CDC Telebriefing: Report shows 20-year U.S. immunization program spares millions of children from diseases

OPERATOR: Thank you for standing by for today's conference. We will begin in approximately one to two minutes. Please continue to hold. Today's call will begin shortly.

OPERATOR: Welcome and thank you for standing by. At this time all participants are in a listen-only mode. After the presentation, we will be having a Q & A. To ask a question at that time, you may press star-1 on your touch tone phone and record your name when prompted. Today’s conference is being recorded. If you have any objections, please disconnect at this time. i would now like to turn the call over to Mr. tom skinner. Go ahead, sir. You may begin.

TOM SKINNER: Thanks, Sharon and thank you all for joining us today for this telebriefing on today's MMWR report on the benefits from immunization during the vaccines for children program era in the United States from 1994 to 2013. today we have the director of the Centers for Disease Control and Prevention, Dr. Tom Frieden, who will provide some opening remarks. And then turn the call over to Dr. Anne Schuchat, who is the director of the National Center for Immunization and Respiratory Diseases who will be available to answer your questions after the opening remarks. So I’ll turn it over to Dr. Frieden.

TOM FRIEDEN: Thank you very much for joining us. This year marks the 20th anniversary of the implementation of the U.S. Vaccines for Children Program, VFC. Since 1994 VFC has provided vaccines at no cost to uninsured children throughout the country and today we're releasing a report that shows that our national immunization program and VFC will save hundreds of thousands of lives and over $1 trillion. I’ll say a bit more about this report and then Dr. Schuchat will provide an update on measles which is, in fact, the disease that prompted the creation of the VFC 20 years ago. And I can say speaking personally, I joined CDC in 1990 in the midst of a resurgence of measles, a measles outbreak that caused over 100 deaths, more than 50,000 cases, and that affected children throughout the country and really was a wake-up call. It also impressed upon me just how infectious measles is because a single undiagnosed case in a hospital could result in dozens of secondary cases among health care workers or other patients who had come in for care at the same time. The program allows CDC to buy vaccines at a discount and to distribute them at no charge to more than 44,000 enrolled VFC providers across the country. To summarize the impact of the U.S. immunization program on the health of all children, both VFC eligible and VFC non-eligible children, CDC used information from a variety of sources and previously published models to estimate how many illnesses, how many hospitalizations and how many premature deaths were saved in this 20-year period and what we found was that for the 79 million children born in this 20-year period, vaccination over the course of their lifetimes, will prevent 322 million illnesses, 21 million hospitalizations, and 730,000 early deaths. In addition, the net financial costs saved because these illnesses will not occur are substantial. According to the report, use of the vaccination will avert $295 billion dollars in direct costs and $1.38 trillion-- with a "t" -- dollars in societal costs because of illnesses prevented in these cohorts. This is an enormous impact. It demonstrates why the VFC program is one of our country's most successful public/private partnerships to improve the health of our children and our country. By providing vaccine to public and private health care providers, VFC helps reinforce the medical home for children throughout our country and has helped bring about a fundamental change in how we deliver vaccines here. As a result, diseases such as measles and influenza type B are no longer common in the U.S. When I was a medical resident, it was very common to see children who were at risk of death from infections that are now virtually never seen in our hospitals. While the VFC program was implemented to help people who had a financial need, in fact, it's benefited everyone; because when vaccination rates go up, we are all safer. But we can't let our successes result in complacency. In fact, measles is still far too common in many parts of the world. Globally, an estimated 20 million people get measles and 122,000 die from the disease each year. And with more global travel and trade, diseases can spread faster than ever. Before I turn the call over to Dr. Schuchat to give more information about the current measles outbreaks in the U.S., I’d like to comment on how important it is that we in this country are engaged in working with other countries so that anywhere in the world where a new disease or an old disease like measles emerges, it's found quickly, stopped promptly, and prevented wherever possible. This is an initiative that CDC and others are leading called global health security. There is no way we can effectively protect Americans unless we strengthen systems to find, stop and prevent health threats around the world. and the measles outbreaks that Dr. Schuchat will describe in a moment are just one more illustration of that through the global health security initiative, we've focused on countries' abilities to do things like mobilize an emergency response within two hours, vaccinate at least 90 percent of people throughout their country against measles, and track new infections as they emerge so that we can find them quickly, stop them quickly where they're emerging before they destabilize and damage one country and before they become a threat to us here in the U.S. They’re a reminder of the importance of keeping our immunization strong. Borders cannot stop diseases any more, but vaccinations can. Dr. Schuchat?

ANNE SCHUCHAT: Thank you, Dr. Frieden and thanks, everyone, for joining today's call. Today’s MMWR includes a report detailing the measles outbreaks that have occurred in California. Measles has gotten off to an early and active start this year. I’ll briefly share the national perspective with you and then open it up for questions on both of the articles in today's MMWR. As of April 18th, 129 people from 13 states in the U.S. have been reported as having measles. This is the most measles cases reported in the first four months of the year since 1996. States and cities with the highest number of cases reported so far include California with 58, New York City with 24 and Washington State with 13. To date, 13 outbreaks have been reported, and we define an outbreak as three or more related cases. As Dr. Frieden mentioned, we're impacted by what happens globally. In cases of measles anywhere create a threat to us here in the U.S. 34 of the 129 cases reported so far here in the U.S. were importations involving both U.S. residents who traveled abroad and foreign visitors who came here. Seventeen, or half of those importations, were from the Philippines where there is a very large outbreak occurring with about 20,000 confirmed or suspected cases and 69 deaths through late February. So not direct imports. Most of the remaining cases are known to be linked to importation. While the story of the 1989 measles resurgence was one of poor children missing out on vaccines because they didn't have insurance, today's measles outbreaks are too often the result of people opting out. Most of the people, or 84 percent of the U.S. cases that are reported to have measles this year so far were not vaccinated or didn't know their vaccination status and of the unvaccinated U.S. residents, 68 percent had what we call “personal belief” exemptions or essentially opted out of being vaccinated. Because measles can spread so easily, pockets of unvaccinated people become very vulnerable once the disease is introduced. and, of course, in a population that's susceptible, those that are most at risk for the serious health complications for measles include infants who are too young to be vaccinated. As today's MMWR from California shows, health care settings can unfortunately be a place where measles spreads to unsuspecting victims. Back in 1989 to '91, busy emergency rooms were a hotbed of transmission. Today, fewer clinicians and parents are familiar with measles, and delays in isolation of suspected patients are a real challenge. Measles outbreaks in these settings like in emergency departments and doctors' offices can disrupt care of patients and put them at risk for severe disease. In response to exposures in health care settings can be very expensive and intensive. A single hospital-associated outbreak can cost hundreds of thousands of dollars for the health department and institution to deal with. We can't predict what we're going to see in the upcoming months and just how record breaking a year 2014 will be. 129 cases in the first four months of this year is more than we typically have, and health departments around the country today are working hard to stamp out the chance of transmission from the imported cases. Measles is making a lot of visits here this year, but we don't want it to take up residence. In today's world, we're interconnected across oceans, countries and continents like never before. With increasing travel, a country that's far away on the map can easily be the source of vaccine-preventable diseases within our own communities. Parents and health care providers should be vigilant about measles. But we would see far more cases and much larger outbreaks of measles if not for the very high immunization coverage we've achieved in thanks in part to the VFC program, combined with these rapid public health responses by our state and local colleagues who actively investigate every single suspect measles case. Outbreak responses are ongoing today, but we need clinicians and parents to do their part. CDC recommends two doses of MMR vaccine for everyone starting at age 12 months. But for those families who are planning international vacations and for anyone who's thinking of going to the Philippines, I want to remind you that infants six through 11 months of age are recommended to receive one dose of MMR vaccines before international travel and everyone else needs to be up to date on their measles vaccine. We need physicians and health care practitioners to be aware of the presenting symptoms and act swiftly to keep disease from spreading. They should promptly isolate patients with suspected measles to avoid disease transmission and immediately report the suspect measles case to their health department. Today at our website, you can see pictures of what the measles' rash look like, and we really want to encourage people to remember this terrible virus so that we can keep it from spreading. While it's always disappointing to report any outbreaks of vaccine-preventable disease, today's MMWR articles together provide perspective and underscore how hugely successful our nation's immunization program has been in protecting the health of our children and communities. We’re very grateful to the health care practitioners who are real immunization champions going above and beyond every day to keep people healthy and safe and next week as we celebrate national immunization week in conjunction with world immunization week, we'll be celebrating immunization champions in most of the states. The resurgence of measles in 1989 was a tragedy with over 100 people, mostly children, dying from an easily preventable disease. By creating the VFC, our country turned tragedy into epic success. But we can't be complacent and need to take the threats coming in on airplanes every day seriously. So I think we can take questions now, Tom?

TOM SKINNER: Yes, Sharon, we're ready for questions, please.

OPERATOR: Thank you. We will now begin the question and answer session. If you would like to ask a question, please press star-1 on your touch tone phone and record your name when prompted. That is star-1 for a question; you may withdraw your request by pressing star-2. One moment, please, for our first question. Our first question comes from Eben Brown of Fox News Radio. Go ahead, sir. Your line is open.

EBEN BROWN: Thank you and good afternoon, doctors. Either of you may take this. I’m wondering how much of a thorn in your side are certain celebrities like Jenny McCarthy who advocate no vaccinations for children for various reasons?

ANNE SCHUCHAT: You know, celeb -- this is Dr. Schuchat answering. Celebrities do get a lot of attention, but I want to stress that the most important influence on parents' decision about vaccination is their clinician, their doctor, nurse, and pharmacist. These are the people they trust and respect to know what's going on with vaccine-preventable diseases and to know about the vaccines themselves. We think it's critical for our nation's providers to be well informed and comfortable having those conversations with parents and we know that nearly all parents are vaccinating their kids. You know, it's less than 1 percent of toddlers that have received no vaccines at all. Vaccinating your children is still a social norm in this country, and we think that's a good thing. Next question?

OPERATOR: Our next question comes from Alok Patel of ABC News. Go ahead, sir. Your line is open.

ALOK PATEL: Hi, I’m calling from ABC News in New York City. Thank you so much for all the great information. One topic I wanted to ask about is- you spoke about the international cases of things such as measles, and I’m citing a report from the CDC about the two adopted orphans from China that brought over cases. And the highlight of that article for us was that the Department of State has regulations in that kids under the age of 10, I believe, are exempt of vaccination if their birth parents agree to get them vaccinated within 30 days of arrival. Is that something that's going to be addressed in the future in an effort to prevent those imported cases?

ANNE SCHUCHAT: Pre-departure vaccination is really critical to keep infectious diseases out of the country. And there's been progress in working across the different parts of government and with provider organizations overseas. So that we can protect children in the countries where they're living as well as before they immigrate here. So I think that gap you're identifying is something we would expect to be looked into. Thank you.

ALOK PATEL: Thank you.

OPERATOR: Our next question comes from David Beasley of Reuters. Go ahead. Your line is open.

DAVID BEASLEY: Yes, I have two questions. Have there been in deaths in the U.S. this year from measles? And also, is there any connection between relief workers traveling back and forth to the Philippines at all and the spread of measles from the Philippines?

ANNE SCHUCHAT: Thank you for those really good questions. The last time we had a reported death from measles in the U.S. I believe was in 2005. So we're grateful that we haven't had a death from measles so far this year. But unfortunately, it's probably just a numbers game. Probably just a matter of time till we have more. We know that in affluent populations, measles doesn't kill that frequently, but about 1 out of every 1,000 or so cases can be fatal. And we really don't want to get to the point where babies or young children are dying again from measles here. Sorry about that.

Your second question was about relief workers. And I really want to stress this. We know today relief workers, students, so many people are interested in overseas work, travel for leisure, for humanitarian purposes. It's crucial that they make sure they're up-to-date on vaccines including measles. And we are very concerned about the back-and-forth with the Philippines which is, of course, a place where we have great collaborations and relations. People don't think about getting their measles up-to-date before they go to the Philippines, and they really need to think about that now, given the number of imports we have so far.

So, again, a strong reminder, wherever you're traveling, to think about getting yourself caught up with measles. And if you have young children who are under a year of age, they wouldn't typically be vaccinated here in the U.S. till they hit 12 to 15 months. But if you're going overseas, please get your children a dose of vaccine if they're at least six months of age. Next question?

OPERATOR: Our next question comes from Liz Szabo of USA Today. Go ahead, ma'am. Your line is open.

LIZ SZABO: Hi. Can you tell me, how many children are vaccinated to the Vaccines for Children's program each year and what's the annual budget for that?

ANNE SCHUCHAT: Yes, thanks. The VFC program covers children who are uninsured, Medicaid eligible, American-Indian and Alaska Native, as well as underinsured children whose insurance doesn't cover vaccines. In 2014, that's about 50 percent of all kids under 19 years of age in the U.S. The VFC budget most recently is around $4 billion a year. Most of that is the purchase of vaccines. The vaccines are provided to about 45,000 providers who can vaccinate on site children who are eligible for the VFC program. So CDC is buying about 90 million doses of vaccine every year, most of it for the VFC program and vaccinating to achieve high coverage in both VFC eligible and then, of course, non-VFC-eligible kids through their private insurance. Next question?

