OPERATOR: Welcome and thank you all for standing by. At this time all participants are in a listen-only mode until the question and answer section of the conference. Today’s call is being recorded. If you have objections, please disconnect. I would like to turn the call over to Benjamin Haynes.
BENJAMIN HAYNES: Thank you Holly. Thank you for joining us on the briefing on the U.S. measles outbreak. We are joined by Dr. Anne Schuchat, the assistant surgeon general, United States Public Health Service and director of CDC’s National Center for Immunization and Respiratory Diseases. Dr. Schuchat will provide opening remarks before taking your questions. I will now turn it over to Dr. Schuchat.
ANNE SCHUCHAT: Thank you so much for joining us this afternoon. I want to talk to you today about measles and here’s why. It’s only January and we have already had a very large number of measles cases. As many cases as we typically have all year in typical years. This worries me and I want to do everything possible to prevent measles from getting a foothold in the United States and becoming endemic again. I want to make sure that parents who think that measles is gone and haven’t made sure that they or their children are vaccinated are aware that measles is still around and it can be serious. And that MMR vaccine is safe and effective and highly recommended. From January until January 1 until January 28, 2015, a total of 84 people in 14 states have been reported as having measles. Most of these cases are part of an ongoing large multistate outbreak linked to the Disneyland theme parks in California. CDC is working with state and local health departments to control this outbreak which started in late December. Many of you know that in 2014, the U.S. experienced the highest number of measles cases we had reported in 20 years, over 600. Many of the people who got measles last year were linked to travelers who had gotten measles from the Philippines, where an extremely large outbreak of over 50,000 cases was occurring. Although we aren’t sure exactly how this year’s outbreak began, we assume that someone got infected overseas, visited the parks and spread the disease to others. Infected people in this outbreak here in the U.S. this year have exposed others in a variety of settings including school, day cares, emergency departments, outpatient clinics and airplanes. The information that we have is preliminary and the data are changing. We will be updating our website every Monday with the latest total counts. However, based on what we know now, we’re seeing more adults than we have seen in a typical outbreak. Children are also getting measles. The majority of the adults and children that are reported to us for which we have information did not get vaccinated or don’t know whether they have been vaccinated. This is not a problem with the measles vaccine not working. This is a problem of the measles vaccine not being used. Measles can be a very serious disease and people do need to be protected. Measles spreads quickly among unvaccinated people and can spread quickly from state to state or around the world. We must insure that vaccination rates remain high among children as well as insure that adults receive MMR vaccine if they’re not already protected against this virus. I want to briefly review the national measles situation this year and remind you about measles around the world as well as briefly go through the main recommendations for the vaccine. Thanks to the strong immunization system that we have and high vaccination rate here in the u.s. we declared measles eliminated. Measles continues to be brought into the country by people who get the disease when they’re traveling elsewhere. They can spread the disease to others which can lead to outbreaks. For several years after measles elimination, our numbers were very low. Between 2001 and 2010, we saw a median of 60 reported cases of measles each year. In recent years, we have had a higher number of reported cases and as you can see in January alone we have had more cases and was the median for the last decade. Measles is still common around the world and we estimate about 20 million cases each year. In 2013, about 145,700 people died of measles across the world. Measles can come into our country easily through visitors or when Americans travel abroad and bring it back. It can be a serious disease for people of all ages, even in developed countries like the U.S. for every thousand children who get measles, one to three of them die despite the best treatment. In the U.S., 28% of young children who had measles had to be treated in the hospital. Measles can also result in complications. In children they can develop pneumonia, lifelong brain damage or deafness. Of course measles spreads when an infected person breathes, coughs, or sneezes and people don’t always know they are infectious because you can spread the disease before the rash is evident. Measles is so contagious that if one person has it, 90% of the people close to the person who aren’t immune will also be infected. You can catch it just by being in the same room as a person with measles even if that person left the room because the virus can hang around for a couple of hours. This year so far as I mentioned from January 1 through 28, 84 cases of measles have been reported to us at the CDC from 14 states. There are an estimated 67 cases since December 28, 2014, that are linked to the outbreak — that are linked to the Disney land reports theme parks. State and local health