cc  >> Thank you for joining me for  Wednesday Nite at the Lab at UW  Madison Biotechnology Center.  Tonight, we welcome Dr. Pete  Shult, director of the  Communicable Diseases Division  and Emergency Laboratory  Response of the Wisconsin State  Laboratory of Hygiene which is  located here on the UW Madison  campus, actually right next door  to the Biotechnology center.  Dr. Shult received his PhD from  the University of Wisconsin  Madison in medical microbiology.  He has 30 years of experience in  clinical and public health  microbiology with service in  private university and public  health sectors and directs  statewide emergency laboratory  response during disease  outbreaks and public health  emergencies including  bioterrorism.  He currently serves on a number  of local, state, and national  public health planning  preparedness and response  working groups dealing with  pandemic influenza,  bioterrorism, and emerging and  vaccine-preventable diseases.  And I find tonight's seminar on  vaccines quite timely.  Some of you may have watched PBS  last week, Frontline in  particular aired an episode  called the "Vaccine War."  So it's an ever interesting  topic, and certainly I think  with PBS highlighting, yet again  tonight's seminar should be  fantastic.  So please join me in welcoming  Dr. Pete Shult to Wednesday Nite  at the Lab.  (applause)  >> Peter Shult: Thank you, Nadia  and thank you all for attending.  I suspect there will be a little  interest in the topic here. 

 And some of the objectives,  actually there are two main  objectives.  I want to give a public health  perspective on the importance of  vaccines.  I'm a lab director, I work on a  lot of the vaccine-preventable  disease outbreaks, I've seen the  effects of the disease in the  absence of vaccine, and I want  to come from that perspective  because so often when we hear  about vaccines, it's most often  in a negative light.  There are problems with them,  we'll talk a little about that.  We heard a lot about them,  usually in a negative way, with  the 2009 H1N1.  They didn't come soon enough,  why did we need to get them, and  so on and so forth.  What I want to do is recast this  in a more positive light from a  public health perspective, but I  also want to recognize some of  the ongoing challenges and  controversies that do exist and  they absolutely exist and they  are absolutely having an impact  on public health.  What I don't want to do, I'm not  a clinician so I'm not going to  make the recommendations on  these vaccines.  The debating, there's going to  be a lot of feelings about  this in the audience.  I'm not going to debate in the  detail of some of the things I'm  going to present. 

 I certainly can point you toward  resources, either for or against  vaccines, that you might want to  look at.  As a starting point, one of the  resources is, and it's a safe  one again from a public health  and a scientific perspective,  going to the CDC's website, and  specifically their vaccine  website, you're going to be able  to branch out into a lot of  different sites that will give  you authoritative, science-based  information about vaccines.  You can also Google vaccines and  vaccine controversies and  vaccine problems.  And, as I tell my students on  campus, I'm a professor here,  you do so at your own risk, and  you have to sort of filter the  information you're going to get  to get the balanced view here.  I'm going to be talking about  the public health importance of  vaccine.  Just kind of set the table a  little.  Just a simple definition here  about public health.  In its purest sense, and as I'll  point out it's a relatively  young discipline, it's about  preventing disease.  The fact is we do a bit of  preventing disease when you look  across the total breadth of  public health, but most often  we're responding to problems  that have occurred and that's  where we probably get the most  spotlight put on us.  But when we look at this  definition, the key words here  are preventing disease and  disability, and also we're doing  this through organized community  effort. 

 I mentioned the science or  discipline of public health is  relatively new.  And you go back to about 1850  where it really has its roots.  And where I've highlighted in  red are the key elements that  help those of us in public  health carry out our science and  our craft.  Birth of epidemiology, that is  monitoring and studying disease  progression through communities  and activities to prevent  disease really began in the  1850s.  Germ theory, which provides the  basis for microbiology or  understanding the organisms that  cause infectious disease, was  developed in the 1850s through  1890s.  At about the same time the  science of immunology, which is  very relevant to how we respond  to vaccines, was developed at  about the same time period.  And through then really the  golden age for public health  occurred through the late 1890s  into the 1900s, 1910 and so on,  where our key elements of  hygiene were developed.  Things that we take for granted  now and we can rely on  relatively safe foods, safe  water, we learn basic concepts  of food preservation, basic  hygiene and so on.  But vaccines have turned out to  be one of the key elements of  public health in combating  infectious diseases.  I want to point out, and as I go  through the talk I'll make  certain comments just to counter  some issue about vaccines, and  one of the issues has been, we  don't need vaccines, if we just  practice good hygiene we'd be  able to prevent a lot of these  diseases. 

 And the fact is for many of  these that just isn't the case.  It goes beyond hygiene and  without vaccines we would have  problems here, and I hope to  demonstrate that over a number  of the slides.  The outcome of public health and  the outcome of all the elements  of the discipline of public  health I think are well  demonstrated in the slide that  shows the death rate for  infectious disease in the United  States from the 1900s to almost  2000.  And you can see it was more or  less a precipitous decline in  infectious disease as we went  through the last century.  The notable exception being this  peak that occurred in 1918 that  I think now most people  recognize as the great influenza  pandemic or Spanish influenza.  And it was really based on the  impact that that pandemic had  that a lot of our response to  the 2009 H1 was predicated.  The impact on death rate was  also accompanied by an increase  in life span of almost 30 years,  30 to 35 years.  Right around the early parts or  through this progression through  the 20th century.  And what we've known throughout  history, the biggest impact of  infectious disease has been in  children, on infants and  children.  And, in fact, at the turn of the  century infant mortality rates  were approaching 20%, and  childhood mortality rates, less  than five years of age, were up  around 25%-26%. 

