 First of all, thank you all for joining. Michael, thank you for pulling us together. And Heidi for coming and spending time with us here. This is all really oriented around trying to hear from Heidi about the very creative and thorough work that she's done trying to establish this framework for understanding how trust and confidence is endangered and sustained and what kind of engagement strategies and what are the multiple variables that come into the equation. And I think this is terribly important given the complexities of the situation and the priorities that are attached now around vaccines and expanded priorities and focus on immunizations. And so we're thrilled to have you here today, Heidi. What I would suggest is that we roll through your presentation. People hold their questions and comments unless there's some factual clarification on a particular slide. Then we're going to have a discussion towards the end. Please use the microphone where Julia Noggle kindly has agreed to videotape our session. And we'll post that shortly thereafter. And so please use the microphones when you speak so we're sure to get that onto the video recording. So Heidi, why don't we just kick off here and you can lead us through your presentation. Thank you. Great. Thanks, everyone, for coming. I titled the talk addressing the vaccine confidence gap. It's a title of a paper I recently led in the Lancet. It was part of a series on vaccines. And really it was trying to capture what the state of public trust is in vaccine and as I subtitle it, why do we need to listen? Vaccine questioning is as old as vaccines themselves. I think we've got one of my favorite pictures is the vaccination monster from early 1800s where smallpox vaccination was mandated in the UK and it was not well accepted by the public. But really it was not an obsession or concern as much about vaccine safety as about the compulsory angle of vaccines. And when we think about some of the questions and issues and resistance to vaccines in different settings, and this is, there's really a lot of political undertones that we should not, we should be conscious of and sometimes it's just the fact that they're mandated and it's more an issue of autonomy than necessarily the specifics of the particular vaccine. That's an old thing and it's only gotten stronger. 200 years later, I don't know if you'd pop onto iTunes and look at the vaccine zombie song. It's another iteration, a more contemporary interpretation of the vaccine monster. That the whole tone of this is I forgot to think for myself, yeah, I don't understand a thing about health, yeah, I do the same as everyone else, yeah, I'm a vaccine zombie. The details of this, it's quite a sophisticated animation and quite long and I won't get into the whole thing. But the whole thing is about sure, I'll do anything you say boss, CIA, NIH, and it goes into a whole wrap of acronyms of health agencies, telling them what to do and it's like yes, I'll do what you say, I don't have a mind of my own, which is really the sentiment. So it's quite an interesting, similar issue about autonomy and don't force this on me, I have a mind of my own. What's driving this confidence gap? As I was saying, it's the tension between individual rights and societal rights, sometimes distrust in government, do either previous bad experience or an unrelated to health issue about a trust relationship with the government. Vaccines and immunization are one of really the most and in some cases only mandated health intervention or regulated, even if it's not mandated, it's not the kind of thing you can go to the shop and buy condoms or you can buy other health interventions that really are up to your choice. It's the mechanisms where you get vaccines are much more controlled and managed. There are safety concerns, genuine safety concerns, real safety concerns, perceived safety concerns. There's also a lot less tolerance for vaccines that are injected into healthy, particularly babies than when you're sick and you want a drug, you can, you'll tolerate much more risk if you're really sick and want something to make you better. And there's an emerging elitism, believes that they shouldn't take the risk for their child, even there's enough other kids getting vaccinated that's not unique to wealthier countries, it's also true in some of the developing countries, the wealthier elite. I've seen in a number of countries are the ones that are least accepting sometimes of these vaccines or some vaccines. There's also a growing skepticism in scientific truths and that's not unique to vaccines, we see it with genetically modified organisms, they call them GMO, with climate change skeptics, we see it in a number of places. The AIDS denialists and vaccines are not immune to that overall environment. Perceptions of business and financial motives, particularly in, well we've seen it in a big way around H1N1, but also in some of the poorer countries, why are you pushing, the perception of pushing more expensive vaccines on us, and then there's the philosophical or religious beliefs which has been a historic and continues to be a contemporary issue. So what's our current paradigm for dealing with this, the perception is give them more information and they'll support vaccines, and I think we've hit a wall with this that just, the just shout louder issue is not going to solve the problem. In fact it's aggravated the problem in a number of cases. What we're seeing is that actually it is the under informed and the over informed that are creating the anti-vaccination questioning vaccination, and then there's this kind of medium in the middle that actually doesn't question that just takes immunization as a norm and has enough information but not too much or too little. So it's a different kind of paradigm that the reality is that we're seeing based on our research. So my conclusion and my start is do not assume communications will fix the problem without understanding the problem, and I learned this in a deep way, heading up communications for immunization globally for UNICEF and heading up the Advocacy Task Force for the Global Alliance on Vaccines. I often