departments are investigating the large multistate outbreak related to the theme parks and the initial cases reported visiting the resorts between December 17th and 20th, 2014. So far we know of 67 confirmed cases of measles linked to the outbreak and they have occurred in California and six other states. We don’t know exactly how this outbreak started but we do think it’s likely a person who was infected with measles overseas visited the Disney parks in December while they were still infectious. This reminds us that measles exposures can happen in this country in many settings and insuring age appropriate vaccination for all U.S. residents is very important. Maintaining high vaccination coverage is very important and it’s the best protection we have against disease outbreaks. I’m urging all health professionals to think measles. Health care professionals do need to know the guidelines for infection control and reporting of measles and they should work that their patients are getting the best protection possible which is on time MMR vaccination to protect them from acquiring this virus whether at home or abroad. The news this year is concerning and serves as a warning that measles is still coming into the united states and that unvaccinated people can get exposed. These outbreaks the past couple of years have been much harder to control when the virus reaches communities where numbers of people have not been vaccinated and of course when the virus comes into the country and exposing people at venues where many people gather, the chances of exposure are greater. One in 12 children in the United States is not receiving their first dose of MMR on time. That makes them vulnerable to get measles and spread measles. 9 5% of children are recommended to have received the measles vaccine on time. 17 states have less than 90% of children having received at least one dose. This sets them up for risk of spread of disease in their communities and in their schools. It’s not just young children that need to be up to date on their vaccines and we are starting to see more adults get measles and spread it. For adults out there, if you’re not sure if you have had measles vaccine or not or if you have ever had measles, we urge you to contact your doctor or nurse and get vaccinated. There is no harm in getting another MMR vaccine if you have already been vaccinated. I do want to remind you that unvaccinated people put themselves others at risk for measles for complications. Young babies cannot get this vaccine but they are very vulnerable to measles and complications. Pregnant women and people with compromising conditions like leukemia can’t get the vaccination and they are depending on others to have been vaccinated. We hope pregnant women have been vaccinated as children but we are learning of some who have not been vaccinated so they have to be protected through other means. This is not just to protect ourselves and our families but to protect the vulnerable people in our community. If a pregnant woman gets infected it increases the chance of many complications. We don’t recommend pregnant women receive the vaccination but they need to be vaccinated before pregnancy. For travel abroad, we don’t have the cut off of one year, but we recommend children six months and over get MMR vaccine before international travel to make sure they are protected when they go to parts of the world where measles is still circulating widely. A key reminder about the routine MMR vaccinations. The routine ones are for children to get their first dose at 12 months of age and a second dose between four and six years of age. But it’s fine for the second dose to be given earlier and doesn’t need to wait until the four to six years of age. And again for those adults and over that age, two doses are recommended for a full series. This is a wake-up call to make sure we keep measles from regaining a foothold in our country protecting our most vulnerable babies and others by assuring everyone who can be protected from measles is appropriately vaccinated. The very large outbreaks we have seen around the world often started with a small number of cases. I have told you before that France went from about 40 cases a year to over 10,000 cases in a year. It’s only January and we have already had 84 cases. Let’s work together to keep these numbers down and to keep measles from returning to plague our communities. Operator, i think we can go to the questions now.
OPERATOR: Thank you. If you would like to ask a question, please unmute your phone, press star 1 and regard your full name clearly when prompted. To withdraw your question press star two. First question is from Eben Brown with Fox News Radio. Go ahead your line is open.
EBEN BROWN: Thank you very much for doing the call today. Doctor, what are — a couple questions. One, how are our hospitals ready for this and did the need to further prepare hospitals during the Ebola situation late last year, will we have learned something from that with regard to taking care of measles parents should it become more prevalent? And how frustrating is it that there are these groups of people in the united states who question the effectiveness of the vaccine or potential side effect of vaccines and they don’t vaccinate their kids or themselves when they grow up? And you know, because as you have mentioned, herd immunity aspects that seems to be working counter to that and there seems to be more and more people getting more and more air time if you will about not vaccinating your kids.
