2019 AIMLeadership In

Action Conference

#AIM2019

Thank you to AIM’s Corporate Alliance Program members

INSERT NAMES/OR LOGOS

Conference Planning Committee

#AIM2019

• Shannon Bennett (NV)• Shauntrelle Chappell (CDC)• Aaron Dunn (OR)• Phil Griffin (KS)• Tim Heath (SD)• Jan Hicks-Thompson (CDC)• Molly Howell (ND)• Sarah Leed (ID)

• James Lutz (Philadelphia)• Tom McCleaf (PA)• Dave McCormick (IN)• Tonya Philbrick (ME)• Gred Reed (MD)• Mark Ritter (TX)• Lynn Treferen (CO)

Leadership Institute Advisory Board

#AIM2019

• Shannon Bennett (current PM Nevada)

• Marcelle Bobinsky (Executivedirector, KV Foundation, LC; former PM, New Hampshire)

• Steven Bors (current PM New Jersey)

• Lorraine Duncan (former PM, Oregon)

• Michele Roberts (current PM, Washington state)

• Laurel Wood (IAC; former PM, Alaska

Stacy HallProgram Manager, Louisiana

#AIM2019

Welcome to Louisiana

Purple matches everything

Gold is a neutral color

Welcome AIM!

Dear America,

I suppose we should introduce ourselves:

We’re South Louisiana … You probably already know that

we talk funny and listen to strange music and eat things

you’d probably hire an exterminator to get out of your

yard. We dance even if there’s no radio. We drink at

funerals. We talk too much and laugh too loud and live

too large and, frankly, we’re suspicious of others who don’t.

--Chris Rose

Welcome home!

Second Lines

Gumbo of cultures: Native American, French, Spanish, German

African, Irish, Acadian…

All the words run together

Howsyamommaanem?

Sounds like “homonym”

What you’re being asking is: “How is your momma and them?”

The “them is your family, but your momma’s the important one.

Never “getting ready” to do something

You’re “fixin’ to”

You don’t “grocery shop”

You go “make groceries”

“What ya’ doin’ today?”

“I’m gonna go make groceries.”

“I’m fixin’ to do that too.”

“Come see” means “come here”

“Put up” the toys, not “pick up”

“Take off the lights” instead of “turn off the lights”

In other places they’re: sneakers, trainers, or tennis shoes,

Here they’re just “tenny shoes”

Bet I know where you got those shoes?

Don’t say “how’s it going?” we ask “where y’at?”

You may want to say I’m standing right in front of you, but that

would be incorrect

You’re really being asked, “Where are you in your life?”

“Marie, I ain’t seen you in ages, where y’at?”

Don’t “cheer,” you yell, “who dat?!

Phrase has a long origin that was revived when the Saints won the

Super Bowl in 2009

It can be used as any exclamation!

Supervisor: “You’re being promoted.”

Employee: “Who dat?!”

Beaucoup (boo-koo) means “big” or “a lot”

French word "Cher" means dear one

"Sha" means exactly the same thing. It's used interchangeably with:

dear, honey, babe, sweetheart or with anyone…

You don’t get something extra as thanks from a merchant, you get

“lagniappe” (lan-yap)

Saying: Y’all come back now.”

“Dressed”

This has nothing to do with clothing and everything to do with

how you want your po’boy (a sandwich served on French bread)

When you order, you’ll be asked if you want it dressed, which

means with lettuce, tomatoes, pickles, and mayo

Shrimp, oyster, catfish, sausage, debris (leftovers of roast beef),

rabbit, duck, potato po’boy which are thick french fries with

generouse gravy….

Don’t say ‘this is good”

Say “It’ll make you slap your momma.”

“ya granma” is interchangeable, but please keep in mind there

isn’t any real slapping involved

Means you actually like something

Customer: “Is the gumbo good?”

Server: “It’ll make you slap yo mama.”

“Louisiana has the best food on the planet if you don’t really ask

too much about what you’re eating.”—Jeff Foxwood

“Fais-do-do” (fay-DOUGH-DOUGH) is a Cajun dance party. It

literally means “to go to sleep,” and it originates from parties

lasting so late into the night that the children would fall asleep

on their own without being told.