had calls and people coming in and say, you know, you need to communicate better, we have a problem. And I said, well let's talk about the problem first, because sometimes it wasn't about communication, it was about just about anything else, and communication actually was not the issue. In terms of examples of it's not communication, sometimes a lot of the public health community is saying, well, we just have to communicate better on risk and benefit, but risk is a very relative thing, and as one of the biggest anti-vaccination groups in the states has on their home page or had on their home page when it happens to you or your child, the risks are 100%. So to have a doctor say at you, well, it's only one in a million chances that this vaccine will kill your child, they say, well, or hurt your child or whatever the extreme here, but the notion of risks is different. The internet and social media have, as is obvious to everybody, it's been a big source of new information, but what's less looked at sometimes is it as a mode of self-organization and empowerment. I think it's, the information sharing is one issue, but I think what has really been the most transformational aspect of the internet is it's allowing people to organize across and disparate geographical areas both locally and globally. People are getting different kinds of evidence. This was in 2002 some research in Australia. We've updated this information in our own research at the London School, but it showed that the top 10 sites that came up, if you did a Google search on the word vaccination were anti-vaccination. If you put in immunization, it was a bit more kind. That's changed a bit. We redid this a few months ago since 2002, but there's still a disproportionate number of negative sites that come up just putting in the word vaccination. So something's wrong with that picture. I've been working on this issue of growing questioning and public concerns for 10, 15 years. I've had a number of doors closed in my face at the World Health Organization and other places saying it's fringe, it's not a problem, it's wheatgrass eaters, it's other people who don't get it. And I realized the only way to communicate and get the public health side to come around to this is to give evidence, data of impact that their health programs are being affected. And we've done quite a bit of research on this and this is just a glimpse of the data we have in the Philippines, some fears about the tetanus vaccine led to a 45% drop in coverage between 1994 and 95. In 98, the French government suspended hepatitis B vaccine from schools, not nationally because of public pressure about a concern about a link to multiple sclerosis, which was repeatedly disconnected by scientific evidence. And in fact, WHO gave an advisory letter to the government before they suspended saying this is not a problem. And they went ahead and did it and to this day, France really has persisting the lowest in Europe coverage of hepatitis B vaccine. So these things stick. I mean, one of the other points that the research we're doing is that if there is an issue and a public distrust, don't think you can clean it up and it'll go away forever. It will, depending on how you manage it, can persist. In the Ukraine, a few years ago, there was a campaign on measles ravella vaccine, a ketchup campaign, and they were targeting 7.5 million of the population. And because of one episode that got a bit amplified and a scare about an MR vaccine, only 116,000 people accepted it. So these things do have impact. And the one thing about vaccination and immunization is that it's very quantifiable, very measurable. And if you're looking at an indicator in the health field, that can be evidence for underlying distrust issues around health, it's a good one to get a handle on. One of the biggest episodes that was evidence of the potential impact of distrust was the boycott of the polio vaccine in northern Nigeria that started in 2003. It was five states that decided that they would boycott the oral polio vaccination campaign for a number of reasons that turned out to be a mix of political, historical, the dossier that they put together to give to the head of UNICEF about why they were boycotting included internet searches of US population policies from many years before. There were documents from that episode of tetanus suspicion of sterilization in the Philippines. The US intervention in Iraq meant that the US was trying to eliminate Muslims. This was one strategy. A lot of the USAID logos on boxes was not a welcome thing. In addition to it, the boxes said sterile, which, of course, meant they're about to sterilize us. There were a number of converging factors in addition to which the head of state was saying, we're going to do this. And it was a new head of state who had won over the Northern candidate. And therefore, they were not interested in making the new head of state look good in the face of his peers at the World Health Assembly. So there were a converging number of factors. But this persisted in one state, in Kano State, for 11 months, which was enough to turn the global eradication effort upside down and cost millions of dollars and tremendous effort, including disease spread. Just in that one year and in that part of Nigeria alone, the cases went from 784 to 1100. This was not just uniquely an episode that provoked questioning in Nigeria. It went to India and around the world. It spread from Northern Nigeria across Africa, and interestingly enough to Indonesia. Why Indonesia? Well, they all met at Mecca. So this is an example of the flow. And in Angola, there were cases that had popped over from India. But out of this Northern Nigeria boycott, it had an absolute global impact. They hadn't included the links to Pakistan here, which we're now seeing had a much bigger impact than we had anticipated. What happened there? Well, you can see that the convergence of new outbreaks was in the north, which is exactly where the boycott was, just to make our point about the impact of refusals. And also, another important thing that we learned in the research there, this was with UNICEF, that the reasons in districts that were right next to each other were different. So you can't assume that the reasons for the boycott were uniform across. So one of the important lessons you really need to listen locally to what people are saying here. The biggest fear was a side effect than religious and other reasons. In another thing, the biggest one was religious beliefs. Right next door, it was less than a kilometer different. So you really need to look locally if you really want to address some deep underlying distrust. The sources of what different states, these were the colors here are the different states. In one, the absolute authority was the church. In another, it was a town crier. They called it town crier. It really varied. So not only the nature of the concern, but the source of information varied by local districts. So, and this is not unique to Nigeria. This is just, we have some good data on it as an example. But so what's happened? We've done tremendous progress with polio from the launch of the global eradication effort in 88. And really a 99% reduction by the anticipated eradication goal of 2000. But we've pretty much been stuck for the last decade. It's hard to see on this. I'll show you in the next slide. But those last 10 years have looked like this. And continue to, actually the dotted line has been recently confirmed. That was the big outbreak in the Congo that had not yet been verified when this was made. It has since been confirmed. So it's been a real roller coaster. And you can see in the first, from 2001 to 2002, that was an outbreak of distrust in India, in Uttar Pradesh, between 2003, 2004, or five was the implications of the Nigeria episode. It had been slightly resolved. And then there was another outbreak of problems in Nigeria in 2007. Our next wave is Pakistan. And that's where our biggest problem is right now. I recently did an article in Nature called lessons from polio eradication. The main point of the article there is that we really, one that our next big concern is Pakistan while we've been focusing our attention appropriately on India and Nigeria, the situation has changed there and we have a 90% increase in cases in polio, whereas the others dropped. And the importance of tailoring strategies to communities. In a lot of the work, in the five years I was heading up the communication on immunization in UNICEF and with Gavi, I basically been brought in to be, to develop more positive strategic ways to move and expand on immunization. And, but I developed the nickname, the director of UNICEF's fire department because it turned into one episode, my training, I'm an anthropologist by training one episode after another of crisis outbreaks. Tehran, Sarajevo, Hanoi, you name it, the phone was off the hook. They don't want our vaccines. What do we do about, you're an anthropologist. Go figure out what these people are thinking. And a lot of the times the rumors that we heard were not really what was going on. In Uttar Pradesh and India, for instance, they're gonna sterilize us with the vaccine but when you sit was the perception but when you would sit down again at a local level there were very tangible issues. The women, the mothers didn't want their children vaccinated by a man. They didn't wanna be vaccinated by some person coming from Delhi that they don't know and they don't trust. And there were some very tangible things that when you listened which was the point of my work is that actually there's some very useful things that are not necessarily the big scary things that get picked up in the media because they have a sensational spin so we really need to understand better. After this, with each of these crisis management episodes that I worked on I would sit down at the end of a mission and try to unpack a bit how they got to the problem they got to. And every time we found signals of problems, three, six, nine, sometimes 12 months earlier that somehow they brushed under the carpet or thought would go away or wish they would go away. So I developed a system, what I call an early warning system to move from a focus on crisis communication to one that really looks much more at getting an understanding of the situation because typically you have a disease that the vaccination coverage goes up, the disease goes down, you have an episode of a problem and you lose your confidence, you have to work hard but instead of dealing with it as a crisis to try to preempt that pattern. The objective of the research that we're doing it's we've built an information surveillance system partnering with ProMed which actually does rumor detection for disease outbreaks but we've built a parallel system with them with a whole different set of criteria that is really listening for rumors of public concerns about vaccines. We also look at disease outbreaks when they are vaccine related but and we're doing this globally and then the collection of information is I think less is innovative but not as innovative as the diagnostic tool that we're developing which is assessing the risk level of what we're hearing and that risk level is determined by a number of criteria based on our retrospective analysis of previous problems and understanding what it was that tipped a rumor into a statewide boycott or another problem and then to develop guidance for a response so that's the top three points. This is it, we have a lot of data collection right now. It's we're scanning media, blogs, government reports, it's global a number of different things and in addition to that right now we're developing what we call local listening networks with individuals on the ground. We have a team right now I have in Kenya and we're doing this in a number of countries because it's important to get individual informants also we need a mix of sources. Develop the diagnostic tool and then I have an alert every day I get on my blackberry. The red alerts come straight to me and the yellow ones are watched let's dig into more information and the green is just filed but keep it on track. This is just a glimpse of our database. Again I think what's different here and the immunization field has a reasonable amount of monitoring for adverse events following immunizations if there's any problem with a vaccine anything from redness to any kind of severe or mild reaction is reasonably well documented and there's a system for it it's stronger in some countries than others but there's absolutely no before we started this systematic monitoring of the whole scope and range of other concerns that the public might have some of which may not actually be specific to the vaccine but everything from some of the things that we are gathering up there. This is the typology we've developed this has been described for the first time published in the Lancet article that we passed around but I'm looking at what some of the really some of the best risk analysis that I've drawn from is around environmental risk and energy around how the public deals with like bringing in nuclear energy or other things there's a lot of sophisticated work I was a faculty at Clark University that innovated this concept of social implication of risk I've applied it to vaccines and look at not only what prompts rumors which could be an adverse event could be a problem that people get different understandings of what the problem was could be a piece of new research the famous Dr. Wakefield who actually had a piece of research published in the Lancet which has since been withdrawn and his metals defaulted and everything but he's become an absolute and total martyr and hero of the anti-vaccination groups now and it just got prompted and this and has been around the world multiple times a new recommendation or policy change when the U.S. recommended removing thimerosol from it was a joint statement by the Academy of Pediatrics and it was not a requirement it was a recommendation it created panic at a number of levels because when you do something even in a precautionary way it's interpreted as Houston we have a problem and it has a public reaction new products we found with UNICEF even sometimes when it was the same product I would get a call from Wagadugu saying we have a problem here the people don't want that vaccine it's a red label we say it's the same vaccine it's a red label it was green before we don't trust it so things that you don't think about may provoke some questions and of course political motivations why are they showing up at our door giving us the same bloody polio vaccine 20 times and my neighbor's kids still got polio what's the motivation we don't believe it you're not giving us vaccines for the measles and cleaning our dirty water which is really what's making my child sick so it's suspicion in addition to rumor prompters a lot of what we're doing is we're doing an analysis of what are the sustaining and amplifying factors you can get exactly the same rumors in two different settings that one of them blips and dies and you never hear it again and in another place it can become a statewide boycott and what is it about those what we call sustaining and amplifying factors the framework of social amplification of risk talks about amplifying and attenuating factors but what we're looking at is when a rumor comes up or what we call a signal does it spread geographically we also want to bring in some GIS mapping of clustering of rumors what is the frequency is it picked up in the media is there a historic experience of bad trust in the case of Nigeria and in northern India where we also had distrust problems there were absolute historic reasons for these people to have concerns in India it was a history of forced sterilization in northern Nigeria there was a court case going on about a failed Pfizer clinical trial that was suspected to have killed some children that court case was actively going on in the background in Kano state at the time of this it was an absolute influence on the trust level socioeconomic marginalization there's always a different level of suspicion by communities that feel that they've been marginalized in terms of access to health and other services when you come along with something else that's gonna preempt their trust and previous existence of self-organized community groups one of the things we picked up in our surveillance system was suspicions and concerns about the HPV vaccine in India that was ultimately absolutely shut down by the government because of pressure by a women's highly organized women's group and a communist member of parliament who got together and said we don't like what's going on with this demonstration project trying to look at introduction of hepatitis B vaccine and they successfully did that they were not a health group they were not a vaccine group they were a women's group and a member of parliament who picked up on some of the dynamics there what are the impact potential impacts in this case vaccine refusals or vaccine is withdrawn or we get disease outbreaks as we are in multiple pockets in the U.S. around participants most measles, pertussis and as you saw polio this is an example of what happened after the joint statement to remove the marisol fortunately in the states this was recovered kind of within the year but it was not at all anticipated that the public trust would drop so radically so quickly this which was a bit of what well this is one of the motivations for sharing this talk the example of what happened in Pakistan and I have to say in the various interviews I've given I've said very clearly up front I have an absolute limited amount of knowledge about the process that went up to this and I'm hesitant to make any decisions but something like this once it's out in the media I can promise you for the families that are getting door-to-door vaccination in Pakistan their suspicion will be different than it was before even though this was in principle using a hepatitis B vaccine which is I've never seen hepatitis B vaccine delivered door-to-door so that's particularly interesting but anyway I think when decisions like these are made whoever wherever and as I said I would be very keen to try to understand better what the process of decision-making was and where it was and the consideration of it but I think in some settings it's actually working with health for security reasons is an absolute useful way to go and it's been the history of days of tranquility around vaccines have stopped wars for a day Guinea worm introduction medications have stopped local conflicts for a day you can have very positive ways but in this particular setting with Pakistan being as the most vulnerable place for door-to-door polio vaccination we could see some implications and they may not be next week they may be next year one thing that we're seeing in our research is that things can happen and you think oh we got through that one no problem and then months later two years later we see people use that information particularly now with the web things stay up there for very long time and if the web continues to exist it will only that opportunity for historic justification of contemporary belief systems will only become a bigger thing this is just to give a glimpse of the countries this was from February that our surveillance system is in we've only been up and running on this for a year so that the numbers have gone up quite a bit but just in terms of our reach we have a lot of language translation going on to a lot of the reports we're getting excuse me what is it tracking there we're tracking what is being talked about about vaccines it's not just initially the surveillance is for picking up what's going on in the media and local reports and blogs about vaccines because this is counting stories without necessarily assessing the validity of the story and so forth well it's analyzing the content of the stories it's looking at for instance here between in one year the stories we've picked up the biggest amount this is in developing countries has been India Pakistan and Nigeria have been the top three that have come up and then we look at this is just in the last two months it's actually consistent which is interesting as the last year and then we also look at what are the most vaccines most talked about and then we do an analysis of the type of the topic of it's basically to hear what are the bigger issues and then we do an analysis of if I get for instance a report that comes in that child dies a suspected child death because of polio vaccine in southern India we pay attention to it if it's talking about it's basically we're looking at what is the public thinking and talking about related to vaccines we're adding to that a more targeted information network on negative concerns and that's going to be the network of immunization officers, UNSF communication officers, pediatricians, university people in a number of different countries and that's going to be more targeted to a three point kind of monkey survey monkey approach have you heard anything negative which what was it and what do you know about it so this is more to get the bigger picture because also we want to understand is the negativity out there a half a percent or are we talking about what's the scale of that public discussion that's negative or questioning what's interesting is that I think a lot of the perception has been that if people have a question it's because of the safety of the vaccine and we're finding actually that's not the case at all that the biggest concerns that have come out are about policies and recommendations there's some concern about safety but really policies recommendations, research some of the other issues risk and benefit and this is not only this is the quantity of the amount of reports but we see on the other hand the highest number of red alerts that have come up are adverse events that are reporting deaths but we do have in that yellow alert group are things that we think that when there's a convergence of factors could tip into being what we call a red alert and that's what we I have a team of researchers that when things come up I kind of say we need more information on this and then we also follow over time so this is just individual reports but we're now looking at analytics for clustering of reports and contextual factors what's a low, medium and high alert we could have a new policy that pops up a bit of negative media but the environment is high immunization coverage it's a place that has reasonable amount of trust this could be a one-off negative media report I'm not so worried about that I start to get a little more concern when it's a new product there's been an adverse event and negative media and then of course we add to this does it keep coming up? Do we get 50 reports on the same problem or is it one in a remote village in Cincinnati or in Mogadogu? And then for high alert, a new product, a serious adverse event, a history of distrust like in Northern Nigeria or India or somewhere in the States and negative media when you start to get multiple factors then we move it more into a high alert so it's also trying to take a contextual look at what's going on it's not 100% but we do are very conscious of the uncertainty analysis but I think it's at least helping us get a handle on thinking differently rather than going being crisis management to be conscious of the implications and contextual factors we've taken a number of different historic public crises and developed this, what a retrospective analysis because it's really the criteria for our diagnostic of current things coming up I was very insistent that it was based on a really in-depth look at historic events that were not just sitting around the table and say so what could be the things that would lead to this? This is really based on some deep research on what happened over time that led to effectively tipping points what was the contextual issues what was the specific public concern what prompted it, what sustained and amplified it what were some of the impacts what was the response and what was the positive impact but also positive and negative we have here we did the same with the Philippines what's interesting with the tetanus vaccine in the Philippines and the Nigerian one is religious networks the power of religious networks as social networks in the tetanus vaccine issue a group called Human Life International had picked up on this it was interesting the source of this was also research originally there was a research report about what they call the birth control vaccine I think it was depoprovera or a contraceptive administered in a vaccine format that got picked up and the research would talk about using tetanus toxoid as a protein carrier in the vaccine well this group picked up tetanus toxoid in a birth control vaccine even though it's totally unrelated to tetanus it went through their social network through 60 countries and the fear of tetanus vaccine sterilizing jump from the Philippines to Tanzania down to South America and it was had to be ultimately resolved with WHO at the Vatican and the Vatican selected their own lab to do a test and that because it was clear that the only these people were not gonna listen to WHO they're not gonna listen to public health the people they're listening to are their authorities in the same sense with the Nigeria situation as this distrust of a polio vaccine and sterilization as a Muslim non-Muslim phenomena spread through multiple countries and WHOs had to sit down with the Organization of Islamic States and have an issuance from higher level religious authorities to separately do their own testing WHO and other typical officials hands off let us do the testing and it was only through that confirmation that engaged a number of religious officials I like to talk about the two of these together because I think it's important to recognize that this is a phenomena of social networks it's not a Muslim issue it's not a Christian issue it's an issue of social networks there's other episodes where we've had things go through professional networks through women's networks through it could be a number of different types and particularly with the internet and social media these days the different types of social networks that come up either for an issue or that are out there on other issues are mediums that can quickly pick up this because it's very important I think to make that distinction one of the things we're also looking at is actually the difference that was a vaccine from what we've stated in the absence of an outbreak or in the absence of demonstrated... In both Nigeria and in the Philippines no child had any evidence of becoming sterile Oh, not sterile I mean, so... There was no adverse events Right, increased risk to... Was it an outbreak? That wasn't their concern they were not giving their children the vaccine because they had a perception that it would cause sterilization That was the whole prompter of this whole and it was the same thing in Nigeria the driving theme of the concerns were sterilization So between the vaccine and the Zoom there was a disease outbreak that had a demonstrable impact on children and the community And they said when we tried to use that as a rationale to get your kid... So how do you motivate reinstatement? Well, it was the discussion... It was the discussion of their... The social network discussion was kind of in the background The immediate thing was the religious leaders intervening and saying, okay, it's okay you can do this now and also much more focused understanding of district to district It's actually the... I think one of the best... The whole situation in responding to the distrust around polio has transformed communication in immunization or I hope it will because the specific work of really listening at a very local level particularly in this last piece of the eradication effort has become very sophisticated very block to block what people are thinking and why So the responses has basically been who are the trust relations with? Who do they listen to? And it's been through that It was not... And that's the phenomena I think we have in our hands today across the board is science and the evidence is not gonna solve this problem It's not gonna solve the climate skeptic problem It's not gonna solve the GMO problem It is not gonna solve our problem with emerging anti-vaccination groups We have to take very different approaches to this I'm about to launch a center for decision making in vaccines in immunization and vaccines but actually we're gonna drop the vaccine in immunization part in the long run It's bringing together cognitive psychologists political scientists, anthropologists public health people but also bringing around the table some people who have dealt with AIDS denialists who by the way we've had research that AIDS denialism provoked by Mbeke in South Africa led to 350,000 deaths because of no access to it So we have numbers now on the impact of these Climate change, energy There's a phenomena that's bigger than vaccines I think that the thing about vaccines is it gives us a window to a bigger issue that is measurable You can see the impact and you can learn There's a lot of learnings that we can get through the vaccine experience that I think is gonna be very applicable and appropriate to a number of other areas We've also looked at in these timelines what was the time frame that these issues came up and were resolved in The Polio One, I mean that particular episode of the Boycott took 11, 12 months to resolve and get contained We still have some issues but it was pretty The impact was much longer but just in resolving that local issue Tetanus took a bit longer The HPV that was specifically the India episode that had a limited time and then MMR has dragged on from 1998 and ironically the one in the more educated part of the world has been the hardest to get our hand around So much for the international development mantra, educate the mother, save the child It's like flips around when you get to the other end of education and then rotavirus which is the inter-susception issue that was resolved and I still have some issues to address But anyway, we like to look at I think the time dimension is an important thing The number of times I've seen best practices I get sent all kinds of best practices Trying to find a date on any of them is impossible most of the time and I can promise you that a best practice in 1988 will have little meaning to effective delivery of vaccines today There may be some gems of wisdom in there that will last across time but I think that and just my last slide is I thought I need a little bit of human reality here Thanks