OPERATOR: Our next question comes from Mike Stobbe of AP. Go ahead, sir. Your line is open.

MIKE STOBBE: Hi. Thank you for taking my call. I had two questions. First, Dr. Schuchat, I just wanted to confirm, the last case of measles death in the United States was 2005 or 2003? My second question was, you mentioned in response to that question about celebrity, that the number one influence on parents is doctors. But given this trend of more exemptions, do you have any survey data among physicians which indicates that more of them are becoming ambivalent about vaccinations?

ANNE SCHUCHAT: I’m going to need you to repeat part of the second question. The first question was the last year that we had a confirmed measles death. And a table that I’m looking at says 2005. But let us verify that for you because it may be that that might have been one of the ones when we got the data cleaned, it turned out not to be the case. We'll confirm that with you after the call. But we really haven't had very many deaths from measles for quite a few years since the 1989 to '91 resurgence. We've had, in most years, zero deaths. In other years, one or two. Okay. The second question was -- I didn't quite catch. Was it about the providers?

MIKE STOBBE: Yeah. Right. It's about providers. You know, if they're the leading influence on parents and if we see the small but important trend of more parents getting exemptions for their children from school-entry vaccination requirements, does it follow that there are more physicians who are growing ambivalent about the more vaccination or maybe agreeing to space it out? Do you have any polling data of clinicians on that question?

ANNE SCHUCHAT: We do have some polling data on clinicians with how highly they rank the importance of different vaccines, and they consider MMR very, very important. And in general, we believe are still strong proponents. That said, today's clinicians are likely to have come of age, gotten their training in a period where there wasn't that much measles. They may not know what a rash of measles looks like because fortunately they never had to take care of a child with measles. While we know that they are strongly recommending vaccines, that familiarity that comes with having somebody with a life-threatening illness could be diminishing. You know, that's a good thing that we don't have that much of it, but it may, over time, diminish the commitment that people have.

I would say so far America's pediatricians and family physicians and nurse practitioners who care for young children are extremely strong advocates for strong immunizations like MMR. This was in contrast with some European countries where when parents had questions over its vaccines, it really reduced. I think America's clinicians are still strongly supporting adherence with recommendations. We, though, at the CDC have been trying to make sure they're well equipped with tools for how to have the conversations about vaccines and with the facts about myths and the real story. Next question, please?

OPERATOR: Our next question comes from Erin Sykes of NBC News channel. Go ahead, ma'am. Your line is open.

ERIN b: Hi, good afternoon. Thanks for taking my call. Two questions. Do you have any information or a number you can provide on the number of Americans who have exempted from vaccines for personal beliefs? And could these cases of measles, are they -- could the exemptions with the MMR vaccine be related to the mumps outbreak that we are also seeing in this country?

ANNE SCHUCHAT: We don't track exemptions in the general population, but we track exemptions at kindergarten entry. And that is something that we reported in the August MMWR from 2013. This varies state by state in terms of what percentage of kindergarteners are exempting from various vaccines. In the MMWR, I believe we reported state by state what the measles exemption rates were. About 95 percent of kindergarteners in that report had documented measles vaccination. Some of the exempters would be from medical exemptions, and in some states, other types of exemptions are allowed. So there's a variation state by state. Many states had very low, less than 1 percent, exempters.

Your second question was about mumps and whether that was related to exempters? You know, in the measles story, very much it's a case of importation from other countries and finding unvaccinated people where exempters dominate. With mumps, in general, it's a different story where we're seeing these outbreaks in colleges and other very crowded environments. Mumps vaccine is good -- or the MMR mumps component, it's a good vaccine, but it's not a great vaccine component. So it doesn't have as high efficacy as the measles, for instance. So we do see more people who get mumps despite having the recommended two doses of vaccine. That doesn't mean that we don't have lots of people in these mumps outbreaks who aren't vaccinated. But in these outbreaks, some of the people have gotten all the doses they were supposed to, and they're still getting measles. It's those crowded college environments or other kinds of school settings where we have seen some mumps outbreaks. But again, these are relatively small, hundreds at this point, not the thousands and thousands and thousands of cases we would see with lower vaccination rates than we have. Next question?

OPERATOR: Our next question comes from Robert Lowes of Medscape Medical News. Go ahead, your line is open.

ROBERT LOWES: Thanks so much for taking my call. I’m wondering, given the fact that we do have this trend of parents getting exemptions, and with clinicians, as you say, still being committed to, you know, vaccination, has the CDC considered any action that it can take to reach out directly to the public? It seems like there has been, you know, the continued problem with the exemptions. And I’m wondering what the CDC is going to do about it.