A baby being put to sleep is told “go do-do.”

Let's say a friend gives you home and you want to invite him

inside for a beer or a Coke. You would not ask him to come in, but

rather “Ya get down?”

Gris gris (gree gree) is a Voodoo term, but normally used in fun

with an undertone of warning. You may hear, “You better do

what your momma tole you or she’s gonna put a gris gris on you.”

Challenges

Subsidence

½” per year, 4 times higher than the global average

6’ below sea level

Poverty

1/5 people in Louisiana live in poverty

Childhood poverty is almost twice the national average

Some parishes, it’s about half of the children

Here your zip code matters as much as your genetic code

Directions

French Quarter

Borders: Mississippi River, Rampart,

Canal Street, and Esplande

East Bank of the Mississippi River

West Bank, last exit is Tchoupitoulas

(chop-ah-TOO-liss)

Marigny: MA-ruh-nee

Treme: trem-MAY

Calliope: CAL-ee-ope

Burgudy: ber-GUN-dee

Euterpe: YOU-terp

Melpomene: MEL-poe-meen

Terpsichore: TERP-suh-kore

French Quarter aka Vieux Carre (voo-kuh-RAY)

Brieux Carre Brewing in the Marigny on Decatur Street

Crawfish: CRAW-fish

Praline: PRAW-leen

Muffaletta: muff-ah-LOTTA

Beignet: BEN-yay

Café au lait: hot milk with chicory coffee

Pecan: (pah-kahn)

New Orleans

Name of this city is:

noo OAR-linz

noo-AW-lins

Never, noo-oar-LEENZ

So the parish is…?

“New Orleans makes it possible to go to Europe and

never leave the United States.”—Franklin Roosevelt

“Pass a good time”

means to have fun

Stacy Hall

504-232-9622

Michele RobertsProgram Manager, Washington

#AIM2019

Dr. Melinda WhartonDirector

Immunization Services Division, National Center for Immunization and

Respiratory Diseases,Centers for Disease Control and

Prevention

#AIM2019

Dr. Walter OrensteinAssociate Director

Emory Vaccine Center

#AIM2019

A Diagonal Approach – Eliminating Measles and Building Health Systems

Walter A. Orenstein, M.D.Professor of Medicine, Pediatrics, Epidemiology, and Global HealthAssociate Director, Emory Vaccine CenterDirector, Emory Vaccine Policy and Development

Leadership in Action ConferenceAssociation of Immunization Managers (AIM)New Orleans, LA

December 10, 2019

No conflicts to disclose

Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases

Disease

20th Century

Annual Morbidity†

2018

Reported Cases † †

Percent

Decrease

Smallpox 29,005 0 100%

Diphtheria 21,053 1 > 99%

Measles 530,217 273 > 99%

Mumps 162,344 2,251 99%

Pertussis 200,752 13,439 93%

Polio (paralytic) 16,316 0 100%

Rubella 47,745 5 > 99%

Congenital Rubella Syndrome 152 0 100%

Tetanus 580 20 97%

Haemophilus influenzae 20,000 27* > 99%

† JAMA. 2007;298(18):2155-2163† † CDC. National Notifiable Diseases Surveillance System, Week 52 (2018 Provisional Data), Weekly Tables of Infectious Disease Data. Atlanta, GA. CDC Division of Health Informatics and Surveillance, 2019. Available at: www.cdc.gov/nndss/infectious-tables.html.Accessed on January 4, 2019.* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 11 cases of Hib are estimated to have occurred among the 221 notifications of Hi (< 5 years of age) with unknown serotype.

2/27/2019CDC: Sandra Roush

Comparison of Pre-Vaccine Era Estimated Annual Morbidity with Current Estimate: Vaccine-Preventable Diseases

47

DiseasePre-Vaccine Era Annual

Estimate2016 Estimate

(unless otherwise specified)

Percent Decrease

Hepatitis A 117,333 † 4,000 * 97%

Hepatitis B (acute) 66,232 † 20,900 * 68%

Pneumococcus (invasive)

all ages 63,067 † 30,400 # 52%

< 5 years of age 16,069 † 1,700 # 89%

Rotavirus (hospitalizations, < 3 years of age)

Varicella

62,500 † †

4,085,120 †

30,625 ##

102,128 ###

51%

98%

† JAMA. 2007;298(18):2155-2163†† CDC. MMWR. February 6, 2009 / 58(RR02);1-25* CDC. Viral Hepatitis Surveillance - United States, 2016

# CDC. Unpublished, Active Bacterial Core Surveillance, 2016## New Vaccine Surveillance Network 2017 data (unpublished); U.S. rotavirus disease now has biennial pattern### CDC. Varicella Program 2017 data (unpublished)

1/11/2019CDC: Sandra Roush

Partners in the Immunization Effort

• Academic and other researchers

• Vaccine manufacturers

• Policy makers

• Public and private vaccine deliverers

• Third party payers

• Federal, State & Local agencies

• Political leaders

• Parents

• Many others

Topics to be Covered

• Horizontal, vertical, and diagonal

• Measles background

• US efforts to eliminate measles and it’s impact on overall immunization system

– The role of science and the role of politics

• Why can measles elimination be an incentive for health system strengthening?

• Are we ready for global eradication?

Horizontal, Vertical, Diagonal

Vertical – focused, proactive, disease-specific interventions on a massive scale

Horizontal – more integrated, demand driven, resource sharing health services

Diagonal – proactive, supply-driven provision of a set of highly cost-effective interventions that bridge health clinics and homes

Sepulveda J, et al. Lancet 2006; 308:2017-2027

Horizontal

V

e

r

t

i

c

a

l

Key Characteristics of Measles

• Highly contagious – most infectious of the vaccine-preventable diseases

• Distinct clinical syndrome

• Virtually all cases clinically apparent

• Good diagnostic tests

• Episodic in nature– Epidemics followed by low incidence as susceptibles accumulate

fueling next epidemic

• Substantial complications including hospitalizations and deaths

Making it an indicator disease for immunization programs

52

Community Immunity Threshold (%)

=

𝑹𝟎 − 𝟏

𝑹𝟎

Fine PEM, et al. Chap 77 -Community Protection in Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin’s Vaccines, 7th

edition, Elsevier, 2018, 1512-1531

Complications from Measles

United States Developing World

Otitis Media 7 – 9% Death 2 – 15%

Pneumonia 1 – 6% PneumoniaMost common cause

Diarrhea 8% Diarrhea2nd most common cause

Post-infection encephalitis

1 – 4 per 1,000 – 2,000 cases

Blindness in areas with Vitamin A deficiency

SSPE1 per 2,500 – 10,000 cases

Estimated to cause more than 100,000 deaths annually

Death 1 – 3 per 1,000 casesNeurological complications

1 – 4 per 1,000 cases

From Strebel PM, et al. Measles Vaccine, Plotkin’s Vaccines, 7th edition, Elsevier, 2018

Epidemiologic Basis for Eradication of Measles in 1967†

• Virtually universal infection

• Reservoir is humans, no non-human reservoirs

• Chronic carriers do not exist

• Transmission dependent on balance between immunes and susceptibles

• Transmission dies off before all susceptibles exhausted

• Herd immunity threshold –

estimated to be 55% based on

data from Baltimore

† Public Health Reports1967; 82:253-256

Initial Strategy for Eradication of Measles in 1967 †

• Routine immunization of infants

• Immunization on school entry

• Surveillance

• Epidemic control

† Sencer DJ, Dull HB, Langmuir AD. Epidemiologic Basis for the Eradication of Measles in 1967. Public Health Reports 1967; 82:253-256

The Vision Behind Initial Attempts to Eradicate Measles in the United States

• First new vaccine (licensed in 1963), since establishment of the 317 Program in 1962 legislation

• Desire to build a more vigorous domestic immunization program

• Worldwide eradication not in initial vision

Impact of Initial Measles Eradication Program 1966-1968

• >90% reduction in measles cases

• >500,000 reported cases annually in pre-vaccine era to 22,000 in 1968

• Actual cases in pre-vaccine era in the millions, many unreported

• With improved reporting in the vaccine era, actual reduction likely much greater than 90%

• Funding for measles eradication program switched to rubella

0

50

100

150

200

250

300

1965 1967 1969 1971 1973 1975 1977

Re

po

rte

d C

ase

s (T

ho

usa

nd

s)

Year

MEASLESReported cases, by year, United States,

1966 - 1977

Data from CDC, Epidemiology & Prevention of Vaccine Preventable Diseases, 13th Edition, Appendix E-3 (April 2015)

Accumulating Knowledge1969-1977

• Smallpox was being eradicated with “an outbreak control strategy”

– Could measles be eradicated with a similar strategy?

• Demonstrating measles could be eliminated from the US could set the stage for potential worldwide eradication

• School laws make a major difference in controlling measles

• Need for continuous source of funding

• Surveillance documented a change in age pattern with a greater proportion of cases in middle and high schools

• Political leadership critical for success

Key Differences Between Smallpox and Measles

Clinically distinctive illness Yes No

Contagiousness Ro 5 – 7 Ro 12 – 18

Herd immunity threshold 80 – 85% 92 – 94%

Spread prior to rash Rare Common

Effective 1 dose intervention

†††† ††

Differentiate vaccine successes vs. failures

Yes No

Smallpox Measles

Measles, Los Angeles - 1977†

Mid January – outbreak detected

Mid March – 2 deaths, 3 encephalitis cases, multiple pneumonia cases

March 31 – school exclusion order issued for May 2nd, if no measles immunity

April – clinics in most schools, night and weekend clinics

May – ~50,000 / 1.4 million students excluded within days, most back in school

† Orenstein WA, Hinman AR. Vaccine 1999; 17:S19-S24

1978 ‡

Measles in 6 States Strictly Enforcing School Laws vs. Other States*

* MMWR 1978; 27:303-4† per 100,000 < 18 years‡ 1st 31 weeks

‡ ‡ Alaska, Colorado, Hawaii, Maryland, New Mexico, South Dakota

1975-76 1977

6 states ‡ ‡ 47.0 40.6 2.7

Other states 50.4 90.3

Measles incidence †

35.2

Measles Cases by Age Group United States, 1976-2000

0

5

10

15

20

25

30

35

40C

ase

s (t

ho

usa

nd

s)0- 4 yrs

5-19 yrs

>19 yrs

Figure 4

From: Hinman AR et al. JID 2004; 189 (Suppl 1): S17-S22

Political Leadership - 1977

Mrs. Betty Bumpers –First Lady of Arkansas

Mrs. Rosalynn CarterFirst Lady of Georgiaand later First Lady

Senator Dale BumpersSecretary JosephCalifano, Jr.

Childhood Immunization Initiative - 1977

• Attain 90% immunization level in the Nation’s children by October 1979

• Establish a permanent system to vaccinate the birth cohort each year

• Focus on enactment and enforcement of comprehensive school laws

1978 93(3): i2.

Editorial. Childhood immunizationinitiative off to a good start

Establishment of a Measles Eradication Goal - 1978

• School immunization coverage moving toward >90%

• Eliminate indigenous measles by 1982

• 3 component strategy

• High coverage with a single dose

• Disease surveillance

• Prompt response to outbreaks

Experience Between 1977 and 1988

• Measles incidence dropped from 57,000 cases in 1977 to an average of ~3,000 cases during the 1980s, <1% of total prior to vaccination

• A pattern of 2 types of outbreaks was recognized –preschool and school aged

• A one dose strategy was questioned

Median (Range) Median (Range)

Measles Outbreaks, United States, 1985-1986

32

14

Patients’ characteristics (%)

<16 mos of age

Vaccinated at >12 mos

Outbreak Classification (Age)

Preschool(n=40)

School(n=101)

(0-80)

(0-42)

(0-29)

(0-100)2

60

N Engl J Med 1989; 320: 75-81

The Debate about 2 Doses

• Incremental cost

• Incremental cost effectiveness

• We had not achieved high coverage with one dose in preschool children, maybe it only required one dose

Vaccination Status of Measles Casesby Age at Rash Onset, US 1985-88

0

500

1000

1500

2000

2500

3000

<1 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30+

Nu

mb

er

of

Cases

Age of case (years)

Vaccinated unVaccinated

Recommendations for a Two Dose Schedule – 1989 – A Champion Prevails - I

• Failure to respond to 1st dose, not waning immunity

• Large number of college outbreaks

• Revaccination in outbreaks frustrating and difficult

• Most academic experts had bought into a second dose for measles elimination because measles was so contagious it could cause outbreaks in primary vaccine failures

Recommendations for a Two Dose Schedule – 1989 – A Champion Prevails - II

• Public sector resisted because of cost

• New York State Health Officer declares New York State would have a 2 dose schedule

• Opposition melted

• Both ACIP and AAP recommended a 2nd dose

– AAP recommends at entry to middle school, 11-12 years of age

– ACIP recommends at entry to school, 4-6 years of age

Measles Vaccine First Dose Coverage, U.S., 1973-1999

0

10

20

30

40

50

60

70

80

90

100

1965 1970 1975 1980 1985 1990 1995

Perc

en

t co

vera

ge

Year

USIS (1-4 Y)

NIS (19-35 M)

School (5-6 Y)

Figure 3

From: Hinman AR et al. JID 2004; 189 (Suppl 1): S17-S22

Interest in Children’s Defense Fund (CDF) in Immunization

• Looking for ways to measure access to care and failure of health care system

• Immunization readily measurable

• CDF issued report warning of the dangers of low immunization coverage

• Invited Kay Johnson from CDF to speak at National Immunization Conference

• CDF and CDC Immunization became allies

• CDF Board members playedpivotal roles in future administrations

http://www.childrensdefense.org/ Accessed 22 Oct 2019

Measles Resurgence 1989 – 1991

• >55,000 cases compared to annual averages of 3,000 cases 1980-1988

• 123 deaths

• >11,000 hospitalizations

• Two groups of cases

– unvaccinated preschoolers

– vaccinated older children including college students

From: Katz S and the National Vaccine Advisory Committee. JAMA 1991; 266: 1547-1552

The Measles White PaperNVAC – 1991†

Main contributors to measles

1. Primary cause of measles resurgence was failure to vaccinate young preschool children on time

2. Opportunities for vaccination were missed in physician’s offices and clinics as well as public health programs such as,

• Department of Agriculture’s Supplemental Nutrition Program for Women, Infants and Children (WIC)

3. Children were referred out of private practices to public clinics because they could not afford the cost of vaccines

† National Vaccine Advisory Committee, JAMA 1991; 266:1547-1552

The Measles White PaperNVAC – 1991†

Selected Recommendations - I

1. Provide funds through 317 program to enhance immunization delivery infrastructure

2. Eliminate by legislation, if necessary, underinsurance

3. Develop immunization coalitions at state and community level

4. Issue standards of immunization practices

† National Vaccine Advisory Committee, JAMA 1991; 266:1547-1552

The Measles White PaperNVAC – 1991†

Selected Recommendations - II

5. Develop coordinated interagency plan to assure clients served are immunized (e.g., WIC)

6. Government should reach out to medical societies to help achieve high coverage in patients served

7. Measure immunization coverage – explore ways to do it at state and local level

8. Support research on health services and measles

† National Vaccine Advisory Committee, JAMA 1991; 266:1547-1552

The Childhood Immunization Initiative (CII)

• Achieve 90% coverage

• Implement Immunization Action Plan

• Implement National Immunization Survey

• Disease elimination goals

• Fix vaccine financing system

Vaccine FinancingEstablishment of the Vaccines for Children Program

• Cost established as barrier in private physician’s offices because of uninsuranceand underinsurance

• Multiple groups supported universal government purchase of vaccines to remove cost as a barrier

• Universal purchase opposed by others because of large expenditure of Federal funds and monopsony purchase could be disincentive to R & D

• Compromise – Vaccines for Children Program

Source: Benefits from Immunization during the Vaccines for Children Program Era — United States, 1994-2013 Accessed 22 Oct 2019

Key Features of Vaccines for Children Program

• Entitlement

• Covered 54% of children aged 0-18 years, in 2017, based on the CDC Population Estimate Survey

• Eligibility

• Uninsured, Medicaid, Alaskan Natives, American Indians

• Underinsured at FQHC only

• ACIP recommendations lead to automatic funding

• Supports public-private partnership where health departments provide vaccine to private physicians and have ability to work with providers to enhance performance

Estimated Vaccination Coverage of 4:3:1:3:3 Vaccine Series Among Children Aged 19-35 months

National Immunization Survey – ChildUnited States, January 2017 – December 2017

https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/data-reports/5-series/reports/2017.html Accessed 22 Oct 2019

Reported Measles Incidence, United States, 1950-2001

0.01

0.1

1

10

100

1000

50 55 60 65 70 75 80 85 90 95 2000

Case

s/100,0

00

po

p.

Year

Vaccinelicensed

One dose school

immunization laws started in all states

Second dose strategy

and school laws

Improved first dose preschool coverage

Figure 2

From: Hinman AR et al. JID 2004; 189 (Suppl 1): S17-S22

Measles Cases, United States, 1962 - October 2019*

*data through 3 Oct 2019

0

100,000

200,000

300,000

400,000

500,000

600,000

1960 1970 1980 1990 2000 2010

Nu

mb

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of

case

s

YEAR

1963

Vaccine

Licensed

1989

2nd Dose

Recommended

2000

Elimination

Declared

0

5,000

10,000

15,000

20,000

25,000

30,000

1985 1990 1995 2000 2005 2010 2015

1993

Vaccines for

Children

Program

2014-2015

Measles

outbreaks

2019

Measles

resurgence

2019

https://www.cdc.gov/measles/cases-outbreaks.htmlAccessed 22 Oct 2019

What was Diagonal about Measles Elimination in the US?

1. School Mandates – impacted other vaccines

2. Immunization Financing – impacted all vaccines

3. National Immunization Survey – measured coverage of all vaccines

4. Need for constant source of immunization funds

US Experience with Focus on Measles & Building the Overall System

• Led to the enactment and enforcement of school and licensed day care immunization mandates covering all vaccines, not just measles

• Led to financing system to remove cost as a barrier for all childhood vaccines

• Led to a National Immunization Survey measuring immunization coverage of all vaccines for preschool children

• Led to two Presidential Initiatives

Measles Elimination –Lessons Learned

• Strong Scientific Base – vaccine science, epidemiology, health services research

• Limited number of measurable goals

• Compare and contrast good and poor performers –accountability

• Develop key partnerships to help build political base

• Focus not only on vertical measles elimination but also building the system

Thank you

Announcements

#AIM2019

• Sign up for dine-arounds• Wear your badge• Visit exhibits and get your passport stamped• Complete the conference evaluation

at www.surveymonkey.com/r/2019AIMconference

Announcements

#AIM2019

• Attend a breakout session• New location: Grand Ballroom

BREAKOUT SESSION LOCATION

From Survivor to Strategic Leader: Creating a

Meaningful Strategic Plan

Choctaw Room

Grand Ballroom

Note: This session will only be offered once

Managing Up: Building a Great Working

Relationship With Your Boss

Regal Suite

Leading Through Turmoil Madewood/ Oak Alley

Room

BREAKOUT SESSION LOCATION

Five Relationship Building Steps That Will Change Your Life

Choctaw Room

Grand BallroomNote: This session will only be offered once

Managing Up: Building a Great Working Relationship With Your Boss

Regal Suite

Leading Through Turmoil Madewood/ Oak Alley Room

TUESDAY: WEDNESDAY: