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The Risk of Measles in International Travelers and the Role of Infection Prevention · The SHEA Podcast

• 0:07
  SPEAKER_05: Welcome to the International Travel Podcast brought to you by Society of Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:25
  SPEAKER_05: She is excited to launch the first episode of this podcast, The Risk of Measles in International Traveler and the Role of Infection Prevention.
• 0:35
  SPEAKER_05: We have four panelists in this podcast, Dr.
• 0:39
  SPEAKER_05: Bernard Cayman's, who is an infectious disease specialist and professor of medicine at Mount Sinai Hospital, New York.
• 0:46
  SPEAKER_05: He will be representing the United States East Coast and the system's perspective on this outbreak.
• 0:53
  SPEAKER_05: We have Dr.
• 0:54
  SPEAKER_05: Jane Zucker, an infectious disease specialist, who is the Assistant Commissioner for Immunization Program at New York City Health Department.
• 1:03
  SPEAKER_05: She will be addressing special populations.
• 1:05
  SPEAKER_05: Dr.
• 1:06
  SPEAKER_05: Soteros Diodris, a professor of medicine and infectious disease at Capodistrian University of Athens.
• 1:14
  SPEAKER_05: He will be giving us European perspective.
• 1:16
  SPEAKER_05: And finally, Dennis Trabicia, Regional Director of Infection Prevention and Control at Kaiser Permanente Northwest.
• 1:25
  SPEAKER_05: He'll be speaking to the United States West Coast population.
• 1:29
  SPEAKER_05: I'm Wali Jaweed.
• 1:31
  SPEAKER_05: I'm a hospital epidemiologist at Mount Sinai Downtown.
• 1:34
  SPEAKER_05: I'll serve as your moderator.
• 1:37
  SPEAKER_05: With this, we'll get started with the following questions.
• 1:41
  SPEAKER_05: So, Dr.
• 1:42
  SPEAKER_05: Zucker, can you give us a brief overview of the impact of measles outbreak in the US?
• 1:49
  SPEAKER_00: Yes.
• 1:50
  SPEAKER_00: 2019 was not a good year for measles.
• 1:54
  SPEAKER_00: There were 1,282 measles cases reported in the United States.
• 2:00
  SPEAKER_00: And that's the greatest number of measles cases since 1992.
• 2:05
  SPEAKER_00: 31 states were affected by the increase in measles, which means for those of us in the United States, really everybody is vulnerable, and healthcare facilities across the country really need to be prepared.
• 2:20
  SPEAKER_00: Three-quarters of these cases were linked to outbreaks in New York State.
• 2:25
  SPEAKER_00: In particular, where I am in New York City, we had 649 cases.
• 2:30
  SPEAKER_00: Our outbreak lasted from October 2018 to July 2019, and most of the cases were not vaccinated.
• 2:38
  SPEAKER_00: And just to remind everyone how serious measles is, for the U.S., there were 128 persons with measles who were hospitalized and 61 had reported complications.
• 2:49
  SPEAKER_00: Fortunately, there were no deaths in the United States.
• 2:53
  SPEAKER_05: Thank you, Dr.
• 2:55
  SPEAKER_05: Diodris.
• 2:56
  SPEAKER_05: Can you inform us of the measles impact in Europe?
• 2:59
  SPEAKER_02: Yes.
• 3:00
  SPEAKER_02: I would like to say that in December 2019, the World Health Organization announced that a disease that we were thought was almost eliminated around the world came back.
• 3:13
  SPEAKER_02: And by November 2019, cases had difficult compared with the same period in the previous years, but the most cases recorded worldwide since 2006.
• 3:22
  SPEAKER_02: And apparently more than 140,000 related deaths attributed to measles happened over the last couple of years.
• 3:30
  SPEAKER_02: As far as Europe goes, over the last year, 30 member states of the European Union reported more than 13,000 cases of measles, 79% of which were laboratory confirmed.
• 3:43
  SPEAKER_02: No countries amazingly reported zero cases during this 12-month period.