 And we're nowhere near that in  the United States.  We're at 1%, probably a little  less, and some of that is due to  infectious disease, a lot of it  isn't.  So really public health, in  general, has had a huge impact  on infectious disease.  And then when you break out some  of the key elements of public  health, again vaccination really  does rise to the top for a  number of the diseases that were  major killers of children.  I highlight this reference.  There was a series of articles  in the morbidity and mortality  weekly report in 1999 that  highlights the 10 great public  health achievements in the  United States.  They chose vaccination and  control of infectious diseases  as two of these.  This is worth reading because  it's really interesting, not  only for this topic, but for a  number of the other elements of  public health.  To get started then, we're going  to be talking about vaccines,  and then I want to explore a  little, what is vaccination?  And to start out we often  intertwine or use the terms  vaccination and immunization.  Immunization is the process by  which the human immune system  prepares itself against an  attack by a microorganism or a  foreign substance. 

 It can do this in one of two  ways.  Either be naturally exposed to  the microorganism, and therefore  quite often you will have  disease, or you can do this in  an artificial way, that is  develop a vaccine, which is  essentially defined here as a  preparation of a killed,  weakened or fully infectious  microbe or their products given  to produce or increase immunity  to a particular disease.  The idea being, by using a  vaccine we get all the benefits  and stimulate all the benefits  of the immune response without  suffering the impacts of the  disease.  And I'll say at the outset and  I'll mention a number of times,  all vaccines have some side  effects.  Some vaccines have more than  others.  Some individuals suffer more  severe side effects than others.  But it's like any other  pharmaceutical, any other drug,  there are side effects here.  And we'll explore some of those.  But what it will come down to,  and I'll mention this a number  of times through the talk, is  risk versus benefit.  And I hope to convince you that  overall the benefit of the  vaccines, to us as individuals  and certainly globally, far  outweigh the risks. 

 And we'll be exploring a number  of those risks.  There are many different types  of vaccines.  I don't want to go into a lot of  detail here.  But I do want to point out the  area here I have highlighted in  red.  It's obvious, we know one of the  major reasons for vaccine is to  protect the individual from the  disease.  We understand that.  But what a lot of people don't  understand that you also protect  the community through a herd  immunity that you can develop by  the vaccine.  If it's a successful vaccine,  the more people you can  vaccinate and you eliminate the  number of susceptible people  should the real disease emerge,  and that's very important.  And it's going to one of those  side effects that we'll talk  about a little later on.  People who choose not to  vaccinate themselves and  vaccinate their children  certainly are going to have that  personal effect, but if there's  a high enough number of those  people, they absolutely have an  effect on the community at  large. 

 And keep in mind, in our  communities there are a large  number of people for various  reasons, cancer, they're  immunocompromised in some way,  they've undergone transplants,  they often cannot take some of  the critical vaccines, they rely  on herd immunity to protect them  from certain infectious  diseases.  I just have this slide up there  as a historical perspective.  It overlaps the one I showed you  earlier.  The only point I want to make is  actually work in vaccines and  the theory behind vaccines and  the first attempts at using  vaccines began well before that  period of public health.  Before we even knew what  microorganisms were, before we  understood the importance of our  healthy immune system and so on,  these were experiments that were  done empirically.  And Edward Jenner is really a  true father of vaccines here.  And that occurred during just  prior to the 1800s.  This is just a list of diseases  for which we do have vaccines.  We're going to explore this in a  little more detail, but I want  to point out that these vaccines  have been being developed for  many years.  A number of the ones that were  developed earlier in the last  century we still use but they've  been significantly modified. 

 They've been made more  effective, their side effects  have been much reduced, and we  continue to produce vaccines  even up to today.  Now this slide ends at 1999, but  we've had vaccines being  produced, either modification of  existing ones or new vaccines,  throughout the 2000s on up to  2008, and I'd anticipate we're  going to continue to have them  as we move forward.  Now, first question, how  successful have vaccines been?  And to answer this there are a  couple criteria for success that  I want to discuss.  The first point to realize when  you're talking about whether a  vaccine has been successful or  not is at an individual level.  If I get a vaccine, has it  prevented disease in me, the  individual?  From a public health  perspective, we certainly want  healthy individuals but we're  also wanting a lot of healthy  individuals which equate to  healthy communities which equate  to a healthy world.  So the public health, and again  go back to the definition of  public health, is about a  community effort in improving  the health of the community.  And some of the criteria for  success I have listed here we're  going to talk about as we talk  about some of the vaccines.  Everything from containment,  that is getting the diseases  down to a level that we're  willing to live with.  Through elimination in a set  population.  Getting rid of disease that's  endogenous to that population so  that the only disease that will  occur there is that that is  brought into the population. 

 On out to eradication, removing  it in its natural state.  And we've only done that to one  disease and that's smallpox,  and we'll talk about that a  little because it's important to  understand the lessons learned  from smallpox.  Now the other thing that I want  to mention, at the individual  level that's where the issues  with vaccine safety arise.  And again, we're going to talk  about some of the elements of  vaccine safety, some of the  controversies here.  On a global basis, I will make  the statement that  when you look at the millions,  tens of millions,  hundreds of millions of people  who have been vaccinated, the  relative number of people who  suffer serious adverse effects  or have had problems is very,  very small.  And you look at it on a global  perspective, vaccines are safe.  It's when you get down to the  individual, there can be  problems.  And most people and a lot of the  controversy is centering around  impacts on individuals or small  groups of people.  And we'll talk about that.  Oh, gosh. 

 We've got them all.  Okay, effects of immunization in  the United States.  And what I have listed here, you  don't need to look at all the  detail here, but these are the  key immunizations, vaccinations  that we give our children in the  United States.  And these are data when you  compare the pre-vaccine era to  2005.  First of all, notice the trend,  they're all sloping down to the  right.  And if you look at the Y axis,  this is a logarithmic scale.  So we're going from 10 million  cases down to one case.  So even for some of these  vaccines which don't seem to  have a real steep slope, we're  still, in some cases, preventing  millions of cases of disease or  hundreds of thousands of cases  of disease.  Then you can look at a number of  the diseases that have bottomed  out in 2005.  We no longer have smallpox. 

 We have minimal, only the rarest  cases of diphtheria.  Polio, endogenous polio no  longer occurs in the United  States.  And we'll talk a little more  about that.  Measles, endogenously, that is,  sustained transmission in the  United States, no longer occur.  All of that because of vaccines  for those respective  microorganisms.  And all of these diseases have  that varying slope to the right.  You can look at this in numbers  as well for a number of these  that show accumulated data of  baseline information that was  taken from the 20th century, and  then compare it to 2001.  And all you have to do is  compare the numbers.  There's been a dramatic impact  on a number of these diseases.  And, again, a number of these  diseases, without vaccine simple  hygiene alone would not have had  this impact. 

 Now, talking a little more about  the successes.  The biggest success in history  is smallpox.  And there's a huge history here  you can follow.  If you go to the CDC website,  you can read a lot about it.  It is one of the oldest diseases  of mankind.  It is one of the most feared.  And when you accumulate  mortality throughout the period  of human history that it was  present, few diseases had as  much impact.  And those who survived often  suffered very severe after  effects, significant scarring,  and like so many infectious  diseases, the real target  population were the very young  on through childhood.  And with a mortality rate with  30%, even up in close to the  last days that we had smallpox  circulating in the world, there  are few diseases that were that  bad throughout history.  We had our last case in the  United States in 1949. 

 As I'll point out, we had  universal vaccination and  looking at the age spectrum in  the audience, many of us did  have our smallpox vaccine.  That was discontinued in 1972  when we were getting very close  to eliminating smallpox  globally.  And it should have been  relegated to the textbooks at   that point except the concern  now, which arose with the  concerns of terrorism and  specifically bioterrorism, a  real concern that there are  stocks of smallpox that still  exist outside of the hands of  secure scientific or government  laboratories.  So it's out there for us to  worry about a little in public  health.  And obviously now we have many  generations, or a number of  generations who are totally  susceptible to smallpox because  we haven't been vaccinating for  three or four decades here.  In controlling it, and the next  slide will show you a great  reference if you want to get  into the history of what went  into this.  Key to its control was the  vaccine.  We had mass vaccination  globally, and then as the amount  of smallpox was reduced, we  backed off on mass vaccination  and went more to a search and  containment type strategy where  certain cases would be  identified, you would try to  vaccinate that case, contacts of  that case, contacts of the  contacts.  It was called ring vaccination.  And this was critical in  ultimately eradicating smallpox. 

 The other point was vaccines  cannot act alone.  As good as they are, you still  need other community containment  measures.  When you're sick, you need to be  isolated from the rest of the  population, either by yourself  or forcefully, so you cannot  transmit.  If you've been exposed to a  disease, you need to be  monitored to see if you're going  to develop that.  And this can be done by keeping  you secluded.  And this was done throughout the  period of smallpox eradication.  All outlined in this book.  And the reason I put this up  here, it's an interesting  resource to read about because  they really do cover the  scientific, the political, the  economic of what went on in the  latter years of the eradication.  As a scientist, as a public  health professional, it is also  a blueprint for how we will move  forward for other diseases that  might be candidates for  eradication.  And there are a number of these. 

 I have a couple lists here.  There's a World Health  Organization priorities for  eradication.  I'm going to talk about polio,  that's why it's highlighted.  But measles and neonatal tetanus  is on that list, as well as some  other diseases for which we  don't have vaccines but because  of their ecology and their  natural history could  potentially lend themselves to  being eradicated on a global  level.  The Carter Center has indicated  a number of targets for  eradications as recent as 2008.  Heading that list, they're  acknowledging that we're very  close to eradicating polio.  Their primary targets now are  measles, mumps, and rubella.  And we're going to talk a little  more about measles.  These have been chosen, and I  can't go into the detail here,  there are certain  characteristics of a number of  these diseases that really lend  themselves to being eradicated.  Humans are the only host. 

 They often cause a very  identifiable disease.  We have a very effective  vaccination, and a whole host of  other reasons why, like small  pox, these might be candidates  for eradication.  And these are efforts that  hopefully we're going to read  about as the years go on here.  Now the one I wanted to  highlight briefly was  poliomyelitis, and, again,  looking at the age distribution  here, many of us remember it.  We were either touched by it in  our families, remember it,  remember friends having it,  remember relatives having it,  were among some of the firsts to  receive the vaccinations and so  on.  And these are some of the images  that I think we became familiar  with.  The children in the braces and  the wheel chair.  FDR who actually really led the  effort for the ultimately to get  the vaccine was that produced by  the mid-1950s that brought polio  virus under control.  And then I think the most  incredible image is the iron  lung which was, literally, the  only way a number of these  patients were kept alive.  Some of these graphics are taken  for, we mentioned that other PBS  documentary. 

 There was one in 2009 called the  Polio Crusade from the American  Experience Series.  You can get the DVD.  I'm not sure if you can get it  online yet, but that is a  tremendous hour's history of the  vaccine development and how we  brought polio under control.  And the impact that had on  through the '50s during the  summer where kids couldn't go to  the swimming pools anymore, and  during '51 and '52 where we  suffered the most significant  epidemics in the United States.  I'm not going to talk about a  lot about polio virus, but  basically the main concern with  it is its effect in a small  number of those who were  infected with the virus  paralysis, either of the limbs,  the legs, the arms, in more  severe cases respiratory  muscles, gastrointestinal  muscles, a rather substantial  death rate when you did have  paralytic poliomyelitis, and  sequelae that could last in the  acute illness out for months or  years, and then there's elements  of that disease in those who  were severely affected that can  come back many decades later.  And there are still people who  are coming down with some of  those post-polio syndrome  symptoms even now, decades after  that would have been infected.  If you look at poliomyelitis in  the United States, we start in  1950, and you start here because  this was really the peak when we  were seeing paralytic polio.  And you see the impact of the  vaccine.  First the inactivated vaccine  and then the live, oral vaccine.  A point I didn't make, and it  gets back to hygiene, the real  irony here is the paralytic  disease tended to affect older  children and adults, those who  were affected later in life,  that is as older children and  adults, because hygiene got to  be so good throughout the 1900s  infants didn't get the disease  anymore. 

 When young infants, when polio  virus was widely circulating and  young infants were infected at a  very young age, they were,  essentially, mostly suffered  relatively mild disease, some  did go on to suffer paralytic  disease but not a very high  percentage.  Even much less percentage than  as you became an older child, on  into young and even middle age  adulthood.  So clearly this was a disease  that really emerged as hygiene  got better.  And without vaccine we would  have serious and continued  serious issues with polio virus.  Interesting with it then, and  let me go back to the previous  slide, we've started out with an  inactivated vaccine.  This was a dead vaccine but then  there was an oral, live,  attenuated vaccine.  It was intended to better mimic  the disease with a very minimal  risk of actually causing severe  illness.  And when you compared its  effects to when we had wild type  polio, there really was a very  small number of people who  suffered severe effects.  But by 1980 when we had our last  indigenous case, what happened  is we were still having cases of  polio in the United States but  the vast majority of these were  actually being caused by the  vaccine itself.  This attenuated vaccine was  reverting to a form that could  cause paralytic polio. 

 Now you look at those numbers,  there's only ones to tens back  compared to when we had  20,000-30,000 cases, hundreds of  thousands of cases elsewhere in  the world.  But since we weren't seeing real  polio, this was an unacceptable  risk.  So by 2000 we stopped using the  oral polio vaccine in the United  States and currently only use  the inactivated form.  But there should be zero risk  now of getting poliomyelitis  indigenously in the US.  Although, as I'll point out,  there's still issues elsewhere  in the world.  I put this up there, don't read  it.  These are immunization  schedules.  If you're really interested, and  we'll talk a little more about  this later, on what the vast  array of immunizations, of  vaccinations that our children  get and we get throughout life,  go to the CDC website.  We'll come back because this is  one of the touchy issues here.  We are getting a lot of these. 

 And we're getting a lot in a  very short time period and we'll  explore that.  I put this up here only to show  you we still continue in the  United States to immunize for  polio, and actually we're  immunizing throughout the world.  And the reason is it has not  been eradicated.  However, if you look at this  map, and I'll show the website  this comes from because now you  can monitor this essentially on  a weekly basis as we go down the  road to eradication, we  currently have four endemic  countries.  Endemic meaning polio is  naturally occurring and  transmissible within that  country.  There's sustained transmission.  These countries are Nigeria,  Afghanistan, Pakistan and India.  The same four countries have  kind of been stuck here,  suffering hundreds to a  thousand, maybe 1500 cases a  year.  We can't get over that final  hump to eradicate the virus in  these countries.  And then if you look, there's  other surrounding countries that  are suffering epidemics in cases  that are spillover. 

 People who are coming into their  country infected with polio  virus and then infecting  susceptible individuals.  That fact that we have what will  probably be a long-term war in  Afghanistan really makes, in my  opinion, fairly remote that  we're going to be eradicating it  at least in Afghanistan.  There's issues in these other  countries as well.  But the good news in this in  1988 there were 350,000 cases of  paralytic polio in the United  States.  Last year there were 1600 cases.  We're on track so far this year  to perhaps come under a thousand  cases globally.  That is an incredible effort and  although it's not eradicated, we  have made a big dent.  The problem is it's still out in  the world, the rest of the  global population is still at  risk because it can come here.  So we can't let down our guard  and stop vaccinating.  And one of the issues has been,  look, we have a number of these  diseases, I'm going to show you  a couple others really quickly  here, they're such low level in  the US, why are we taking the  risk with vaccinations?  The reason is this: because we  have it elsewhere in the world  and most of the problems that  we're having with a number of  the vaccine-preventable diseases  started with imported cases  coming into the US. 