ANNE SCHUCHAT: Thank you for those questions. We are so interconnected and the Ebola problem in West Africa has reminded Americans about health problems around and world and that our best protection is to fight outbreaks where they originate. The efforts to improve hospital preparedness do have relevance for measles. The importance of taking the travel history when people present with febrile illnesses. It’s not just measles and Ebola. Very important to ask about travel history in anyone with fever or rash. A second issue is infection control. We know with the Ebola concern and with measles that we really need strong infection control in hospitals. That starts with a clinical suspicion of illness, that illness can be spread from infected patients. And we have seen times where there is hospital spread of measles and a huge effort is needed in the case of hospitals to make sure their workers are protected and to reduce the risk of spread whether it’s in emergency departments or on the wards. But you know there’s a huge difference between Ebola and measles. In measles we have a very safe and very effective vaccine that has been given for more than 50 years so there’s an easy way for us to protect our hospitals and communities and I strongly recommend appropriate on time vaccination with the MMR. It is frustrating that some people have opted out of vaccination. I think it’s very important for people to have good information they can rely on about the safety and effectiveness of vaccines and for our system to serve people in making it easy, efficient, and convenient to get vaccines. But we do have a number — really a generation that has not seen these diseases. So whether it’s clinicians who have never taken care of measles before or parents who wonder whether this disease still exists, I think it’s important for us to educate them and remind them that we have safe and effective vaccines. Most parents are trying to do the best thing they can for their kids and most parents are vaccinating their children against all the recommended conditions. But some parents have questions and those questions I hope we can answer and I do hope people can realize these viruses and other germs are out there still and our vaccines really are still needed. Next question?
OPERATOR: Our next question comes from Anna Edney from Bloomberg News.
ANNA EDNEY: Hi. Thanks for taking my question. Are you concerned that the outbreak could get a lot worse with the super bowl coming up in Arizona? We know there are cases there and people have been exposed that might not know it yet?
ANNE SCHUCHAT: We have cases of measles right now reported from 14 states so it’s important for people everywhere to be on their guard. Very important for people to make sure their kids are vaccinated and if they are traveling abroad to make sure that they have been appropriately protected. Measles can spread in any setting, especially in places where many people are unvaccinated. I wouldn’t expect the super bowl to be a place where many unvaccinated people are congregated. I know it’s a highlight that many people are looking forward to this weekend.
ANNA EDNEY: Are there any special precautions that you are taking just because it is a large event?
ANNE SCHUCHAT: No — no. I think the main thing is that if people are having fever or rash, they need to let their doctor or nurse know about that and that clinicians caring for people with fever or rash need to think measles at this point and take a travel history and take appropriate steps. I think people really need to know that you can get measles anywhere. It’s invisible. And we have importations every year. As i mentioned, 20 million measles cases around the year in the world. So measles is being acquired in a lot of different contexts. We happen to know that there was transmission at the large entertainment venue in California but we know that measles is also being acquired in the community, schools, and elsewhere. What we can do about that is make sure that people are being vaccinated appropriately.
OPERATOR: Our next question comes from Maggie Fox from NBC News.
MAGGIE FOX: Thanks so much. Can you tell me a little bit about the hard epidemiology that is being done right now? How many people are you doing contact tracing on?
ANNE SCHUCHAT: Thank you for that question. I don’t have the actual numbers of the work in progress because I think that the people doing the work in progress are so busy they haven’t had a chance to put those numbers together this is a reminder that we are so dependent on the state health work force. They are diligently following up suspect illness to the laboratories are testing people to figure out whether it is measles or not and they are following up the contacts and trying to protect them if they recognize the context within a short period of time. They may be able to make sure they’re vaccinated or that appropriate other therapies. This is a huge effort. It’s a big effort with 84 cases being followed up. We really don’t want that number doubling and tripling or adding digits to it. So we really want people to be thinking about this now and if there are any questions whether your child is up to date or not, make that appointment.
OPERATOR: Our next question comes from Erik German with Retro Report. Go ahead your line is open.
ERIK GERMAN: Thank you. I just wanted to confirm you said at the top that there are 84 cases in 14 states but then later said there are 67 that can be definitely linked to the Disneyland theme park. I just wanted to know if the other additional cases are from somewhere else or if they just — the link has not been established yet.
ANNE SCHUCHAT: It’s a mixture there are some that might be linked when further investigation is completed. In a number of instances, we know of travel history or exposure to travelers from a number of other countries. So — that have another source that is not the Disneyland theme park. So I would say that so far this year we have a smattering of importations which is actually a greater number of importations than we usually would have in January, but the largest number is linked to the outbreak in California.
ERIK GERMAN: And that number is 67?
ANNE SCHUCHAT: Yes and let me clarify. The 67 people associated with the California outbreak includes Californians and people from six other states but it also goes back to December 28th, so it includes a handful of cases from 2014. 84 people i mentioned is the count from January 1.
ERIK GERMAN: Thank you.
OPERATOR: Our next question comes from Mike Stobbe with Associated Press. Go ahead your line is open.
MIKE STOBBE: Hi. Thank you, doctor for doing this. Back on the numbers. Let me finish that off. You said there’s two time frames here. Of the 84 this year, how many of them are related to the California outbreak and also could you say a little bit more about the 67 confirmed cases? Were any of them in a country that had a recent measles outbreak? You mentioned there are more adult cases than usual. Could you say how many of the 67 were adult versus children and what proportion of the 67 were vaccinated? Did you say there were pregnant woman and how many pregnant women? What proportions have been hospitalized?
ANNE SCHUCHAT: Thank you. The reality is I won’t have the answer to most of those questions. The ones that I can answer I would like to get correct. In terms of the outbreak that is related to the Disneyland resorts theme parks in 2015, there are 56 cases that are related to that and in 2014 there were 11. That’s where the 67 comes together for the Disneyland issue. The adult and children issue, we don’t have all of the details yet about the ages and so there is quite a bit that’s pending. I think we will be…of course it is going to be important to put this together. The median age of cases has been increasing. It’s over 20 right now. In terms of the hospitalization, so far for the information that we have, which is not on all 84 of these cases, 15 percent have required hospitalization and that is not that different than what we would typically see. I think it’s too soon for us to know whether the whole clinical spectrum and severity for this outbreak for this year is going to be different because of the larger number of adults. You know, one question we get is why are we seeing it in adults? I think a good answer is most children are vaccinated. There are a lot more adults than children and adults travel a whole lot more than children do in general. But we will need to wait for the full statistics to come through. As you know, 50 years ago we didn’t have a measles vaccine. Those of us who are over 50 were almost universally exposed to measles and got measles and became immune to it. Since then we have had more and more people in the U.S vaccinated and protected. We may be seeing a change in the epidemiology over the next few years and it’s an important question. We do have an easy way to not have to get into those questions by just making sure that people are vaccinated and in particular we don’t let ourselves get large communities with high levels of unimmunized people where the disease could be harder to control.
MIKE STOBBE: What about if any of the 67 have been to a country with a recent outbreak?
ANNE SCHUCHAT: The 67 — we don’t — I guess your question is do we know a travel history that will help us understand where measles came from to get into Disneyland whether it’s from an American traveling abroad or somebody from abroad visiting Disneyland. We don’t have that information. We do know that the genotype of the virus that’s associated with the Disneyland outbreak is causing outbreaks in 14 different countries around the world. So the genotyping won’t tell us the specific source yet. But — and we don’t have a travel history from the early case. There may be someone who was here and gone and will never know. But I think the investigation is ongoing. Next question.
OPERATOR: Our next question comes from Dan Childs with ABC News. Go ahead your line is open.
DAN CHILDS: Thank you very much for taking my question. It’s sort of a two-part question. We took a look at MMR vaccination rates in the U.S. throughout the decade and they have stayed pretty stable throughout the last few years and definitely higher rates than we saw in the 90s. We saw that California doesn’t have a rate — they are not that far below the national average in terms of MMR. To what extent is this wholly attributed to the pockets of under vaccination and is it that these pockets are getting worse?
ANNE SCHUCHAT: That’s a great question. The national estimates hide what’s going on state to state. The state estimates hide what’s going on community to community. And within communities there may be pockets. I think we do have some communities with many who have not received vaccines and the — five of those cohorts are increasing. It’s one thing if you have a year where a number of people are not vaccinating, but year after year in terms of the kids that are exempting, you do start to accumulate. We may have a number of communities, but this also may just be that there was a big — a whole lot of people around the virus in Disneyland and started quite a few individual chains that need to be followed up. We track coverage at the state level and the states track school entry MMR coverage. And things generally look good, but there are some schools and some school districts where things are a problem. I really appreciate the states that have been posting their school coverage data and their school exception data so community members have a chance to see what’s going on. But as you see, the overall picture has been getting better, not worse. It’s just the micro communities that we think make us vulnerable.
DAN CHILDS: And just one follow up if it’s okay. Should we in light of this be revisiting the notion of non-medical exemptions and whether they should be allowed? Also, if we have time, I would like to know what the 14 states are where measles has occurred so far in 2015.
ANNE SCHUCHAT: For the states I think we can get you that in follow-up. It may not be efficient for me to read them off. We will get you them. In terms of the non-medical exemptions, medical exemptions are absolutely essential. A six-year-old with leukemia can do not get the vaccine. But when she is well enough to go back-to-school we really want to make sure that she’s not going to get sick from others in the school. There is a reason for medical exemptions. It’s just absolutely essential in terms of not doing harm to a child. A number of states do have other types of exemptions. I know state by state they have been revisiting that sometimes states have made the exemption opportunities easier, sometimes they’ve made them harder. We know the easier it is to exempt, the more people will exempt. When states make it easier to get vaccinated than to exempt, we see higher rates of vaccination. I think it’s just important for us to know that vaccines protect individuals and they also protect the vulnerable people around the people who have been vaccinated. Next question?