• 3:48
  SPEAKER_02: The highest number of cases were reported by France, Romania, Italy, Poland, and Bulgaria.
• 3:55
  SPEAKER_02: The notification rates per million populations were above the European Union average of 26 or 11 countries.
• 4:04
  SPEAKER_02: And I have to say here that the number of business cases reported to the European surveillance system may be an underestimation in certain countries, since there have been delays in case-based reporting for some of the countries that the numbers are not close to the real numbers reported or reported by the European authorities.
• 4:22
  SPEAKER_02: Infants and gun children were the most vulnerable population and at the highest risk of death in Europe.
• 4:27
  SPEAKER_02: However, the disease affected great percentages of people aged 15 years or older, depending on the vaccination situation in the country.
• 4:38
  SPEAKER_02: And I have to say that in the European region overall, more than 100,000 children and adults were infected with males in 2019.
• 4:47
  SPEAKER_05: Thank you.
• 4:48
  SPEAKER_05: Question for Dr.
• 4:49
  SPEAKER_05: Caymans and Mr.
• 4:50
  SPEAKER_05: Tropezia.
• 4:52
  SPEAKER_05: How was this outbreak managed from the health system perspective?
• 4:56
  SPEAKER_05: And how did you prevent the exposures in your facility?
• 5:00
  SPEAKER_05: And how can we best prepare for an outbreak from infection prevention perspective?
• 5:06
  SPEAKER_04: This outbreak was successfully managed through a cooperation between the health care systems within the New York metropolitan area as well as the public health agencies, such as the New York Department of Health and Mental Hygiene, the New York State Department of Health, and the Greater New York Hospital Association.
• 5:25
  SPEAKER_04: Public health officials from the outset were very forthcoming with the number of cases diagnosed, the number of exposures they were tracking and the areas that were heavily affected by this outbreak.
• 5:40
  SPEAKER_04: Educational materials geared to providers as well as patients and parents are very much available through the websites of the public health agencies.
• 5:51
  SPEAKER_04: There was also cooperation among the health care systems within the areas.
• 6:09
  SPEAKER_04: There was also scaring of science and expansion materials as needed.
• 6:15
  SPEAKER_04: In order to control the outbreak, constant communication.
• 6:21
  SPEAKER_04: We conducted several telephone conferences attended by managers and supervisors who ran the ambulatory sites as well as inpatient units that allowed them a forum to ask questions and to troubleshoot any issues that arose from implementing this action plan.
• 6:42
  SPEAKER_04: We were able to promote the use of the infectious diseases screening tool, which was already in place years prior to this measles outbreak.
• 6:52
  SPEAKER_05: Thank you.
• 6:53
  SPEAKER_05: Mr.
• 6:54
  SPEAKER_05: Trapezia.
• 6:56
  SPEAKER_01: So in our institution, infection prevention took the lead in working with multiple departments to ensure that we were ready for this potential influx of patients.
• 7:04
  SPEAKER_01: We tried to establish ourselves as the single source of truth to prevent confusion among staff.
• 7:11
  SPEAKER_01: Finally, we decided to use the three eye tool, which you guys may remember from the proactive steps in patient management used in Ebola and Zika in emergency departments.
• 7:21
  SPEAKER_01: So again, that's to identify, isolate, and then inform.
• 7:26
  SPEAKER_01: So to prevent exposures in our facilities, we really worked to identify cases at points of entry and have that communication with those corresponding personnel in those areas.
• 7:37
  SPEAKER_01: So for example, registration staff, triage nurses, ER urgent care doctors, we made sure they were able to identify the patients by signs and symptoms to appropriately triage those patients.
• 7:49
  SPEAKER_01: So we not only focused on the emergency department and urgent care locations, but since we do have several outpatient locations, we really honed in on our outpatient call center and nurse advice lines.
• 8:00
  SPEAKER_01: So making sure that they knew the signs and symptoms of measles and they could match those with exposure site dates that were provided through that partnership as mentioned with public health.
• 8:11
  SPEAKER_01: So it was through these phone calls that we were actually able to coordinate with all our facilities, either ones that had negative pressure rooms, for example, the large hospitals, urgent cares, and ERs, but also our small clinics, so that in these cases, through those phone calls, they could coordinate with meeting either the patient outside to do some laboratory draws or having a route to go through a back door so that we could do lab draws to confirm diagnosis.
• 8:39
  SPEAKER_01: So beyond properly identifying these potential cases, we wanted to ensure that our isolation ability was sound.
• 8:46
  SPEAKER_01: So we ensured that PPE N95 or equivalent respiratory protection was available and ready to use by staff.
• 8:54
  SPEAKER_01: We ensured that our negative pressure rooms were operational and staff knew how to read that they were operational.
• 9:00
  SPEAKER_01: We encouraged our patients through notifications on our external websites about measles, that potential exposure sites in the community, and there was also a notification message that said call before presenting to any of our locations.
• 9:15
  SPEAKER_01: We placed signs at the entrances to all of our facility locations in common languages spoken in our area and also languages of populations with lower vaccination rates.
• 9:27
  SPEAKER_01: We made sure that these signs had signs and symptoms of measles and directed the patient to immediately mask and notify a staff member.
• 9:35
  SPEAKER_01: A key point here to remember also is that you need to have masks available for both adult and pediatric sizes.
• 9:42
  SPEAKER_01: We also requested for our ambulatory sites, those outpatient clinics, that they come out with an airborne isolation plan.
• 9:50
  SPEAKER_01: So each site was to identify how they would either meet the patient outdoors or bring them through a back entrance to minimize exposure risk to other patients.
• 10:00
  SPEAKER_01: And then, of course, keeping the door closed for the recommended two hours upon patient departure.
• 10:05
  SPEAKER_01: Lastly, inform.
• 10:06
  SPEAKER_01: We ensured that infection prevention and public health were both notified of the potential case.
• 10:12
  SPEAKER_01: On the infection prevention side, we had a templated line list developed for locations so that they could turn it into infection prevention for exposure follow-up.
• 10:22
  SPEAKER_01: We also ensured that the template was identical to what public health was going to be requesting from us later.
• 10:28
  SPEAKER_01: It really helped us keep prepared.
• 10:30
  SPEAKER_01: My best advice to stay prepared is that you ensure you have a way to identify, isolate, and inform.
• 10:37
  SPEAKER_01: Remember that your goal is to prevent the outbreak from spreading in your facility.
• 10:41
  SPEAKER_01: Identification is the first step.
• 10:43
  SPEAKER_01: I'd start there.
• 10:44
  SPEAKER_01: Get your staff prepared.
• 10:45
  SPEAKER_01: Teach them how to identify it.
• 10:47
  SPEAKER_01: You know, some examples might be utilizing a simulation team, engaging your employee health to make sure that vaccination is documented on all of your emergency department and urgent care sites.
• 10:59
  SPEAKER_01: Be prepared for communications across your organization.
• 11:02
  SPEAKER_01: Communication will be key in these events.
• 11:05
  SPEAKER_01: So as I mentioned before, the external websites for patients, we made sure that there was a message to call before coming in.
• 11:11
  SPEAKER_01: On the internal websites, we made sure to have clinical guidelines.
• 11:15
  SPEAKER_01: You know, create those documents now.
• 11:19
  SPEAKER_01: People aren't as familiar with what it looks like anymore.
• 11:22
  SPEAKER_01: Evidence of immunity guidelines, isolation guidelines, both inpatient and outpatient, frequently asked questions about measles for patients and staff, and also ordering protocols, IgG, IgM, PCRs, and titers.
• 11:37
  SPEAKER_01: Simple as knowing that it's rubiola, not rubella, post-exposure prophylaxis order sets, nurse standing orders for vaccinations, signage with translations, list of measles exposure sites, and finally links and phone numbers to those important community public health departments.
• 11:56
  SPEAKER_01: And also, of course, your internal contacts.
• 11:58
  SPEAKER_05: Dr.
• 11:59
  SPEAKER_05: Caymans, can you answer what is the relationship between medical facilities and the public health?
• 12:06
  SPEAKER_03: I think the relationship between medical facilities and public health is very important.
• 12:10
  SPEAKER_03: One of the innovative ways screening patients actually occurred when our public health agencies gave us the zip codes where most of the cases were occurring.
• 12:22
  SPEAKER_03: What happened was we partnered them with our IT experts, then we would screen patients based on their zip codes and actually would have a best practice alert when these patients showed up in our urgent care facilities or our ER that would then warn the care provider that this person was from a high-risk area.
• 12:46
  SPEAKER_03: And we would not have been able to do that if our public health partners did not provide us the zip codes of the high-risk areas within the region.
• 12:57
  SPEAKER_05: Thank you, Dr.
• 12:58
  SPEAKER_05: Diodris and Dr.
• 13:00
  SPEAKER_05: Zucker.
• 13:01
  SPEAKER_05: How does it affect how we deal with international travelers from public health and from the perspective of hospital and outpatient facilities?
• 13:10
  SPEAKER_00: The most important thing from a US perspective is for people who are traveling overseas to know that they should know what their measles' immunity status is before they're traveling.
• 13:25
  SPEAKER_00: What we find is if people are going on an international trip, let's say they're going to Africa for a safari, people will regularly ask about what medication they need to take.
• 13:36
  SPEAKER_00: Do they need any vaccines?
• 13:37
  SPEAKER_00: But they wouldn't necessarily think about that for a European vacation.
• 13:42
  SPEAKER_00: As we've heard, there's a lot of measles in Europe.
• 13:45
  SPEAKER_00: And so it is critical that all travelers, regardless of where they're going, make sure that they're immune to measles.
• 13:51
  SPEAKER_00: And that would be done through vaccination.
• 13:54
  SPEAKER_00: That would mean two doses of a measles vaccine if people have proof of immunity through serology.
• 14:01
  SPEAKER_00: Children can get an early extra dose of MMR if they've only had one dose.
• 14:07
  SPEAKER_00: And the other recommendation is that children who are 6 to 11 months of age should receive an extra early dose of vaccine prior to international travel.
• 14:17
  SPEAKER_00: I will add that for returning travelers and also for international travelers who are coming into the US, travel history is really critical when you're evaluating an ill patient and certainly someone who has a clinical disease that presents with symptoms that are compatible with measles.
• 14:36
  SPEAKER_02: I think what's very important is early detection and management in returning travelers.
• 14:40
  SPEAKER_02: And measles, as Dr.
• 14:41
  SPEAKER_02: Zucker suggested, should be considered in the differential of patients, regardless of the rate, I have to emphasize on that in the country visited, especially in the presence of fever flu-like symptoms in the RAS.
• 14:54
  SPEAKER_02: The important cases defined as a traveler or visitor exposed to measles outside the country during the 70 to 23-day period prior to RAS contract, if this is supported by epier virological evidence.
• 15:08
  SPEAKER_02: For cases that were outside the country for only part of this 70-23-day period prior to the onset of RAS, we have to investigate whether the exposure to another measles case likely occurred outside or within the country to determine the source of infection and whether the case can be considered imported.
• 15:27
  SPEAKER_02: And I have to remind you that imported cases are defined by the place where the case was infected, not the country or residence of origin of the case.
• 15:35
  SPEAKER_02: With regards to Europe, importation status was reported by 30 countries, and uh 4% of our cases in Europe were considered to be import related.
• 15:46
  SPEAKER_02: Now, uh when we talked about the origin of imported cases, this varied significantly by country, and this reflects historical links or tourist behavior.
• 15:56
  SPEAKER_02: But overall, most of the European Union importations came from the European Union followed by the wider European region.
• 16:05
  SPEAKER_02: While we continue to have endemic countries and such a mobile population within the bloc, then achieving elimination will not be possible.
• 16:14
  SPEAKER_02: The current approach to measuring elimination on a country-wide basis, it doesn't support the achievement of a regional elimination goal.
• 16:22
  SPEAKER_02: I believe this in contrast with what happened in the Americas, where the emphasis was placed on supporting other countries so that regional elimination could be achieved.
• 16:32
  SPEAKER_02: In Europe, misses continues to spread because vaccination coverage is above optimal.
• 16:37
  SPEAKER_02: Sustained coverage of at least 95% with two doses of the vaccine at toll subnational levels is recommended.
• 16:45
  SPEAKER_02: However, the latest WHO unic data estimates that only five European Union countries, and namely Hungary, Malta, Portugal, Slovakia, and Sweden, have reported at least 95% vaccination coverage for both the first and second doses in 2018.
• 17:04
  SPEAKER_02: If the elimination goal is to be reached, many countries need to make sustained improvements to the coverage of the routine childhood immunization programs and also close immunity gaps in adults and adults who have missed vaccination opportunities in the past.
• 17:19
  SPEAKER_02: I think right now there is a high risk of continued widespread circulation in Europe.
• 17:25
  SPEAKER_02: It's considered a serious cross-border threat to the health in the European Union, even though most states are deemed to have interrupted endemic transmission.
• 17:35
  SPEAKER_02: And re-establishment of transmission is possible when vaccination coverage is above the fact.
• 17:40
  SPEAKER_02: And I will finish with a number.
• 17:42
  SPEAKER_02: According to the International Air Transport Association, 422 million people, international travelers, traveled within the European Union in 2017, and that was the number of life passages alone.
• 17:55
  SPEAKER_02: This number does not account for other means of transportation.
• 17:58
  SPEAKER_02: You can imagine with this huge mobility and with the disease being endemic in several countries in Europe, there is a high likelihood of transmission through travel.
• 18:07
  SPEAKER_02: And a supplementary dose of the vaccine has to be considered as well as checking and updating vaccination.
• 18:14
  SPEAKER_02: This should be routine practice during any travel medicine consultation.
• 18:18
  SPEAKER_05: Thank you.
• 18:19
  SPEAKER_05: Mr.
• 18:19
  SPEAKER_05: Tupita, can you tell us about the impact on special populations like immunocompromise, pregnant women?
• 18:27
  SPEAKER_05: What did you specifically do?
• 18:28
  SPEAKER_05: How did you manage those special populations?
• 18:32
  SPEAKER_01: Well, these special populations should know their vaccination status to begin with.
• 18:37
  SPEAKER_01: And now is a better time than any for them to identify what vaccinations they're requiring, and whether it be for you or your patients, also identifying what vaccinations our patients may not have and being able to help them complete those.
• 18:53
  SPEAKER_01: So measles infection during pregnancy can definitely be associated with increased maternal and fetal complications, as well as an increased risk of preterm labor and delivery.
• 19:03
  SPEAKER_01: Being up to date on your vaccinations prior to pregnancy is very important, not only for your protection, but also to potentially offer protection to the baby during the first few months of life.
• 19:14
  SPEAKER_01: This is especially important since baby will not get their first MMR until one year of life based on CDC immunization schedule.
• 19:22
  SPEAKER_01: It's also important to note that for post-exposure prophylaxis, the MMR is contraindicated for special populations like pregnancy.
• 19:31
  SPEAKER_01: In these cases, immune globulin is an option and it should always be prioritized to those who are pregnant under six months of age and immunocompromised.
• 19:41
  SPEAKER_01: Remember, it's also important to ensure that immunoglobulin is available at the locations where you're going to send the patients to report for post-exposure prophylaxis.
• 19:52
  SPEAKER_01: Lastly, MMR can be given postpartum and it is safe to breastfeed after receiving the vaccination.
• 19:59
  SPEAKER_01: If possible, these special populations that we've discussed should avoid contact with those diagnosed with measles.
• 20:05
  SPEAKER_05: Dr.
• 20:05
  SPEAKER_05: Zucker, can you talk about healthcare worker vaccination and proof of immunity to measles?
• 20:11
  SPEAKER_05: We keep on getting these questions about the third dose of MMR, or is it even relevant?
• 20:16
  SPEAKER_05: And then is there any time when an additional measles vaccine would not be helpful or would be helpful?
• 20:23
  SPEAKER_00: So the guidance in the United States, and that's the guidance is from the Advisory Committee on Immunization Practices, is that all persons who work in health facilities, and just to emphasize, this is more than just the medical providers, it includes the janitors, receptionists, the people who are working in food service, that everybody should have presumptive evidence of immunity to measles.
• 20:50
  SPEAKER_00: And in the United States, there are some states that actually do have this requirement that healthcare workers be vaccinated and have proof of vaccination.
• 21:00
  SPEAKER_00: What we mean by proof of immunity is written documentation of two doses of a measles-containing vaccine.
• 21:07
  SPEAKER_00: It would be a live measles-containing vaccine.
• 21:09
  SPEAKER_00: In the U.S., this would be given as measles mumps rebelle or the MMR vaccine.
• 21:15
  SPEAKER_00: The two doses should be given 28 days apart.
• 21:18
  SPEAKER_00: It can also be laboratory evidence of immunity, which would be serologic evidence through IgG antibodies.
• 21:26
  SPEAKER_00: A person can also have laboratory evidence of prior disease, and we do consider people with birth before 1957 as having presumptive immunity in the United States.
• 21:38
  SPEAKER_00: I do know that some facilities will still get serologic evidence on these persons, just to be sure.
• 21:44
  SPEAKER_00: We certainly have seen persons with measles who were born prior to 1957.
• 21:50
  SPEAKER_00: A common problem that were asked about is that an employer may still require serologic proof of immunity, so a healthcare worker has two documented doses.
• 22:00
  SPEAKER_00: And then they get titers and the person is seronegative.
• 22:04
  SPEAKER_00: Then the question becomes what do you do in those circumstances?
• 22:09
  SPEAKER_00: The ACRP guidance is that the vaccination records would supersede the serology and the person would not be recommended to get a third dose.
• 22:19
  SPEAKER_00: That's the official recommendation, but I will say that there are many facilities that have given the third dose, and this was especially true in light of the large outbreaks that we had in the US.
• 22:32
  SPEAKER_00: If a facility chooses to give the third dose, they should not check the serology afterwards.
• 22:38
  SPEAKER_00: So my last point about healthcare workers and immunity, the measles vaccine works really well and has high serologic conversion and is very effective, but it's not 100% effective.
• 22:52
  SPEAKER_00: So you still could have healthcare workers who have proof of immunity who can still get measles.
• 22:58
  SPEAKER_00: And because of that, and measles is airborne transmission, it is recommended that healthcare workers who are evaluating a patient who might have measles or as a known measles patient that they should take airborne precautions to prevent nosocomial transmission and the possibility that they can come down with measles themselves.
• 23:18
  SPEAKER_05: Thank you.
• 23:18
  SPEAKER_05: Mr.
• 23:19
  SPEAKER_05: Trapezia, can you provide some final thoughts on the role of infection prevention management of measles outbreaks?
• 23:26
  SPEAKER_01: You know, I think about being part of a larger community and how it's an advantage to you and that it's an advantage that we should take.
• 23:34
  SPEAKER_01: So our community of hospitals in our area, our county public health departments already are there for us to utilize, and we really need to reach out to them.
• 23:44
  SPEAKER_01: In our area, we were lucky that we established a weekly standing influenza meeting to talk about influenza in town, how it was affecting different medical centers.
• 23:53
  SPEAKER_01: We were able to turn that into a weekly meeting about measles updates, what was happening, what was working for different institutions, and what tips could you provide to other institutions that you'd like to share.
• 24:04
  SPEAKER_01: By the end of it, honestly, I had the major healthcare infection prevention directors on text, and we would text each other every day with any issues or concerns, even complaints that we had about certain situations.
• 24:17
  SPEAKER_01: It really helped build that collegiality.
• 24:20
  SPEAKER_01: So one thing I think we all learned is that we're all in this business together, from public health to our other healthcare institutions in town.
• 24:28
  SPEAKER_01: We all serve the same community, and we are all doing and can do amazing work when we work together closely.
• 24:35
  SPEAKER_01: It's really my belief that infection prevention is in a key position to be that one source of truth for outbreak prevention information, and that these are the steps we need to take toward infection prevention, and they start now.
• 24:48
  SPEAKER_05: Dr.
• 24:49
  SPEAKER_05: Caymans, can you provide some lessons learned from this outbreak?
• 24:54
  SPEAKER_03: So one of the things that we really learned was that because our attention was focused on the local outbreak in New York City, some of our healthcare workers actually forgot that international travelers can come in with measles as well.
• 25:09
  SPEAKER_03: So one of our first cases that resulted in exposure was actually a child who traveled from Africa to visit the United States.
• 25:19
  SPEAKER_03: I think it is really important, as everybody else has said, is to keep everybody's attention focused and that what we're supposed to already be doing, which is screening travelers anyway, is that someone actually did not think about it but was worried about the local spread of measles.
• 25:40
  SPEAKER_03: And it turns out the one that we were supposed to be focusing on ended up uh exposing some healthcare workers and other patients in our healthcare system.
• 25:49
  SPEAKER_03: So I think it is important to educate and to continue to focus on our preventive measures.
• 25:58
  SPEAKER_05: Thank you, Dr.
• 25:59
  SPEAKER_05: Zucker.
• 26:00
  SPEAKER_05: What in your opinion can be done to prevent this from happening again?
• 26:04
  SPEAKER_00: So the most important thing we need to do collectively to prevent another large measles outbreak in the US is to ensure high measles containing vaccine coverage, high MMR vaccine coverage.
• 26:20
  SPEAKER_00: We need to address what some of those root causes are of parents delaying vaccination, children not getting vaccinated.
• 26:30
  SPEAKER_00: We need to be able to respond with empathy to parents when they may be concerned whether a vaccine is safe.
• 26:38
  SPEAKER_00: We need to be able to answer their questions, give them the information they need.
• 26:42
  SPEAKER_00: We need to be able to direct them toward trusted resources where they can get reliable and true information.
• 26:50
  SPEAKER_00: The anti-vaccine community has been very effective through social media at spreading misinformation, and we need to be prepared with materials to really counter their information.
• 27:02
  SPEAKER_00: We need to make sure that parents have access to reliable and good information about the safety and importance of vaccination.
• 27:10
  SPEAKER_05: Thank you to our speakers, Dr.
• 27:11
  SPEAKER_05: Bernard Caymans, Dr.
• 27:13
  SPEAKER_05: Jane Zucker, Dr.
• 27:14
  SPEAKER_05: Soteros Diodras, and Mr.
• 27:17
  SPEAKER_05: Dennis Tripiza for sharing your perspective and experiences, looking to expand your knowledge in infection prevention.
• 27:24
  SPEAKER_05: Then join us for the Sixth International Conference of Healthcare Associated Infections, Decennial 2020.
• 27:30
  SPEAKER_05: This conference will be held in Atlanta, Georgia from March 26 to 30th and is co-hosted by SHA and CDC.
• 27:38
  SPEAKER_05: Find out more and register at www.decennial2020.org.
• 27:44
  SPEAKER_05: This concludes the first episode of International Traveler Podcast.
• 27:48
  SPEAKER_05: Stay tuned for our next episode, The Risk of CRS and CRE from International Medical Care and the Role of Infection Prevention.
• 27:57
  SPEAKER_05: Thank you.