 This is the website, it's the  global polio eradication site.  And this website's sponsor,  there are multiple agencies  working on this.  WHO, World Health Organization,  Centers for Disease Control and  Prevention, UNICEF, Rotary  International and others.  And this is kind of a website  dedicated to monitoring the  eradication efforts.  There's other diseases we've all  grown up with that we've had  similar success in the United  States in bringing under  control.  I show here pertussis which that  vaccine was first made available  in 1940 and since then we have  been knocking down the number of  pertussis cases.  Measles, the vaccine came out in  1963, and the number of cases in  the US dropped off the table and  we've kept them really low.  Same with mumps where we had the  vaccine in 1967.  Now I'm going to come back to  these diseases in a few minutes  to tell you all isn't rosy with  them.  We still continue to have  outbreaks, and there are reason  for that occurring even in the  United States. 

 If you look globally, we're  having similar success but not  to the same magnitude.  So if you look at the number of  cases of measles, and again  these are rough estimates, you  can see a downward trend in the  number of cases that coincides  to the upward trend in the use  of vaccines.  And then you can see the  different countries who have  active immunization programs.  Those in blue are actively  immunizing to a high level for  measles.  Those in the red and pinks, not  so much so.  The current global figures, it's  estimated around 150,000 to  200,000 deaths.  The reported cases are  underreported here by a factor  of a hundred.  Estimates are actually 15 to 20  million cases of measles  occurring worldwide.  Similar data with pertussis.  Whooping cough, which if you saw  it, I think a number of you did  given your age. 

 I got to see it professionally  in unvaccinated children and  it's horrible.  I got to see it in my family  when we lived over seas.  It was a modified version.  They were vaccinated, they still  got it, and it was only a little  less horrible.  I was pretty certain they  weren't going to die, but it is  something that went on for weeks  that has kind of burned into my  mind.  When you look, same trend with  pertussis throughout the globe,  same positive trend in  immunization.  Same countries not really able  to immunize a large part of  their population, and there are  still a substantial, almost a  quarter million or more, deaths  due to whooping cough,  pertussis, throughout the world.  And, again, the number of cases  is underreported by about a  factor of a hundred here.  So that's a good news/bad news  thing.  We're making progress globally,  but there is a lot of measles  out there, there's a lot of  pertussis. 

 I didn't show you the data for  mumps, there's even more mumps  out there.  And any of those diseases can be  brought to the US.  Well this kind of segues now  into talking about some of the  challenges and controversies.  Hopefully to this point you're  buying on somewhat that vaccines  have been a tremendous public  health benefit.  They will continue to do so as  they're used more and more  globally.  But there definitely are  challenges and controversies,  and a large number of these  really are focused in the  developing countries.  When you look at infectious  diseases, the threat is a global  one.  I showed you some of the figures  for pertussis and measles.  But if you look at infectious  disease percent of mortality,  these data are about four or  five years old, there's roughly,  and these are all  underestimates, 15-20 million  people die of infectious  disease, minimum, globally.  And again, that's a pretty  substantial underestimate. 

 That's almost a quarter, 20%-25%  of total mortality.  You look at the diseases, I  think a number of these are  familiar to everybody.  HIV/AIDS, tuberculosis, a  variety of respiratory  illnesses, gastroenteritis,  malaria and so on.  On the right hand side, as has  occurred throughout history, is  we recognize in the United  States at the turn of the last  century the primary target and  the highest morbidity, highest  mortality, highest of incidence  of the disease occurs in young  to school-aged children.  This is globally, this has been  the case and still remains the  case in the United States.  And they bear a large burden of  the mortality rate here  throughout the world.  I show this map.  If you compare this with the  ones I showed with measles and  pertussis.  The biggest issues right now are  in the developing world.  And this is based on gross  domestic product, an economic  indicator, and the biggest  issues right now are in  sub-Saharan Africa and  throughout much of Africa and  also areas throughout Southeast  Asia, India, Pakistan, and so  on. 

 What I failed to point out on  the measles, and it doesn't show  up here, even in the developing  countries there are resurgences  of a number of the key vaccine  preventable diseases, most  notable, measles, also  pertussis, directly linked  because over the last several  years people have been failing  to immunize their children.  So the major problems in the  developing countries, the  emerging problem is us sliding  backwards in the developed  countries.  Another challenging controversy,  most of you don't have handouts,  but it's quiz time.  There should be some diseases,  really conspicuous because I  haven't talked about them, they  haven't showed up on any of our  lists.  Does anybody have an idea of  what?  There are three, the big three.  Hazard a guess?  >> Heart disease?  >> Shult: Infectious diseases,  I'm sorry.  >> Bubonic plague?  >> Shult: No, actually  fairly low down.  >> Malaria.  >> Shult: One.  One of the big three. 

 Two others?  I'll give it.  Tuberculosis, HIV/AIDS.  We have no vaccine, why is that?  Well first of all just to show  you, these next three slides go  through really quickly, and you  can get more information on site  here, but when you look at  tuberculosis a full third of the  global population is infected  with tuberculosis.  There are millions of cases  here.  The biggest threat now, although  we have tuberculosis throughout  the world, we have less of it in  the developed countries,  although we still have cases  here, the biggest concern now  are the multidrug-resistant  strains coming and the extremely  drug-resistant strains.  And a number of these have made  the news over the last years.  So TB is the single highest  incident infectious disease, or  highest prevalent in any given  time.  A third of the global population  is infected.  Malaria and this is the area and  malaria is a mosquito-born  disease so its range is going to  be dictated by where the  particular mosquito resides, and  through areas of South America  and Africa and on an annual  basis 300 to 900 million cases  of malaria and probably right  now current estimates over a  million children die each year  from malaria.  We don't have a vaccine but  there are a lot of other efforts  to try to attack the mosquito  populations. 

 Put something between the humans  and the mosquitoes, bed nets,  cover up windows and so on.  But even that's run into  problems because with the  wholesale use of insecticides  and so on have met a lot of  pressure from environmental  groups and their environmental  concerns.  Right now, attacking the  mosquito is the only realistic  way we can kind of stem this.  And then finally, HIV/AIDS and  this is really our biggest and  scariest global pandemic now.  Throughout the world millions  are affected.  There are two million deaths,  again underestimate, globally.  The question is, why no vaccine?  I could spend several lectures  on this but there are a lot of  reasons, it's not for want of  trying.  There are huge research efforts.  But unlike a lot of the other  organisms we've talked about,  the organisms that cause these  three diseases are  extraordinarily complex in their  makeup.  They have many targets that your  immune response has to deal  with. 

 They have very complicated ways  they cause disease.  And they have very cleaver ways,  they hang out in your body sort  of hiding from your immune  response or constantly changing  to stay a step ahead of the  immune response.  And then the immune response to  these organisms is so complex no  one has found the right recipe.  What's that one target to get  that can prevent that disease.  And the efforts have been going  on for decades here and likely  will continue.  And there are a variety, a  number of other more common  viral diseases and so on that we  also don't have vaccines for,  and bacterial diseases, all for,  basically, the same reasons.  And then I show this slide.  Is this a reason for optimism or  not?  When you look out to 2030 here,  when you look at the infectious  diseases, you see the big three.  And although we're on a very  gentle downward slope, when you  add up the projected mortality  and then throw in some of the  acute respiratory infections,  which influenza is a significant  one and a number of the  childhood respiratory viral  illnesses, they're projecting  millions of people will still be  dying from these illnesses for  which we do not have a vaccine.  These projections seem to   indicate and the text that goes  along with it, the feeling is  it's not a strong likelihood  we're going to have these  vaccines. 

 Vaccines are not perfect.  I've already mentioned there are  side effects to a number of  these, and we'll talk a little  about that in a few minutes.  But we've had recent outbreaks  of whooping cough in Wisconsin.  The biggest outbreak in a number  of years occurred in the United  States.  Largest outbreak in a number of  years occurred in 2003-2005.  When this was analyzed, when all  was said and done, the main  issues were, and we knew this  for some time, the immunity  following the vaccine, and the  natural infection for that  matter, is not long lasting.  And we know there's a low  prevalence of this disease  circulating all the time.  And we've been unable to, up  until recently, revaccinate  people because the vaccine was  too toxic in older children and  adults.  They've developed a new vaccine  now, the T-DAP.  It's recommended we all get it  if we haven't had it,  particularly those of us who  have children, who have  grandchildren. 

 It's the very young who are at  greatest risk for whooping cough  so we need to be protecting  them.  We had a major mumps outbreak in  2006.  Heavily affecting the Midwest.  And a much older age group than  we were used to.  What was curious, or it looked  curious at the time, until once  this study has been looked at or  this outbreak has been looked at  in some detail, again multiple  factors in reemergence.  Going to the bottom one, just  like with mumps and I'm going to  mention with measles, there's a  worldwide reservoir of these  bugs.  So they're going to keep coming  into our country until they're  eradicated.  With mumps, even two vaccines,  it's a pretty good vaccine, but  even when you get the two doses  of vaccine, it only has 90%  effectiveness.  There are still people who are  susceptible.  And over time you accumulate  these people who are  susceptible, and when you crowd  them together in college dorms  or in a daycare setting or in a  family setting, you're going to  have outbreaks of mumps. 

 And that's what happened in  2006.  There's a big outbreak going on  in the eastern United States now  in New York and a region of New  Jersey.  Measles, and this is the scary  one, measles, hands down, it's  responsible for 40% of the  mortality of all  vaccine-preventable diseases in  children.  This is a nasty disease.  Many of us, in fact, did suffer  it through childhood.  I had my bout with it.  And it can be a life threatening  disease, and a large number of  people have severe after  effects.  A large number are hospitalized.  We had a big outbreak in 2008.  Again, Wisconsin was heavily  involved with that. 

 There's currently a big outbreak  going on, or substantial  outbreak, in Vancouver.  Viruses were introduced during  the Olympics, and now it is  going through the population.  The problem is, and if you look  at the 2008 outbreak, we've been  having these imported cases for  some time, and we know,  occasionally, these will get in  fine susceptibles in the  population and transmit to those  individuals.  In 2008, the vast majority of  the cases were in children just  in the normal community setting,  in daycares, in school setting.  What happens, these were  imported cases that got loose in  the community, and of those who  have been studied, the real  disturbing trend here is almost  70% of those who ended up coming  down with measles, did not have  the vaccine.  The parents had chosen not to  vaccinate them.  And this is a trend that's being  repeated over and over  throughout areas of western  Europe, Japan, much of the  developed country.  And, again, that's just  highlighted on here.  And measles is the biggest  concern because it is such a  very serious disease when it  does emerge.  So that's the natural segue into  the last thing I want to go  through here and that's people  choosing not to be vaccinated or  not vaccinating their children. 

 And, obviously, this is where a  lot of the controversy arises.  Now, the opening statement I  want to make, and you can find  these statistics at the CDC.  In the US the overall  vaccination rates across the  whole spectrum of vaccines  children get is very, very high.  For the key ones, DPT,  diphtheria, pertussis, tetanus,  measles, mumps, rubella, polio  virus, it's over 90%.  Excellent vaccination rate.  When you get to the teens, the  vaccines they're supposed to be  getting and then the ones the  adults are supposed to be  getting, the rates of  vaccination drop off the table.  So we're just ignoring the older  age groups here, but then that's  kind of always been the case.  So the good news is we have,  generally, good vaccine  coverage.  The bad news is we're getting  these groupings of the  population who are choosing not  to be vaccinated.  And it's a particular concern  with measles. 

 And it was interesting for me,  and I do a lot of work with  influenza, the public early on  about a year ago should have  been scared to death about the  emergence of 2009 H1N1.  We were not only not scared to  death, when we did get the  vaccine in a far quicker time  than anybody could imagine or  plan for, only 20%-25% of the  population has bothered to get  immunized.  So that's telling you a lot of  things are going on here as far  as our perception of vaccine.  And this is what I want to talk  to here, and just lay out the  issues here rather quickly.  And as we get near question and  answer, if you want to weigh in  on some of these we'd be glad to  do it.  First and foremost, the biggest  issue is safety issues.  I've characterized these, and I  tell you I'm bending over  backwards here to be correct and  not to have missiles thrown at  me.  There are proven safety issues  and I've already said some of  these have side effects and I'll  review some of the issues there  have been with some vaccines.  And I'm going to characterize  other ones as unproven and  debatable for this.  I think the bigger core, and I  would rework this slide if I had  to do it all over, is the core  problem, my opinion I think and  public health opinion, vaccines  have been so successful that we  find ourselves today faced with  a dangerous situation where we  really have minimized the  importance of vaccines. 

 We don't see a lot of these  diseases anymore and we have  generations of parents who never  will.  A number of us, in fact, either  suffered the disease or saw the  disease in our children.  Apart from those of us who deal  with this professionally.  We're losing the memory and the  firsthand experience with a  number of diseases.  And I think that provides a  backdrop for a lot of these  issues which I suspect would not  be issues a number of years ago.  We do have lots of vaccines.  There's a real issue here, are  we getting the right information  out to the public.  I'll make a couple comments on  that in a minute.  And there's some of these others  that I'll wrap up with in a few  minutes.  Great site for safety, again, is  CDC website. 

 Vaccine safety is obviously the  elephant in the room here.  There are definite safety issues  with some vaccines, and I'll  mention this in a second, but  again from a risk benefit  standpoint impact of vaccines on  the population, overwhelmingly  positive here.  The question is, I don't know  how much real realistic  scientifically valid safety  information people get about  vaccines.  Or I do know they don't get very  much.  There is an incredible  infrastructure in place, and has  been for the last two decades,  to ensure the safety of vaccine  from its development, and the  development process can be years  if not the better part of a  decade, through FDA approval and  it continues even after  licensure with ongoing  surveillance for adverse  effects.  And when these are identified,  setting up studies to see if  this is a real effect of the  vaccine and what can be done  about it.  This is all outlined at the CDC  website.  Time doesn't allow me to go into  this, but it is not appreciated,  I think, how fully and carefully  all along the way the whole  vaccine development and use  process is monitored and checked  for safety.  There have been past and recent  safety related events.  One of the most notable occurred  in the earliest days of the  polio vaccine where, and this  was due more to the technology  at the time, a lot of vaccine  which was supposed to be  inactivated was not inactivated  and an actual live virus was  given to thousands of children,  hundreds of whom came down with  paralytic disease. 

 Despite that event, because it  was early enough in the vaccine  program, within eight to 10  days, they resumed vaccination  and brought polio under control.  A number of more recent events  have occurred with vaccines for  rotavirus, which is the leading  cause of infantile  gastroenteritis, it was in this  country until we started using  the vaccine, and is the leading  cause globally.  This is the website that brought  this, again, to the forefront.  There have been a number of  television shows related,  countless websites and documents  on the side of vaccine, against  vaccine, and everywhere in  between.  I put that one up there just  because, mainly, it was the most  recent, I reviewed it, I think  the biggest complaint, not only  does it address the controversy,  it generated controversy about  the controversy because the main  complaint was it didn't give a  balanced view.  As I read it, the fact is it  didn't.  It really didn't.  And the counter argument from a  number of people in public  health was a lot of the issues  that were raised frankly don't  need a balanced view.  I don't agree with that  approach.  I'm a public health person and  I'm 100% behind the vaccine and  I don't believe a lot of the  concerns or I'm convinced a lot  of the concerns that have been  stated aren't real concerns, and  I think there's plenty of  science to indicate that. 

 But I think there has to be an  effort to continue to provide  balance and dialogue to talk  these things through.  Because the outcome in public  health, letting it just slide,  is we still got a public health  problem here that we're going to  have to start dealing with and  we got to continue talking about  this.  Biggest issues, thimerosal in  autism and MMR, measles, mumps,  rubella, and autism.  I just put these up here, I'm  not going to talk about these.  There are rafts of literature at  any of the websites I gave you,  and you can follow any string to  get the detail.  I will summarize it by saying in  the scientific community, and in  the legal community, the  controversy has been laid to  rest.  The people who still believe  there is the linkage, it hasn't  been laid to rest.  Although I got to say there is  an overwhelming amount of  scientific data, epidemiologic  studies that simply do not  support the link here between  either the measles, mumps,  rubella vaccine and autism or  thimerosal.  But there are a lot of other  issues.  Even if those had been laid to  rest, and I don't think they  have, there are a number of  other issues here as well, and a  lot of these are articulated in  that documentary. 

 Are we giving too many vaccines  too early?  And that argument will be made.  And if you start talking to the  immunologists and the  microbiologists, the amount of  antigen, that is that part of a  microorganism or what we put in  as a vaccine that we mount our  immune response to, the amount  given in most of those vaccines  pales to what we are exposed to  naturally from the minute the  child goes through the birth  canal and eats their first food,  either whether it comes from the  mother or their first hard food,  we are absolutely swarmed with  things that are foreign to our  bodies.  So the immune system is active  all of the time.  That is the argument against.  Too many vaccines given at the  same time.  Many more vaccines need to be  thoroughly studied.  And there are a lot of them.  14 are currently given to the  children.  A stated need to look at some of  the other additives.  Then there's other issues here. 

 One's a parental choice and this  raises its own kind of  interesting argument.  Do you have the right to refuse  vaccination for your child  knowing you have an impact on  the society's herd immunity?  And that's a fun one to fight  with because the individual, the  protective mother, is going to  say I'm worrying about my kid.  Public health is going to say  you got to be worrying about the  entire community because we're  protecting each other given our  immune status.  And then, at the extreme, and  I'm pretty sure this is kind of  a minority view, vaccines are  produced purely for corporate  benefit.  I just want to show this slide.  This gives you a visual  determination that within these  early age groups here there is  no doubt children get a lot of  vaccines on a very condensed  timeframe.  I'm trying to find my cursor  here.  So this is the typical time  where you're giving most of the  vaccines.  These are all the vaccines that  are being given.  And those of us who are parents  who gone through repeatedly for  that two, four and six month,  there's no doubt they get a lot  of them. 

 They get as many as five at a  time.  And this practice has been  called into question.  They cost a lot of money.  Although I'm not sure there are  a lot of safety nets, both  through private provider,  through the federal government,  through the state government to  make sure vaccines are covered.  The one that has struck me, and  I throw it out there, and this  is what I really like to debate  is scientific resources versus  social media.  Where are we getting our  information?  My particular favorite is  influenza and this is a list,  I've given talks for influenza  for 20 years, talk about the  vaccination, and these are a  short list of issues that are  raised why we don't get our  influenza vaccine and only about  25%-30% of the population does,  in a good year.  We only vaccinate 70% of the  elderly, 35,000 of whom die  every year from seasonal  influenza.  So to me that's disgraceful.  But these are arguments.  You can debate and you're going  to believe what you're going to  believe here. 

 But it's an issue out there that  needs to be dealt with.  Finally, the last thing I want  to talk about here is one other  thing is the ethic issue here,  and this is a whole other realm.  Our most recent vaccine is the  human papillomavirus, which is  interesting over the last couple  decades certain subtypes of  human papilloma have been linked  to essentially 100% of cervical  carcinomas in females.  It is caused by a virus.  It is caused by a virus that we  now have a vaccine for.  But the effective time to give  this vaccine to prevent the  infection that can lead to the  cancer is when the individual is  as young as nine years of age.  Nine to 13 or 14.  And I'll tell you as a parent  I'm public health guy, that one  hit you as well.  You want to do discuss something  controversial, this is it.  And now we have the vaccine has  been approved for boys as well  so they can do their part here. 

 So there's going to be no end.  I put this up there not only to  inform you that's out there, but  there are going to be other  vaccines and other public health  interventions for a number of  the other sexually transmitted  diseases.  And we're going to have to deal  with that given the young age  that our children are becoming  sexually active.  And for those of us as parents,  or depending on your religious  beliefs and so on it's going to  be quite a balance for what the  public health needs have to be.  So I want to end on this slide  then.  I've gone over, hopefully I've  convinced, on a global scale and  a historical scale, I find it  hard to argue against the value  of vaccines.  I don't know who could.  That's my personal view.  But there are issues here  related to safety, related to  the ethics, related to should I  be commanded to take my vaccine,  what role, what say do I have in  this?  I put this up here.  I don't hear anybody or at least  only a very small group of  people saying do away with all  vaccines. 

 I think a lot of people are  saying we need to re-look at  some of this.  I'm saying we've looked at a lot  of these things, people want  more data here.  In any event, they're going to  need to be the dialogue.  I don't know how much of that  will happen after the meeting  here.  That starts getting into heavy  ethical issues and way heavy  scientific issues that go beyond  my hands-on knowledge here.  But I want to end pointing out  that vaccines are a good thing  but to reap and continue to reap  the full benefit, we've got to  confront some of these problems  so we don't continue to slide  back like we're doing in parts  of the world now for measles and  some of the other vaccine  preventable diseases.  So with that, I'll stop.  Thank you for your attention and  I will handle questions.  (applause)