OPERATOR: Our next question comes from Rosanna Xia with LA Times. Go ahead your line is open.
ROSANNA XIA: Hi Dr. Schuchat. Thank you for taking our question. Real quick for the other non-Disney related 67 cases, are there any links that you have identified or are they individual cases per state from international travel?
ANNE SCHUCHAT: I believe most of what we are seeing is individuals. You know, of course these are active investigations, but and the incubation periods may not have been followed because it is only January 29th. It may be too soon whether they will be related cases. At this point California’s Disneyland related outbreak is the one we’re following closely.
ROSANNA XIA: In your experience from looking at outbreaks, is the number of cases right now state to state from one specific epicenter like Disneyland, is this rate right now concerning? It seems slower than what a typical outbreak would be. Could you talk a little bit about how well officials are containing this outbreak or whether or not they should be doing more.
ANNE SCHUCHAT: We have had outbreaks that are of variable sizes. If we look at the outbreaks going back to 2008, you know, a number of the outbreaks were only 20 or 30 cases total and we have already got 67 cases from this and we know the number is going to be somewhat larger at least. The largest outbreak we had in recent years in the U.S. was related to the Amish community in Ohio. That was quite unusual because it was a large population where vaccine use was very low at the time. In most of these other settings, we are not seeing the virus introduced into a very large population with hardly any vaccination. So, the situation here is that we know that already, a number of states are following up cases related to this and we really don’t want chains of transmission to begin in those states or gain a foothold. We don’t expect this to be like thousands but we don’t want to give it an opportunity to become that. And again this cautionary tale that there are countries where they have started with 40 to 50 a year and gone to the many thousands in just another year. We don’t want to let that happen here. We want people to realize they should be checking vaccine records and thinking about this before they travel. Next question.
OPERATOR: Next question comes from Betsy McKay from the Wall Street Journal.
BETSY MCKAY: Hi and thanks. I have a couple of questions. One is, again, on the cases which are not part of the Disneyland resorts outbreak that you said were — looked like a smattering of importations. Do you know what countries those are from and in particular, I’m wondering if the — what you’re see something more from the Philippines if that outbreak is still going on. The second question or if not, is there a big outbreak going on someplace else in the world that is causing a larger number to come into the states right now. And the other question was about vaccines. There is a pretty sizable percentage it looks like in Disneyland outbreak who were vaccinated including something like 13% in California who had had two doses of the vaccine so I’m wondering, is there any indication or are you looking into at all into the possibility that vaccine effectiveness or immunity may wane with age?
ANNE SCHUCHAT: Thank you. Let me read a few countries where we have a history to links of recent measles case with a different country of origin, not to say that the person was of origin of the other country but there was a travel history. Indonesia, India and Dubai at a minimum and there is probably some additional ones that are under investigation. That’s for the 2015 importations. So we don’t have a definite Philippines travel history in any of our 2015 cases. Of course last year there were a number of importations that were associated with the Philippines last year. Now in terms of the vaccine history, the coverage of MMR is very high and the higher the coverage that you have, the more chances that you will have some fully vaccinated people get measles even though the vaccine is highly effective. We think two doses is probably like 97 percent effective but if you have really, really high coverage, if 95 percent or more are protected you will get some people who are two-dose failures. We’re at too early a stage to measure whether there is a problem of waning immunity or some unexpected vaccine efficacy but based on what we have seen so far we are not suspecting that. We like to keep an open mind and fully investigate but so far what we are seeing is consistent with a highly effective vaccine and a number of people that have not been vaccinated. Next question?
OPERATOR: Our next question comes from Matthew Stucker with CNN. Go ahead your line is open.
MATTHEW STUCKER: Thank you. Can you tell me how many people have been quarantined or isolated in this outbreak and of those people, how many did have measles or became infected or who didn’t become infected and also if there are still in people in quarantine or isolation? And also just to go back to the super bowl thing, there is tons of contacts that are still being watched. It didn’t seem like a place where people with measles would be congregating, but i don’t think that the people that went to Disneyland expected to get measles. I’m wondering why there is no precautions being taken there, especially in phoenix where they are still trying to track down 200 people from that hospital.
ANNE SCHUCHAT: Thanks. I don’t have the number of people who are being followed up and interventions that are being recommended for those people. What i can say is that if you have been vaccinated appropriate to age and are exposed to someone with measles, there is no special steps that need to be taken. So the easiest thing for the public health departments and families who are traveling is to be appropriately vaccinated and to have documentation of that. Certainly these are ongoing investigations in terms of what is being done. We — we don’t have those numbers. Now in terms of the super bowl, what i can say is that it’s — there are large public gathering in many places and they are cherished and valued events. The important thing in terms of our usual recommendations is if you’re ill, we recommend you not travel that you don’t get on an airplane if you’re sick or having fever. Of course it’s flu season. We’re seeing an enormous amount of people with illness right now and we are trying to suggest that people who are ill rest and stay away from others so that others can enjoy festivities. And just a reminder with an event like the super bowl going on that good vaccination can keep you healthy and able to go to these kinds of events. I think we have time for two more questions.
OPERATOR: Our next question comes from Jodie Tillman with Tampa Bay Times.
JODIE TILLMAN: the cases where the patients were not vaccinated, were some of them on the so-called alternative schedule where they didn’t get their second dose — had their first dose but delaying their second dose for whatever reason? If so if you could talk a little bit about the risks of that strategy? You do hear it sometimes from some of the parents.
ANNE SCHUCHAT: Thank you. We do know that some of the reported measles cases this year had exempted from vaccines. We don’t have all the details yet to know what proportion had delayed vaccine. We just, you know, had not yet gotten around to it yet versus who didn’t want it. We do know that the measles cases we have been seeing have generally been in people who have been unvaccinated and many of them not vaccinated due to personal belief exemptions. We do have some cases where people were at the doctor’s office and didn’t get the vaccine because of another illness or something. We recommend you should get vaccinated unless you have a severe illness. In 2014, 79 percent of the unvaccinated cases of measles in the U.S. were unvaccinated due to personal belief exceptions. Whether that data will hold up this year we don’t know.
JODIE TILLMAN: Do you know, if they have got their children —
ANNE SCHUCHAT: That’s a great question. Because i have spoken to parents who think, oh, you know, 12 months, do i really want to get my baby vaccinated at that age? Can’t i just wait? The reason that the MMR vaccination is recommended routinely at that age is because babies are vulnerable to measles and complications of measles and 12 months is the age where it reliably works well. We would give it routinely earlier if it were highly effective at much earlier ages for instance, less than six months. Between six and 12 months, measles vaccine will protect but it doesn’t last that long and you need to give two more doses so we recommend in the setting of outbreaks or if you are traveling internationally babies between six and 12 months babies get a vaccine they will just need two more doses. People who think my baby is too young to be vaccinated, that’s when your baby is at a vulnerable stage. The concerns that people had about whether the vaccine may not be safe or linked to autism have not borne out at all. The MMR vaccine, very safe, very effective, really necessary. And the 12 month routine first dose we strongly recommend. As we look through cases we have seen a lot of cases in infants and toddlers who were planning to get it but didn’t want to get it at the 12 month period and i would revisit that if that’s your children that I’m talking about. Last question?
OPERATOR: Last question comes from Lenny Bernstein from the Washington Post.
LENNY BERNSTEIN: I wanted to follow up on the 79 percent Do you have any good data of the number of people, the percentage of people in the United States who have chosen not to get the vaccine? Not the medical reason? Personal beliefs?
ANNE SCHUCHAT: No. In terms of the general population, we don’t. We have been tracking a number of things over time. One of the things we have been tracks something the percent of infants and toddlers who get no vaccines at all. There is a misunderstanding that when we talk about vaccine acceptance that everybody is dropped out of the system. We continue to have less than 1% of toddlers in the u.s. have received no vaccines at all. Almost every toddler is getting vaccinated with some vaccine most of the time. We don’t have data on, for the whole nation on exemptions. We do track kindergarten entries every state. And we report that every summer. Our website has that information. So state by state you can see what percent of kindergartners have gotten MMR vaccine as recommended and what percent are exempting due to medical or other exemptions. That is a number that we are following. Our effort has been to make the data easier to compare state to state and year to year. Measles is still around with 20 million cases around the world and this year we’re off to a bumper start. I strongly recommend people make sure their children are appropriately vaccinated and that they are vaccinated before travel or are protected against measles. Thank you for following the story and we will be updating our website on a weekly basis with the latest numbers. And thank you to the state and local health departments that are working day and night to follow up on all of the cases.
BEN HAYNES: Thank you. This is going to conclude today’s briefing.