smallpox was 
approximately 50 percent. The Government did not mandate the 
vaccine though, but within two generations it was accepted 
enough that George Washington insisted that Martha be 
vaccinated with the smallpox vaccine before visiting him in the 
military camps.
    Today though, instead of persuasion, many governments have 
taken to mandating a whole host of vaccines, including vaccines 
for non-lethal diseases. Sometimes these vaccine mandates have 
run amok, when the Government mandated a rotavirus vaccine that 
was later recalled because it was causing intestinal blockage 
in children. I am not a fan of Government coercion, yet given 
the choice, I do believe that the benefits of most vaccines 
vastly outweigh the risks. Yet, it is wrong to say that there 
are no risk to vaccines. Even the Government admits that 
children are sometimes injured by vaccines.
    Since 1988, over $4 billion has been paid out from the 
Vaccine Injury Compensation Program. Despite the Government 
admitting to it in paying $4 billion for vaccine injuries, no 
informed consent is used or required when you vaccinate your 
child. This may be the only medical procedure in today's 
medical world where an informed consent is not required.
    Now proponents of mandatory Government vaccination argue 
that parents who refuse to vaccinate their children risk 
spreading these disease to the immunocompromised community. 
There does not seem to be enough evidence of this happening to 
be recorded as a statistic, but it could happen. But if the 
fear of this is valid, are we to find that next we will be 
mandating flu vaccines? Between 12 and 56,000 people die from 
the flu or have been said to have died from the flu in America, 
and it is estimated to be a few hundred for measles. So, I 
would guess that those who want to mandate measles will be 
after us on the flu next. If the current science only allows 
for educated guessing when it comes to the flu vaccine, each 
year before that year's flu vaccine or strain is known, the 
scientist put their best guess into that year's vaccine. Some 
years it is completely wrong. We vaccinate for the wrong 
strand--the wrong strain of flu vaccine. Yet, five states 
already mandate flu vaccines. Is it really appropriate to 
mandate a vaccine that more often than not vaccinates for the 
wrong flu strain?
    As we contemplate forcing parents to choose this or that 
vaccine, I think it is important to remember that force is not 
consistent with the American story, nor is force consistent 
with the liberty our forefathers sought when they came to 
America. I do not think you have to have one or the other 
though. I am not here to say, do not vaccinate your kids. If 
this appearing is for persuasion, I am all for the persuasion. 
I have vaccinated myself. I have vaccinated my kids. For myself 
and my children, I believe that the benefits of vaccines 
greatly outweigh the risks, but I still do not favor giving up 
on liberty for a false sense of security.
    Thank you.
    Senator Cassidy. Do you yield back?
    [Applause.]
    Senator Paul. I yield back.
    Senator Cassidy. Senator Warren.
    Senator Warren. Thank you, Mr. Chairman. So, we have heard 
today about how important vaccines are to preventing and 
controlling many diseases. And, I want to see, row in on one 
that we are battling right now in Massachusetts. Since last 
April, 318 outbreak associated cases of acute hepatitis A virus 
have been reported in the Commonwealth of Massachusetts. Hep A 
is a contagious virus that causes liver infection. Older 
children and adults who acquire the hepatitis A virus can 
experience a slew of incredibly unpleasant symptoms, fever, 
nausea. And in rare cases, the virus can even lead to death.
    In Massachusetts, four people have already died since the 
outbreak began. Now, we did not use to have a hepatitis A 
vaccine at all, but in 1995 and '96 the Food and Drug 
Administration approved two hepatitis A vaccines, and soon 
after CDC recommended vaccination for certain populations, 
including routine vaccinations of children living in areas with 
elevated rates of the virus. Dr. McCullers, you study 
infectious diseases, what impact did the introduction of the 
hepatitis A vaccine have on the national rates of the virus?
    Dr. McCullers. Well, thank you very much Senator Warren. 
Yes, hepatitis A can be a very sever disease in particular high 
risks groups. The vaccine that came out in the late 1990s is a 
very safe, very effective vaccine, and as we have increased 
vaccination rates, we have seen a tremendous decrease in the 
rate of the disease. We have seen more than a 50-fold decrease 
nationally over those years, primarily eliminating a lot of the 
disease in children as well as some of the food-borne 
outbreaks. But there is still a lot of public health work to do 
as it is illustrated by your current outbreak.
    Senator Warren. That is the question I want to ask. We have 
developed a vaccine, the rate goes way down, so we now have a 
vaccine-preventable virus here. Why are we seeing so many 
hepatitis A cases emerging now?
    Dr. McCullers. Well, what we are seeing is the vaccines 
administered in childhood. It has only been around for about 20 
years so if you are 21 years or older, have not had it. Now it 
is recommended that high-risk groups such as recreational drug 
users as is part of the problem in Massachusetts, be vaccinated 
and we have not gotten all those groups yet. So, efforts to 
really find the high-risk individuals, which are well-defined, 
and to get them the vaccine would help prevent these outbreaks 
in the future.
    Senator Warren. Yes, and this is part of what is happening 
in Massachusetts. We have been battling the Opioid Crisis for 
years, and hepatitis A is just another place we need to fight 
on this. But we are learning from this. Just this past October, 
the same CDC committee whose recommendations in the 1990s 
helped the rates of the virus decline sharply, added persons 
experiencing homelessness to the list of those who are 
recommended to get hepatitis A vaccine. I see you are all 
nodding, right.
    In Massachusetts, our public health workers, our community 
health centers, and our jails have sprung into action to try to 
get the vaccine to those who are most at risk. Dr. Wiesman, as 
Secretary of the Washington State Department of Health, you 
overseer your state's public health response. What can we be 
doing to ensure that local public health officials have the 
resources they need to be able to do their work?
    Dr. Wiesman. Yes, thank you. So, really part of this is 
making sure that the prevention public health fund is funded 
and that we look at funding the CDC. We have been asking ASTHO, 
the Association of state and Territorial Health officials and 
local public health for increasing the CDC budget 22 percent by 
FY2022.
    Senator Warren. Alright. So, we are talking money now.
    Dr. Wiesman. We are talking money.
    Senator Warren. We are talking money, and whether it is a 
situation like hepatitis A outbreak in Massachusetts or the 
measles outbreak in Washington State, how do the preventive 
costs of a vaccine program compare to the containment and 
treatment cost of an outbreak?
    Dr. Wiesman. Well in general we do know that for about 
every dollar spent on vaccines, you save about 10, so it is 
definitely a cost-effective intervention.
    Senator Warren. Good. So, the more we do on the front-end 
to ensure that everyone gets access to the vaccines, the less 
we will see individuals contracting hepatitis A, measles, 
whopping cough, all of the other vaccine-preventable diseases.
    This Administration has repeatedly sought to cut the 
Prevention and Public Health Fund, which supports key 
immunization programs, and they have continued their efforts to 
weaken the Medicaid program, which covers all of the 
recommended vaccines for children and for many adults as well. 
I am glad that most of my colleagues are on the same page about 
the importance of vaccines.
    Now let us make sure we are also on the same page about the 
importance of the public health funding, so people get access 
to those vaccines.
    Thank you.
    Senator Cassidy. Senator Roberts.
    Senator Roberts. Thank you, Mr. Chairman. I am going to go 
a little crosscurrent here, and I want to state that the 
importance of vaccine in infants and young people cannot be 
overstated. I understand that. But I want to talk about the 
seniors who are also at increased risk of experiencing serious 
and life-threatening effects of vaccine preventable diseases. 
We have quite a few octogenarians in the Senate that get 
vaccinated. More specially with flu. Mr. Boyle, you touched on 
this with your reference to this topic on the effect of a herd 
immunity syndrome, which I appreciate, particular settings in 
which adults and seniors are more susceptible to infectious 
diseases if they are not vaccinated.
    But to figure out if we can look for ways that Federal 
programs can help by removing barriers to services like 
vaccines and providing the right incentives for people to use 
them. And, what procedural barriers exist to ensuring that 
seniors have proper access to vaccines? Do we need more 
education so seniors provide--overcome these challenges? I want 
to give you a personal illustration. A young lady, but she was 
in her 80s, but she was young.
    [Laughter.]
    Senator Roberts. She makes sure that all six of her 
children got flu shots, had in turn all of her grandchildren 
and that was a bunch of folks. And yet, she got the flu in 
Kansas this time around--bad just a very bad flu season. And 
for some reason, she did not get a flu shot. So here she is, a 
mother who has told her kids to get vaccinated and made sure it 
happened. And then, in her own situation, she did not get a flu 
shot along with her husband. We lost both. The sniffles became 
flu, the flu became serious, and we get into pneumonia, and we 
get into all sorts of other problems.
    I am not going to go into what kind of treatment they 
received, but they were very important folks and they were 
pillars of their community, and they were still very active. I 
sometimes think that the octogenarian caucus in the, well in 
the Senate, we are known as potted plants.
    [Laughter.]
    Senator Roberts. We are also known as chairmen of the 
various committees around here.
    Dr. Omer, you have written about vaccine confidence. And I 
am interested in how this applies to adults in recent years, 
who have seen outbreaks of vaccine preventable diseases in 
which unvaccinated adults are an important factor. CDC also 
noted that a drop in the immunization rate contribute to rise 
in hospitalization and deaths during the last flu season. I do 
not get it. I do not understand why in a period of your life 
when you would be obviously saying I need a flu shot and then 
respond to why you did not do it, well we just did not get 
around to it. I do not know.
    If any of you would like to offer any opinions. We are 
talking about young people all the time but there are people 
who still contribute to this society even though there is no 
bar graph after 80 for anything. We are just out there. Anybody 
want to comment? Dr. Omer.
    Dr. Omer. Thank you Senator, and the story that you noted 
is not unique, unfortunately, in this country and throughout 
the world.
    The elderly are one of the highest risk groups for count 
complications after influenza. The vaccines are slightly less 
effective in the elderly, but that is the reason we need more 
of them to be vaccinated. And this is one of the gaps that I 
was talking about, that we do not have evidence-based to 
communicate to several groups, including the elderly. And this 
is not a group that is actively opposed to vaccines. They have 
the concept of vaccines, and they have seen what infectious 
diseases can do. But the--at that time when a lot of the 
discussion has revolved around childhood vaccines, we need 
evidence-based strategies to communicate to not just the 
elderly, but also to their health systems. The providers, who 
deal with the elderly do not have, unfortunately, the muscle 
memory to talk about vaccines and to make it part of their 
routine clinical practices. There is a lot to be done and thank 
you for highlighting that issue.
    Senator Roberts. Mr. Chairman, my time has expired. I want 
you to know that we did not plan this, Dr. Omer and myself 
before the Committee hearing, but he certainly hit the nail on 
the head. I think it is an issue that we overlook. Thank you.
    Senator Cassidy. Thank you.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chair, and thank you to the 
witnesses. This has been a fascinating topic. Timely, I noticed 
yet another study has come out just in the last 24 hours, a 
study dealing with a very significant longitudinal study with a 
big chunk of children in Denmark that also, again, demonstrates 
no link between the MMR vaccine and autism, and so it is a 
timely date to have this hearing. I want to ask a question 
about--begin with a question about vaccination shortages, which 
as a former governor, worries me a lot. Problems in the supply 
chain that could lead to shortages of important medications.
    In 2017, outbreaks of hepatitis A increased demand and lead 
to constraints supplies of that vaccine. Many constituents have 
contacted my office about their inability to access the 
shingles vaccine, shingrix. So, last year I joined the 
bipartisan group of Members of this Committee in a letter to 
commissioner Gottlieb of urging him to convene the drug 
shortage task force to develop a report on the root shortage of 
drug vaccines. I look forward to reading that report and I 
think it may be on the verge of being published. I think the 
Committee has completed the work and it is very close to 
publication. It might be worthy of some Committee consideration 
when it is done.
    What more can we do, and I guess I will direct it 
specifically to Dr. Omer and Dr. Wiesman, what more could we do 
at the Federal level to make sure there is an adequate supply 
of vaccines?
    Dr. Wiesman. Well, just to start out and then turn it to my 
colleague. So, one, we would need to continue investing in 
vaccine research figuring out new technologies for producing 
vaccines. We use sort of egg technology and it is a very long, 
laborious process in many of these. So, we have to move towards 
new technologies, I think, around cell-based or recombinant 
vaccines, so that we can produce them more quickly and assure 
the safety. And it is a problem with the vaccine shortages.
    Dr. Omer. Yes, so one of my mentors has said a few times 
that it is not--vaccine is in a vial, that remains in a vial, 
is 100 percent safe, but 0 percent effective. And so, inventing 
a vaccine or developing a vaccine or licensing a vaccine is not 
sufficient. We need to have a stable supply of vaccines. And 
that requires A. a Federal-wide thinking and response from 
regulation to working with our research entities to say that 
there is a robust pipeline of new vaccines, and there are 
multiple approaches.
    Infectious diseases attack our bodies through multiple 
mechanisms, therefore there are multiple vulnerabilities. What 
it does is that it creates an intellectual marketplace of ideas 
so that if there is more than one strategy that we are focusing 
on at the science level, we have more likelihood of having 
multiple products that compete with each other and have a--sort 
of give us more options as a country. Then working with 
manufacturers. Sort of ensuring that we understand that there 
is a stable manufacturing pipeline.
    The third thing is sometimes in certain specially 
pandemics, etc., one policy intervention is BARDA, which invest 
in preparedness related interventions. And for example, some 
flu vaccines that would be required in a pandemic, there it is 
in our interest to ensure a stable seasonal flu pipeline. And 
so, there are interventions and investments which are a little 
bit more direct that sort of straddle that divide between 
emerging and routine vaccination, etc. So, it will require a 
nationwide--a national response, not just a Federal response in 
this sense, that sort of bringing in states and other partners 
as well.
    Senator Kaine. Thank you for that. Yes, Dr. McCullers. You 
need to be quick because I have one more question.
    Dr. McCullers. Alright, very quickly then. Three quick 
issues, one is that these are for-profit companies generally 
that create the vaccines, so having a Federal buy that gives 
them some surety will make them produce more, which will help 
the vaccine shortages. The second is, we really have a problem 
not so much with shortage but with maldistribution, so it 
becomes a logistics effort and we can do better at that at the 
local level, being able to make sure every physician, practice, 
or hospital has that. And the third is to reinforce the 
importance of the strategic national stockpile, which again 
keeps these vaccines in reserve when we might need them. Thank 
you.
    Senator Kaine. Thank you. I just in my last minute Mr. 
Lindenberger, I just want to compliment you. We revere 
Jefferson in Virginia and one of the things that he said that 
still is so powerful is, ``progress and Government and all else 
depends upon the broadest possible diffusion of knowledge to 
the general population.'' He believed that the diffusion of 
knowledge and giving people knowledge would enable them to make 
the right decisions. Now, fake knowledge, misinformation, 
intentionally misleading information can also be disseminated.
    In this social media age with the internet, the competition 
between the true and the valid, and the fake and the dangerous, 
even the manipulated by people who want to do us harm is very 
difficult, but I think it is interesting probably both your 
mother and you reached your conclusions because you had an 
internet and tools to do your own research. And so, the 
different between, your mom and you, you are using some of the 
same tools and reaching different conclusions, but I applaud 
your critical thinking skills and your willingness to share 
your story.
    Mr. Lindenberger. Thank you. I do not want to go overtime, 
but just to comment on that very quickly, I think part of the 
issue is being able to inform people about how to find good 
information because with my mother it was not that she did not 
have the information, but she was manipulated into disbelieving 
it. And that is part of the attack, which is that the CDC was 
made out to be a fraudulent group that was pushing vaccines for 
its own demand and--but that is not the case and the evidence 
proposed is genuine. And so, I just want to comment on that.
    Senator Kaine. Thank you, Mr. Chairman.
    Senator Cassidy. My turn. Let me give some color to what 
Senator Paul said. You may or may not know I am a physician, 
and I have seen people who have not been vaccinated. Who have 
required liver transplantation because they were not, and or 
who ended up with terrible diseases because of no other reason, 
they just for whatever reason did not understand that 
vaccination was important. It is important to point out that 
even a flu shots are not completely effective, they do 
mitigate.
    There is a cross benefit that will decrease the severity, 
number one. Number two, hospitals commonly require their 
employees to be immunized because they understand that herd 
immunity is important, and if the nurse's aide is not 
immunized, she can be a typhoid Mary, if you will, bringing 
disease to many who are immunocompromised, as Mr. Boyle points 
out. And as regards to the Federal Government requiring, there 
is a Federal statute requiring that vaccine information 
statements should be given, that is a Federal requirement. And 
in the name of liberty we should rely therefore upon states and 
localities to make a further requirement, but they typically do 
require informed consent.
    That is important to note, not to be misled by--not to be 
misled regarding that. Secondly, I think our next--I think we 
should point out that in terms of requirement, the requirement 
is just that you cannot enter school unless you are vaccinated. 
Now, if you are such a believer of liberty, that you do not 
wish to be vaccinated, then there should be a consequence, and 
that is that you cannot infect other people.
    Mr. Boyle, if your child is born with immunodeficiency, and 
someone comes to your school who is not vaccinated, and the 
lack of herd immunity means that your child, who no fault of 
their own, cannot be immune, is it a victimless crime that 
somebody does not get vaccinated and your child dies? I mean, 
my gosh, you are the guy who is representing those people, who 
for whatever reason the vaccine does not work, and they are 
particularly susceptible. Now, Dr. Wiesman, I seem to remember 
a particularly tragic case in Washington State from about six 
years ago of a child who was immunocompromised on steroids 
chemotherapy for cancer, and someone brought measles to the 
school and I think I remember that child died. Do I remember 
that correctly?
    Dr. Wiesman. If we are talking about the same child, yes, 
he dies a number of years later from a follow-up reaction.
    Senator Cassidy. Now, so the parent has had the child 
vaccinated, but now she is on cancer chemotherapy and she is 
immunocompromised, and she is in school thinking that she can 
be a normal child, even though she is on cancer chemotherapy, 
but because someone else has made a decision not to vaccinate 
their child, her child dies. Now, do you believe in liberty? 
That is fine. Do not get immunized, but I do not think you need 
to necessarily expose others to disease. Dr. McCullers, tell 
me, you are in a state--you mentioned a practice where you have 
people from three different states, and hats off to 
Mississippi, they always have the highest immunization rate. 
You did not elaborate. What are the differences between the 
patients from these three different states in terms of, okay, 
Mississippi is always immunized, do you imply that maybe 
Tennessee and Arkansas are not?
    Dr. McCullers. Alright, so Mississippi does not allow any 
non-medical exemptions and they have nearly a 100 percent rate 
of immunization at school entry. They pay a lot of attention to 
it. Tennessee is in the middle. They allow religious exemptions 
but not philosophical exemptions. In Tennessee we have about a 
97 percent vaccination rate at kindergarten entry, but we have 
seen the rate of non-medical exemptions under religious 
exemption triple in the last 10 years, so you can predict where 
that is going. Arkansas on the other hand allows both religious 
and philosophical exemptions and has a rate that is around 93 
to 94 percent, below the level for community immunity.
    Senator Cassidy. In what state do you see the most vaccine-
preventable diseases, nonetheless, presenting themselves?
    Dr. McCullers. Well, all of these are rare, and we see them 
from all--we see things from all the states. Tennessee, we get 
about one a year measles case, always imported from outside the 
United States.
    Senator Cassidy. We have adequate herd immunity that would 
still protect even if people are coming in and bringing another 
disease?
    Dr. McCullers. To this point the problem is as you have 
seen in California, in Oregon, and Washington, is that there 
are pockets where it low and it could happen easily in 
Tennessee next week. Even though we are 97 percent, there is 
plenty of communities that are below that level, and we might 
see the outbreak in that community.
    Senator Cassidy. Now, Mr. Lindenberger, so obviously we 
have a bunch of Docs or people who I cannot help but notice 
that your beard is not as heavy as the other peoples'.
    [Laughter.]
    Senator Cassidy. This was not total--you do not have to be 
an MD or PhD, or a Master of Public Health to understand these 
issues, correct?
    Mr. Lindenberger. Correct.
    Senator Cassidy. You just need to bring your critical 
faculty to it, and look at it, and understand it is not just 
the individual who is affected but it is the individual whom 
the person goes to school with, correct?
    Mr. Lindenberger. As I have stated before, my decision to 
get vaccinated was based on the health and safety of myself and 
other people. And I approached my family physician. I spoke to 
her. She encouraged me to get vaccinated. Even at school, I was 
told I would not be able to attend if I did not get my vaccines 
but was opted-out. And so, my school viewed me as a health 
threat. And so that for me also pushed me to getting my 
vaccines despite my mother's beliefs because I saw the threat 
that was being imposed.
    Senator Cassidy. I am out of time, although I am the Chair. 
I will nonetheless defer to myself.
    [Laughter.]
    Senator Cassidy. But I thank you very much. And Mr. 
Lindenberger thank you for caring for the people you went to 
school with, as much as you cared for yourself.
    Mr. Lindenberger. Thank you.
    Senator Cassidy. I yield my time. Senator Hassan.
    Senator Hassan. Well, thank you Mr. Chair and Ranking 
Member Murray for having this hearing. Thank you all for being 
here. I had the great good fortune of having a grandfather who 
was a pediatrician, and he practiced medicine from 1921 to 
about 1985. And my childhood was filled with his accounts on 
the changes that he saw on the medical landscape over the 
course of his career. I still remember him describing what it 
was like to see somebody suffer from lockjaw, which is tetanus. 
The jaw locks, the swallowing stops, the breathing stops, the 
muscles spasm, and he was talking about what a difference it 
made when the tetanus vaccine became available.
    I remember my mother who had three children, youngest one 
born in 1960, remarking during my childhood that now that there 
was a vaccine against rubella, German measles, pregnant women 
did not have to worry nearly as much about going out of their 
house during pregnancy, accidentally contracting German measles 
which could be so damaging to the fetus.
    I think it is incumbent on all of us to remember these 
stories because a number of you have made the point that 
without this experience of what these diseases actually do and 
mean, we have gotten less vigilant as a society about the 
importance of this, the importance of vaccinations. Dr. Omer, I 
wanted to follow-up with you. You talked about the importance 
of work you are doing on helping pregnant women get vaccinated. 
We know that in the United States, almost all vaccines are 
administered to infants once they are at least 2 months old. 
So, for the first two months of their lives, infants rely on 
the antibodies of their mothers. The antibodies that moms 
transfer during pregnancy to protect them from preventable 
diseases or viruses such as the flu.
    We now that vaccines like the flu vaccine currently 
available, not necessarily the new ones you are working on, are 
critical for pregnant women and their babies. And we know that 
these populations face a greater risk of complications due to 
the flu, including premature birth delivery, hospitalization, 
or in severe cases, death. But astonishingly, only about half 
of women receive the flu vaccine during pregnancy. With infant 
and mortality rates reaching startling numbers in the United 
States in recent years, it is absolutely critical that we take 
basic steps to help protect women and babies during pregnancies 
and childbirth.
    Dr. Omer, what do you think is the leading cause for the 
lone number of vaccinated pregnant women, and what can we do 
moving forward to help improve these numbers and keep mothers 
and babies save?
    Dr. Omer. There are several causes, and there are only few 
women who are outright opposed to vaccines. And there is this 
huge gap, this huge groove, which is the fenceter groove. And 
so that is an opportunity to persuade, to educate, to have 
these meaningful conversations. So, in terms of how to 
intervene, we proposed a model called the P3 model. It is 
practice, provider, and patient. We changed it at the third P 
to pregnant women because pregnancy is not a pathology. It is a 
very physiological state to be in and we advocate for and 
evaluating strategies.
    There is emerging evidence that there is promise to this 
strategy to work with the practice, for example, things like 
standing orders, which use behavioral economic studies concepts 
to notch a practice into vaccinating, working on the supply 
side issues, working on physicians communications, and 
persuading pregnant women. In terms of the specific reasons, 
there is this focus on the baby. And so, we have found this is 
one of the other universal things, that mothers are both 
motivated to protect the baby, and scared to harm the baby. And 
as we generate safety evidence, which is very robust for 
influenza vaccine, we need to find better ways and evidence-
based ways, as I alluded to, to communicate to pregnant women 
as well.
    Senator Hassan. Okay. Well, thank you. And maybe what I 
will do then just with my limited time is also as, Dr. 
McCullers, as a practitioner, I am curious about how you go 
about communicating with parents who are having vaccination 
hesitancy? Among parents who choose not to vaccinate their 
children, what is their most common reason? And moving forward, 
what can we do to really help ensure that parents are educated 
about the importance of vaccinations?
    Dr. McCullers. Yes. It is interesting. 10 years ago there 
was one common reason and that was the fear of autism and these 
bad things. Right now, there is really a polyglot of reasons. 
They have all sorts of different minor concerns that come up. 
And so, the most important thing for a pediatrician to do, or a 
family practitioner, or an OB, is listen, understand, respect 
what those concerns are because they are different for every 
person.
    Senator Hassan. Right.
    Dr. McCullers. Then really individualize how you are going 
to approach that and what education you are going to give 
because there are a lot of concerns that are floating around 
out there, and we need to have an individualized message. So it 
is that rapport between the patient and the physician.
    Senator Hassan. The sharing of best practices, I would 
expect, among professionals about how to do this.
    Dr. McCullers. Absolutely. Directed at what their 
particular concern is, what that best practice is.
    Senator Hassan. Right. Thank you very much, and thank you, 
Mr. Chair.
    Senator Cassidy. Senator Smith.
    Senator Smith. Thank you, Mr. Chair and Ranking Member 
Murray, and thanks all of you for being here. I really 
appreciate it. So, in 2017, my home State of Minnesota 
experienced the largest measles outbreak that we had seen since 
1990, and between March and August of that year, we had 75 
cases of measles and 21 related hospitalizations.
    Of course, our State Department of Health, which is really 
a model for great Departments of Health, stepped in and did a 
really remarkable job working with children's hospitals and 
Hennepin County, and a whole range of other partners. So, Dr. 
Wiesman, I know you have been dealing with this in Washington, 
and some of my colleagues have gotten at this, but could you 
just tell us, summarize for us, like how best the Federal 
Government can be a good partner as State Departments of Health 
are dealing with these outbreaks?
    Dr. Wiesman. Great. Well, first of all I would say that the 
Centers for Disease Control and Prevention is amazing. They 
have lent us their technical experts around measles, and have 
actually sent people out to our state, in part based on our 
request. So that is incredibly important. I think again we need 
to be looking at how is it we get to the, as the CDC Director 
said in my state last week, how do we get to the hearts and 
minds of people around vaccines and to not put science on the 
shelf. We need to have this national conversation and national 
campaigns that is based on evidence and that we develop the 
evidence on how to best communicate. It is a response effort 
and it happens at the local level. I think we need to remember 
that, which means we have got to fund our local health 
departments adequately, so they have the staff resources to be 
able to respond. But actually, frankly, also to prevent these. 
Work with communities in advanced, these pockets of communities 
that have these unvaccinated folks.
    Senator Smith. This gets to another question related which 
is that in Minnesota when we saw this measles outbreak, we saw 
some communities that were disproportionately affected, and 
there was--in order to communicate and hear well the concerns 
and issues in these communities, it was important that we had 
culturally competent specific kinds of outreach. Can you talk a 
little bit about what you have seen that are good models in 
that area?
    Dr. Wiesman. Right. Well, I think the good model is having 
folks on your staff who are actually culturally diverse. Who 
know these communities inside and out as being really 
important. So, we have to have employees who reflect the face 
of the community, and that is a challenge for a lot of us and 
we are not there. And then I think it is really this community 
development outreach work, building the relationships with 
informal leaders in communities, whether they be church 
leaders, whether they be elders in tribal communities, 
whatever, those trusted folks there that people listen to, and 
engage them in health promotion work.
    Senator Smith. Thank you. Thank you. Would anybody else 
like to comment on that specific question of how we can have 
culturally connected outreach in this area?
    Dr. Omer. If I may add----
    Senator Smith. Yes, please.
    Dr. Omer. That that specific example stood out for many of 
us because that community was targeted for misinformation. And 
there were several visits by folks who were not particularly 
enthusiastic about vaccines, and so the response is also an 
example of to engage communities. So, the children's hospital, 
not just the health department, but other partners came 
together and worked with the community itself, to bring up the 
rates of vaccination. They have the tools which are evidence-
based, and one of the evidence-based tool is that you have a 
disease salient based approach. And you do not just talk about 
the vaccine, which you talked about, but the disease itself, 
because that is what it is what is all about.
    Senator Smith. Mr. Lindenberger, did you want to say--add 
to this?
    Mr. Lindenberger. I would also add that when you were 
talking about a diverse group of people also addressing 
specific communities, one thing I would address in a biased 
level at least, is that for young people, specially moving into 
adulthood with their decisions on a medical level, is extremely 
important because once you become of age, at least for me, most 
of my friends did not even understand that they could get 
vaccinated despite their parents' wishes. And once you move 
into living on your own and starting your career, still that 
push of explaining to young people that vaccines are important 
is especially important. So, I would just add that.
    Senator Smith. Thank you.
    Mr. Boyle.
    Mr. Boyle. If I may, just to add on to that as we are 
talking about the cultural issues here. One of the things that 
I found, while I love most of what the CDC and others provide, 
one of the pieces of the communication that I find missing are 
stories. There is precious little that really connects the 
person, if they are not swayed by facts, to the needs. And so, 
if someone's tia or aunty is receiving chemotherapy and is 
immunocompromised, tying it back to the personal in their 
community, I think is a piece that I have not seen much. And I 
think that as we talk about these sort of campaigns and needed 
next steps, that is another layer to add in to everything else 
that needs to happen.
    Senator Smith. Thank you.
    Senator Cassidy. Senator Casey.
    Senator Casey. Thank you, Mr. Chairman. I want to thank 
you, Dr. Cassidy, and Ranking Member Murray for presiding over 
this hearing. It is an important set of issues. I want to start 
with Mr. Lindenberger. I would like to be able to think that or 
believe that when I was--you are a senior in high school now? I 
would like to be able to believe that at that age, that I could 
do what you have done today. I think the answer to that is 
probably no. There may be some Members of the Committee that 
could have, but I am not one of them. Second, I wanted to say I 
know how difficult this would be no matter what age you are, 
what station in life, because it is a difficult topic and you 
also have a personal story to tell, which is difficult to even 
tell in private and let alone in a public setting.
    Thirdly, you have done something that we do not often do in 
Washington. This is a town where people are pretty good at 
demonizing and dividing, and we are really experts at being 
categorical that someone who disagrees with us is always bad. 
You have been able to be very clear about where you stand and 
what you believe, and bear witness to the truth without being 
categorical and without demonizing. So that is not only helpful 
for this topic, but it is instructive for the rest of us here 
in both parties in both Houses. I hope people are listening.
    I wanted to ask if you could share additional ideas about 
that you have developed over because of the experience you have 
had, as to how to effectively reach out to parents and address 
their concerns so that they are confident in the advice that 
their doctors--advice of their doctors--and do not hesitate to 
have their children immunized. You have spoken of this a little 
bit already.
    Mr. Lindenberger. Yes, thank you for that question actually 
because there is a really important distinction that needs to 
be made between the information provided as we discussed 
earlier, were people do not resonate well with information and 
data numbers, and they resonate better with stories. You see 
that with a lot of the anti-vaccine community, that a large 
portion of the foundation that they build to communicate with 
parents is on a very anecdotal level, sharing stories and 
experiences.
    That speaks volumes to people because, at least for even my 
family, my mom would reaffirm that her position was correct 
because she knows people and she has seen stories. But 
correlation does not equal causation and we do not know a lot 
of factors involved. And even though I could say that, that 
still does not resonate. And so, I have seen that a large 
portion of what we have missed, and to address your question 
even more accurately, just the stories of people suffering from 
preventable diseases. The stories of preventable diseases 
ravaging countries and nations is extremely important, and the 
side effects and complications that these diseases impose. Even 
when talking about measles, there is a huge misinformed belief 
that measles is not a dangerous disease that spreads around the 
anti-vaccine community. But measles is one of the biggest 
killers of young infants because of the dangers it imposes to 
young children. You see the upwards of an 80 percent of measles 
death in certain statistics are from children five and under.
    When convince parents that not that information is 
incorrect, but that their children are at risk, that is a much 
more substantial way to cause people to change their minds.
    Senator Casey. Thank you. That is helpful and I appreciate 
your testimony. I know we are a little low in time. I will just 
ask one more. Dr. McCullers, I want to get to the issue of 
prevention which we repeat over and over again is the best 
cure. We know that vaccines provide the best type of prevention 
not only for the individual, but for the population by way of 
herd immunity, as we have heard so often today. I guess my 
question for you though is, can you describe based upon your 
own experience, your own work, your own research, both in terms 
of your experience and research and in patient care, what are 
some of the both symptoms and the outcomes of typical vaccine-
preventable diseases for children and adults?
    Dr. McCullers. There is a wide spectrum depending on which 
disease you are talking about. Obviously, these are diseases 
that cause severe disease and death, or they would not have 
been targeted 50 years ago for and longer ago for elimination. 
I think one of the things that as physicians and as providers 
that we do not realize really how bad it was. You know, I 
trained at a time where haemopholis B, meningitis was a 
scourge. Or varicella, every kid got varicella and came in with 
chickenpox, and I can remember working in the emergency 
department and seeing three or four kids a night coming in 
almost comatose and with brain damage and some dying. That 
vaccine came in while I was in my pediatric residency, and the 
disease disappeared overnight. And so, trainees now do not see 
that and do not understand just how bad these vaccine 
preventable disease are because they have never experienced 
them.
    Senator Casey. Maybe because of the advancements.
    Dr. McCullers. Absolutely. I think that education piece and 
the ability to really spread that message that these really 
were terrible things and it is good that they were eliminated, 
and we have these vaccines, is important.
    Senator Casey. Thanks, and I have more questions for the 
panel, and we want to thank everyone for being here.
    Senator Cassidy. I thank everyone for participating. 
Ranking Member Murray, thank you. The hearing record will 
remain open for 10 days. Members may submit additional 
information for the record within that time if they would like.
    Senator Cassidy. Thanks for being here. The Committee 
stands adjourned.

                          ADDITIONAL MATERIALS
                          
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]









                      [STATEMENT OF SENATOR CASEY]

    Pennsylvania has worked hard to improve the percentage of 
toddlers up-to-date on their Measles, Mumps, and Rubella (MMR) 
vaccine from a recent low of 87 percent in 2012 to 93 percent 
in 2016. 1A\1\ This seemingly small change is crucially 
important, as measles is the most contagious serious childhood 
infectious disease and population vaccination rates need to be 
93 percent or higher to prevent community outbreaks. \2\ 
Keeping measles vaccine rates high is also essential for 
populations that are especially vulnerable, such as children in 
their first year of life (as the first dose can't be given 
until age 1), people with immune system disorders, and people 
taking medications that suppress their normal immune functions. 
And measles is not the only vaccine-preventable disease that 
regularly causes harm. The United States experienced 13,439 
confirmed cases of Pertussis (``whooping cough'') in 2018, 
including, and 10 children died as a result. \3\ Our health as 
a nation is dependent upon a robust system of immunization to 
keep us all healthy.
---------------------------------------------------------------------------
    \1\  https://www.health.pa.gov/topics/HealthStatistics/
HealthyPeople/Documents/current/state/iid-7-4-measles-mumps-rubella-
mmr-vaccination-coverage-level-children-19-to-35-months.aspx
    \2\  https://www.who.int/immunization/sage/meetings/2017/october/
2.--target--immunity--levels--FUNK.pdf
    \3\  https://www.americashealthrankings.org/explore/annual/measure/
pertussis/state/PA

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


[Whereupon, at 11:50 a.m., the hearing was adjourned.]

                                   