ANNE SCHUCHAT: Yes, thank you. We do a number of things here at CDC to support a strong immunization system in the U.S. It's very much a public/private partnership with CDC and the public health departments at state and local levels providing information, response, vaccine, for instance, for the VFC eligible. But the private sector clinicians are absolutely crucial in protection of kids against vaccine-preventable diseases. So we have really focused attention on support, you know, educational support, materials and tools for clinicians, while we also do PSAs and public-directed outreach. Most of that outreach is just to remind people about vaccines and to encourage them to talk with their clinicians because in the research we've done, we found that the most powerful influencers are the ones closest to you. Your doctor, your nurse, sometimes family members. But very much the people who know you and your children. We at the CDC wish we knew all your children, but we really don't. So we want to make sure that those who are closest to you have the best information possible. That's our strategy, in general. Next question?

OPERATOR: Our next question comes from Leonard Bernstein of Washington Post. Go ahead, your line is open.

LEONARD BERNSTEIN: thanks a lot for taking my question. If you're a teacher or a parent with a kid in child care or even a physician, say, in a private practice and you know that regularly you have unvaccinated children coming into a setting where there are other young children around, what should you do? How should you handle that?

ANNE SCHUCHAT: Yeah. You know, if you have -- if you're a clinician and you have someone -- a parent calls up and says my child has a rash, my child has a high fever and hasn't gotten vaccinated against measles, it's important to separate that child from others. You know, to have them come through a different entrance, to not have them seen at the same time in the waiting room as others who are vulnerable, particularly babies under a year of age because that infection can be spread. We have a really nice information sheet on our website that's directed for parents who don't vaccinate their kids that goes into the roles and responsibilities that you have as a parent to, you know, to protect your child from harm, but also to protect others. Things like remember to tell the ambulance driver that your child hasn't been vaccinated. That ambulance driver won't even think of the differential of measles or other vaccine-preventable diseases because it's so rare to not be vaccinated. So we think there's a responsibility that the parents can take as well as, of course, the clinicians and waiting rooms. These days in emergency rooms and other health care settings, it's important to have triage routing that will keep people who are potentially infectious away from others. It's very important in respiratory illness to do that. You know, when we're dealing with contagious diseases. So we hope that hospitals are adopting those good practices, and we know that the pediatrics offices used to be really good at this when measles was common. And they might have gotten out of practice. We have some reminders about good infection control and isolation practices that are on our website.

LEONARD BERNSTEIN: What about in child care or school settings?

ANNE SCHUCHAT: Right. In general, there are recommendations about when you should keep your child home from school. One of the really challenging things with measles is that you can be infectious before the rash even shows up. So you can be infectious four days before the visible onset and four days after. And so this is why -- I think a lot of parents are shocked about that. They think I don't know if I really wanted to vaccinate my kid, but I’ll keep my kid away from other people. But they don't realize their child could be infectious before they have any symptoms. And so the best answer to that is to get your children vaccinated fully against everything. Because we know parents want to keep their kids healthy, and most parents don't want to hurt anybody else's kids either. Next question?

OPERATOR: Our next question comes from Michael Smith of Medpage Today. Go ahead, sir. Your line is open.

MICHAEL SMITH: Yeah, thank you. I just wanted to confirm, Dr. Schuchat, you said half of children under 18 are eligible for VFC?

ANNE SCHUCHAT: That’s correct, correct. At present our best estimate for the most recent year is that 50 percent of children under 19 are eligible for VFC. Eligibility is determined at the point of care by the clinician who asks a series of screening questions and then if the child is eligible, can administer VFC or vaccine that's been provided for free to that child. That's right. And you know, the VFC program is really has been an incredible success over this past 20 years with that over 300 million illnesses prevented and over $1 trillion saved.

MICHAEL SMITH: Okay.

ANNE SCHUCHAT: Really extraordinary benefit for both the children who were entitled and then the rest of the country in terms of higher vaccination rates, lower health care costs for all the diseases we're preventing, and then, you know, healthier kids.

MICHAEL SMITH: Just a follow-up, because I want to make sure that I understand those numbers in particular, the entire universe of children over that time period, not just the VFC-eligible children, am I correct?

ANNE SCHUCHAT: That’s right, yes. The model that we did didn't differentiate VFC and non-VFC, but the VFC program itself was associated with a return of immunization to the medical home. Instead of children who didn't have insurance having to go to another place like a health department to get vaccinated, they could be vaccinated right in the pediatrician's office. And that meant that quality of care and integrated care and coordinated care was strengthened. Some kids will be VFC eligible one year and not the next year. Continuity of care got better. So the way we chose to model the full program impact was not only on eligible children but on all children, because it's really a reinforcing program. The provision of vaccine for uninsured children to help overcome that financial barrier was a fantastic -- it's an advance. But at the same time, we've been able to really strengthen vaccination of all children. Providers with more knowledge, providers with the tools they have to take care of the kids in their practice. And, you know, the education and other supports that go with that. So as a country, we all suffered when there was a measles resurgence in 1989 to '91. But the families that suffered most were the most disadvantaged ones. And now I think we're all benefiting by a much stronger system through the VFC and the other supports that the public/private partnership has. Time for just two more questions.

OPERATOR: Thank you. Our next question comes from Sabriya Rice from Modern Healthcare Magazine. Go ahead, your line is open.

SABRIYA RICE: Good morning. Thank you very much for taking my question. I was curious, you had mentioned measles and outbreaks of mumps. At the end of last year, I believe there were also reports of pertussis. I was curious to -- if there are other conditions that we've seen cases of in the U.S. This year besides measles.

ANNE SCHUCHAT: Yes, that's right. We haven't eliminated all vaccine-preventable diseases from the U.S. There's some like measles and polio where we've eliminated the viruses from the U.S. And what we see -- we don't see polio, but what we have seen with measles is imported cases that can spread for one or two generations of spread. But we do continue to have some disease besides pertussis and mumps, as you said. We have -- continue to have low rates of rotavirus disease, low rates of pneumococcal disease, very little hepatitis A. We do continue to have influenza. We do continue to have hepatitis B, particularly among adults. But most of the vaccine-preventable diseases right now are at record low levels. The exception is pertussis right now as the major exception to that. You know, for chicken pox, we're 90 percent reduced from what we were before the vaccines were available. So it's really a pretty remarkable story. The MMWR does go through disease by disease for the vaccines that were included in the analysis just how many hospitalizations, deaths and illnesses have been prevented. With measles alone, we think in this 20 years of children vaccinated, about 71 million measles cases have been prevented -- I’m sorry -- yes, 71 million measles cases. And about 89 -- 8,000 -- 8,900,000 measles hospitalizations. So really extraordinary, what we are able to achieve with vaccinating compared to not vaccinating. Last question?

OPERATOR: Our last question comes from Elizabeth Mechcatie of Pediatric News. Go ahead, your line is open.

ELIZABETH MECHCATIE: At the end of the report on the measles outbreak in California, the report recommends that all U.S. Residents born after 1956 should ensure that they've received the vaccine or have serologic evidence of measles immunity. Is that something that clinicians should be doing, making sure their patients have been tested? Including internists and family physicians?

ANNE SCHUCHAT: You know, it's a tricky time right now because we have a lot of adults who really don't remember what they got, whether they had measles, whether they got one or two doses. And we're seeing cases in those people. So that's why we have intensified our recommendations about who needs to have immunity documented. Now, for health care workers, for instance, we have the highest standards. They have to have serologic proof. Even if they have a history of-- or remembering they had measles or of getting two vaccines, they're supposed to have serologic proof at the health care facility to be sure that they had a good take from the vaccine and so forth. So we are -- we do have higher standards than we used to. And I would say if you're about to travel and you really don't know, get another dose. You know, at this point, if you're going to the Philippines and you are not exactly sure, an MMR dose may keep you safe and keep you from not being able to do the work or the play that you're trying to do in the Philippines and help you be safe when you come home. The full details of who needs what and what immunity is are on our website with a link to the ACIP recommendations. So I encourage people to take a look at that. So just in closing, I want to thank everybody for participating, and I want to just remind you that we've heard about this extraordinarily successful childhood immunization program and the 20 years when the Vaccines For Children Program was making it easier and easier for parents and clinicians to make sure everybody was vaccinated appropriately. But we've also heard about measles importations, an outbreak in California, and ongoing investigations in health departments around the country, reminding us that we cannot be complacent. Measles has made a lot of visits, but we don't want it to take up residence here. So thank you all.

TOM SKINNER: Sharon, this concludes our call. Thanks to all for joining us. If you have follow-up questions or need additional information, you can call the CDC press office at 404-639-3286. Thank you once again for joining us on this call.

OPERATOR: This concludes today's conference. Thank you for your participation. You may now disconnect.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES