 My name is Ricky Wong. I'm Executive Director of Community Affairs at the New York City Department of Health and Mental Hygiene. I want to introduce my colleague, Jackie Kennedy. Yeah, I'm Jackie Kennedy. I'm also with the Health Department, but I'm under the Center for Health Equity and I serve as the Director of Community Partnerships. So I'll just kind of give like a little bit of background about, you know, what we do day-to-day and what our role is actually in response to, you know, the measles outbreak here in Brooklyn. Day-to-day, you know, I generally feel I have a staff of five, I have liaison for each borough, and we deal with the day-to-day issues that affect, you know, people from a health department perspective. Whether it's, you know, somebody has a complaint about rats, you know, we inspect the restaurants locally, the local food vendors as well, too. And then somebody may ask us to come and do, you know, have on at a program, give a presentation on obesity or chronic disease prevention, such as tobacco or something like that as well, too. So my staff, we organize that. In the outbreak, I'm considered what they call the Public Information Officer or the Deputy Public Information Officer. And we're basically charged with working with our bureau of immunization and our disease control doctors to basically get information out to the public, whether it's through the media, you know, information pamphlets like this that we help to create. You know, social media is a big component as well, too. And then, you know, and it's by extension working with community partners, which is what Jackie's kind of covering. Right. So it is, we feel that it's incredibly important to tap into our community partnerships. So at the health department, we partner through contracts, both informally through programs to connect with the community, connect with residents, participants. And so our community partners are extremely important. And so as we kind of what we call activate to respond to public health emergencies, we created a community partner engagement unit. And so it's a new unit. And we've been really trying to do things like this where we present out to community partners, get the word out, make sure everyone's informed. And so that's kind of the role that I've been playing in this and this outbreak. So for full disclosure, neither Jackie or I are clinicians. We have no science backgrounds whatsoever. We just have a lot of experience in the backgrounds of engaging communities and working with community partners. I also do a lot with the political realm. So any elected officials or anything like that as well, too, that's my day to day. And, you know, I've been keeping the local elected officials here and City Hall up to date about, you know, what's going on with the outbreak. So just wanted folks to kind of be aware of that. I know this is immunology class, I think that's what it is. So we try to get our doctors to come, but they're unfortunately they're busy working on the outbreak itself and addressing that. So let's get right into the presentation. I will ask folks, if you can't hear me, just raise your hands, but please hold your questions until the end. I know folks are going to probably have a lot of questions. We just kind of want to get to the presentation and we'll be happy to stay around answering the questions. Okay. So we will virus folks are not aware we do have an outbreak in Brooklyn, mostly situated in four zip codes, which we have kind of arbitrarily identified at Williamsburg those parts of Park as well too, but it encompasses other neighborhoods as well too. So just don't think that it's limited to just Williamsburg. There are four zip codes that we officially declared health order for and where the vast majority of cases are. So what exactly is measles it's highly contagious viral infection generally characterized by fever and a rash that you see in the pictures here usually mostly see in children. So folks know where that is. That's what it is. We can talk about how contagious it is later on. How's it spread. So usually if somebody's infected and they're infectious, and they need a call for sneeze, and it becomes airborne, if you know anybody that comes in contact with that can basically become infected if they're not immune, which means they're either not vaccinated or they have not previously been exposed to measles and recovered from it as well too. It's considered one of the most contagious viruses out there. So let's say if I was in one third of the room and I had it. And I just call the person in that corner that we can potentially get it and it'll stay around the environment for up to two hours. All right, so that's how infectious it is. And, you know, and basically can cause other health issues. This is basically exposure to natural measles, usually any fall symptoms or complications are diarrhea, air infections, pneumonia. We have had cases of pneumonia in our outbreak that we have. It's very serious in basically all age groups, but however, much more so in vulnerable populations such as infants, young children, pregnant people, people who have compromised immune systems that are more likely to suffer from measles complications versus a healthy person as well too and versus somebody who's been vaccinated. In some cases, you know, and it's very rare, but there is an instance of where it can cause death. And that's how seriously we kind of want to address it. You know, you'll find folks who take it lightly that, well, you get it, you know, you kind of recover from it. No, then you get exposed to natural occurring measles in our complications from it. So what's the treatment for measles? So you can't, there's no cure or direct treatment for measles itself. You can treat the symptoms. So somebody had a fever. You would give them something from the fever. If you had other symptoms as well too, cough or the rash, you would give other medications as well too. Obviously, the best way to treat measles before an exposure of measles is basically to get vaccinated and that's the most preventative medicine that we can kind of recommend for anybody. It's safe. Vaccines are safe. And we'll talk about, you know, the safety of the vaccines as well too. But, you know, we also advise folks that if they've been exposed and they start, you know, becoming symptomatic that they should avoid, you know, coming into contact with other folks, stay home, especially when the rash manifests itself as well too. Generally, if somebody's sick, we recommend they contact their doctor first, speak with them because there are infection protocols that need to kind of be in place before somebody actually goes to see a doctor. We've had what they call nosocomial transmissions, which means that it's transmissions in healthcare settings because like a waiting gets inundated with patients waiting to see a doctor and somebody's sitting there and they're actively, you know, you know, sick with measles, they can transmit it to other patients if those patients have not been vaccinated or if they have suppressed immune systems or one of those vulnerable populations as well too. And so what are vaccines and how do they work? So vaccines basically, you know, something that stimulates a person's immunity to reduce an immune response specific to that disease and to protect them from that disease as well too. They've been developed to imitate an infection, but usually that imitation infection doesn't call the actual illness itself. They're generally administered through needles, though there are nasal and mouth interventions as well too. I just want to, you know, we'll talk about this more, you know, the measles month's develop vaccine is, you know, categorically safe. There's a lot of misinformation out there about vaccines and how there are concerns about them. That's actually part of the reason why we're dealing with this outbreak because of the misinformation that's out there. So what is the MMR? Is it effective? Right. So MMR stands for measles, month's develop and the reason why we love these three together is because generally they're given to children and if you have like a one-year-old, instead of giving three shots, you give one shot and, you know, you're not dealing with a crying one-year-old that's, you know, struggling to do a whole bunch of shots, and that's why they mount them all together. The recommendations, both from the CDC and from the health departments that usually at age one, you get the first dose and it's 93% effective. Usually between the ages of four and six, you would get the second dose and that boosts the efficacy up to 97%. It's not complete 100% immunity from it, but it's basically like a shield and it's better to have that versus natural exposure to measles and the complications that kind of come with it. Even after exposure, you know, we still recommend getting a vaccination as well too. Most people who receive the MMR generally don't have side effects. The most common side effects is you get a mild fever, but I will say that if it was, you know, somebody who's immunocompromised who we don't recommend getting a vaccination, they potentially can develop measles from the type of vaccination as well too. If they were to take it, that's why the recommendation against giving that, you know, vaccination to those folks. Obviously, again, you mentioned scientifically proven that MMR is safe. Hundreds and hundreds of studies involving thousands and hundreds of thousands of people. There's no links to autism that's been brought up before. There's concerns about the interior chemicals. The actual vaccines have been refined over years. Certain chemicals that were concerned have been removed from those vaccines and it's again proven to be safe. So just really quickly, why is measles back, right? So in 2000, measles was actually eliminated. So it was declared eliminated in the U.S., which is wonderful news. However, it kind of rid its ugly head once again in the 90s. And so in 2013, we had, so in between 2000 and 2013, we had like very small outbreaks. So if anybody get, if people start to get it and transmit it, you know, call it an outbreak. But in 2013, we had kind of the largest outbreak since it was eliminated. And as kind of these graphs, these graph shows, I think we hit across the U.S. about 660, almost 670. And as you know now in 2019, we are currently in the largest outbreak that we've had since it was eradicated or eliminated. It's happening across the U.S. It's actually happening across the world. So oftentimes we get outbreaks because people traveling from other countries. And so not every country has the same kind of guidelines around vaccinations. So for example, in Israel where, you know, the vaccination is you just require to get one vaccine versus we have a booster here. So under vaccination could be a problem. So oftentimes before kind of 2019, our outbreaks kind of happened because of the traveling between countries and bringing it into the states, which is also similar to this outbreak, right? We've had, that's kind of how it started. And at this point, we are at 466 cases. So as of yesterday, we are currently at 466 confirmed cases. We're constantly and Ricky will go into this later constantly doing tests to figure out like who else has carried measles, but this ranges from one years old to 66 years of age, right? So there's no, although most of the cases overwhelmingly are children, which is actually quite scary since they're so kind of vulnerable. We've had 213 were under four and then 98 were five to 17 years of age. And so we've had 34 hospitalizations. Nine people were admitted to ICU, but we haven't had any fatalities, which is a blessing really. And I think it's really because of kind of where we are in this country. So, so we want to really target as we go around and talk to different communities and different people. The fact of stigma, right? Stigma is real specifically in this city where we have so many diverse cultures, so many diverse groups of people. And although measles, the measles outbreak has happened. Mostly it is mostly impacted the orthodox Jewish community. I like to say, you know, the community is insular but not isolated, right? So they really is in that community because it is an insular community, which is kind of, it sucks. It was also helpful for everybody else, but it's challenging because it's so insular. And it's because of, are we trying to say that they're not the reason for the outbreak, right? It's the fact of the community being insular and children being so close to one another. If families being so close to one another, the transmission is much easier. And so what we're trying to do as an agency is to, you know, definitely target our outreach to those communities, make sure that they're vaccinated, get them as much information as possible, but also make sure that everyone else knows if you're immunized, like you don't have to be concerned, you don't have to worry. So the root of the cause is really the spread that we believe of misinformation. So a lot of anti-vax material we have found has gone into this very insular community and other insular communities. I think the Amish were targeted in other cities and across the country. And so the anti-vax movement has targeted insular communities like the Orthodox Jewish community. And now we are seeing an outbreak across the country. And although the current outbreak, again, is predominantly concentrated in this community, it's not a religious issue. There's no doctrine that says do not vaccinate your children. We've talked to several rabbis, we've talked to several folks across the community that believe this and stand by this. And so we just want to pass that on, pass that along to your friends and family because this is how the message starts, right? Stigma starts by word of mouth so we can de-stigmatize also by word of mouth. Like many other communities, it's a close knit community which makes it easy to spread. So I'm going to make sure that the spread doesn't happen in other communities. So vaccination is the key. The Orthodox Jewish community also has high rates of vaccination just like everyone else. But it only takes a small group, a small population of folks for this to spread, right? We know that families want the best for their children, all families want the best for their children including the Orthodox Jewish community. And so I think if we keep that in mind that our Jewish folks are just like everybody else. They want the best for their family, they want the best for their children. They have high rates of vaccination just like everyone else. So we can practice kind of de-stigmatizing this concept and this topic of weasel. I think it will go a really long way specifically as we go through this. I think we have Rick and I were talking a bit earlier today that, you know, we're kind of in the heart of it. Like the incubation period takes 21 days. So this will be, we'll be here for a while is my point. And so we want to make sure that we're not stigmatizing one community over the other. So who should not be vaccinated? This is a question that comes up before I get to who should. Let's talk about who should not. So anyone, as Ricky said, who has a weakened immune system, who has any allergy to any vaccinations in the past, probably should talk to their doctor before they get vaccinated. If you recently had a blood transfusion or have received other blood byproducts. If you have a severe illness at the time, so just like with the fluid, if you're sick, you probably shouldn't get it at the time. You should wait. And lastly, if you're under six months of age, people can only get vaccinated between six years old. Or we start the vaccination to six months old and one years old. So that's about the time you can get your first shot, anything below that you cannot be vaccinated. So these are the groups of people that we like to say is most vulnerable to to measles. So again, these are case by case scenarios. So the greatest recommendation is to talk to your doctor, talk to your provider. If you don't have a doctor, there are tons of FQHCs. Excuse me, this is acronym. Go to the kind of nearest clinic federally qualified health center in your neighborhood to get treated. So who should be vaccinated? Everyone, everyone should be vaccinated. If you're unsure of your vaccination history, go to your doctor, see a doctor somewhere who could support kind of digging into your history or doing a test to find out. If you're vaccinated or not. So we, and you'll learn about this in a minute, as the health department issued an order for everyone who lives, works in 1-1-2-0-5, 1-1-2-0-6, 1-1-2-1-1 and 1-1-2-4-9 must be vaccinated. So when we say who should be vaccinated, everyone, but specifically everyone in those 4 zip codes are by order kind of required and mandated to get vaccinated. So just some special notes. So children between 6 to 11 months, again, specifically living in the affected zip codes. A lot of people like to wait until they're 1 years old. But if you know of a child or there is a child in your household who's between that age, go ahead and get them vaccinated, especially if you live in those zip codes. One years of age or older, again, vaccinated. And if you don't vaccinate, like you're putting your child and you're putting other people and other folks in those areas at risk. So measles is a public health emergency. So we officially declared a public health emergency and we activated what we call our incident command structure at the health department about a month ago. We actually been dealing with this outbreak since September of 2018. And you know, it's basically a domino effect. Reason wise, like single child with measles who attended a local school was an exclusive, which there was an exclusion order in place. And that order was that, you know, within these zip codes, if you have children that either had a medical or religious exemption from getting vaccinations, those schools were ordered to keep those kids from coming to school. Some of the schools unfortunately did not follow those orders. They allowed one kid in and unfortunately it became a domino effect and infected 40 other people. And now, you know, consistently, I would say every week we're seeing anywhere from as little as like a dozen to 20 cases up to this past week, 43 cases. So we're going to kind of continue to see this. And these are the chains of transmissions that we're kind of investigating. This is a very unique and dangerous outbreak with very high number of children in specific community during long vaccine coverage in business codes in comparison to other parts of the city as well to different age groups as well too. So, you know, there's been encouragement, obviously, for folks to get vaccinated. Since we started investigating the outbreak in September, I think about in those four specific zip codes, we have about 20,000 vaccinations. Since we issued our public health order mandating vaccination in these four zip codes in April, we had an additional 2,000 vaccinations. So there's not, it's less so about, you know, vaccine hesitancy or, you know, it's more so about addressing the misinformation and basically preventing people from getting sick. So that's why we've been able to, you know, try to curb and bend number of cases, but we're going to kind of continue to see this. So the role of the health department, and I'm going to kind of expand a little bit about what we're doing, both the reasons for everything else that we do as well too. First things, contact and case investigation. This is what we've turned in the public realm as our disease detectives. These are our doctors, our epidemiologists, some of you folks here in the room as well too one day. By law, measles is what they call reportable disease. Any doctor's office, clinic, hospital, they clinically diagnose a case of measles. By law they have to report it to the health department, that's how they track it. Then the disease detectives take over and get their case and contact investigation. They talk with the family, they talk with the actual case patient to see where they've been, where the potential cases for exposure might be as well too. Then we look for other exposures and that's where we're able to find out more and more cases. The next one is our public health lab. We perform thousands and thousands of diagnostic tests. So we're investigating and checking all those cases that are kind of coming in as well too. So for overall knowledge as well, we also had investigated the Ebola case in 2014. In 2015 we dealt with the large Legionnaires outbreak in Bronx. In 2016 was Zika and then that was measles. So every year something always kind of pops up. If you were here about in the news somebody got an envelope with white powdery substance, that actually goes to our public health lab through the NYPD. So we're the ones actually testing that as well too. So that's that part of the response. School care and child care outreach in the oversight. We actually license a lot of child care providers in daycares, any after school programs. And then we also have school health as part of the health department and working with the Department of Education for the public schools as well too. So we've done, continued outreach to them. In the public school realm, you know, before you enter the public school system, you have to be vaccinated. There are obviously regulations that allow for medical or religious exemptions as well too. But there's very high rates of vaccinations in the public school realm. Provider healthcare facility outreach. So we do the aids and network all the local hospitals. We send out health alerts to the local clinics and also the local doctors as well to advising them when there is an outbreak or a high instance of cases and things that you know that are kind of like come across our table to advise them. Look, something's happening in this community. If you have a case patient that presents something like that, make sure you do such and such guidance as well too. So they know to look for the symptoms and how to also provide treatment as well. And then lastly is what Jackie and I were kind of talking about before as well too. We get the community involved. We believe in transparency. We want to make sure that folks are knowing what's kind of going on in their communities. You know, regardless of there's an emergency, you know, there's general things that happen that affect overall public health and we want to make sure that people are aware about. But especially in an emergency, we want folks to know to know what the symptoms are, what the root causes are, how to seek treatment, where to seek care as well too. And we want to make sure that this information gets across, you know, in an equitable fashion as well too. So just a brief summary of the city's health order is emergency declaration again that Jackie mentioned, you know, it affects four specific zip codes in Brooklyn, 1-1-2-0-5, 1-1-2-0-6, 1-1-2-1-1, 1-1-2-2-9. By order of the health commissioner, it's under her authority that, you know, folks residing, working, traveling into these areas have to be vaccinated. Basically, if we find out through contact tracing or through case investigation that you're not, you know, potentially issue a violation to that person, it goes to the individual. And I think to date, I think we have 80 individuals that have issued violations already. Those have yet to be kind of adjudicated, which means they have to go through the court process and so forth. So, you know, it's not our goals of being somebody who can find our goals and make sure that people get vaccinated and nobody gets sick, anything like that. So that's why we had to declare that order. So, as we wrap up, we just kind of want to drive home the idea of misinformation and how powerful it is. So the document that you're looking at here with the X over it to say, like, this is not what we want to promote. This is, you know, a very, it looks very similar to what we're looking at with the X over it to say, like, this is not what we want to promote. This is, you know, a very, it looks very legitimate. It looks like it's going to capture my attention as a parent. And so these are the kind of things that we're trying to combat as a health department, kind of not not the most legitimate sources of information, but they're promoting this and pushing this to parents across the country and specifically to our communities in Brooklyn. And so we say that the resurgence of measles is not just a measles outbreak, but it's a misinformation. It's an outbreak of misinformation to very vulnerable people. And so it's really been our greatest challenge to counter kind of the anti-vaxxer movement. If you like go on any comment, Facebook, whatever, you'll see like five anti-vaxxers like attacking one person about, you know, really promoting vaccination. And, you know, those are their ideas, but we know that the only way to kind of protect yourself, protect your families and protect others from measles is through vaccination. So it's a true kind of like war of information happening right now. And the most kind of effective way to tackle this is through passing on the information to residents across the city. And so a really good example of this is peach versus pie. So peach is a group of parents who promote anti-vaxxings and they're kind of like what we call anti-vaxxer. And it's really gorgeous, right? It's really pretty. It looks very formal and very legitimate, but this has gone out to thousands and thousands of parents specifically in the ultra-orthodox Jewish community. And people are really taking this on and it really kind of gets at, you know, their cultural beliefs, their religious beliefs. And a person actually within the community that we started to work with saw this and she was a nurse and she said, you know what, this is wrong. You're getting wrong information into the hands of my community and it's causing this outbreak. So she then created pie and we called them a slice of pie to try to get out during Passover. But we tried to partner with this community resident who really saw the need and really tried to get her resources to get this document out to counter the misinformation that we have been seeing. And lastly, we want to make sure we know where you can get vaccinated. And keep telling you to get vaccinated, get vaccinated, get vaccinated. Well, where do I get vaccinated? So one of our health department immunization clinics is at the Fort Greene Health Center. That's where anyone can get vaccinated regardless of your, you know, your documentation, your citizenship, regardless of if you have health insurance or not. This is probably the best place to go in Brooklyn. It's on Flatbush Avenue extension. So I'm not too far from here. And there's four other kind of health care centers that we have. So we want to make sure that we're promoting where you can actually get vaccinated. And lastly, you have additional resources. So the health department, again, we're trying to really push this transparency angle. And we update every week update our website with more information with our case count. So if you're ever wondering like where we are in this, you can definitely go to our website at www.nyc.gov. Very simple. CDC, because this is a national outbreak right now across the U.S. They are also updating their website. They also have tons and tons and tons of information that you can tap. They have flyers. We have posters and flyers too, but they have posters and flyers. So if you want to access to that, I also have. So a slice of pie, which is not the easiest website link to remember. And then then there's another useful resources, useful resource that we kind of supported getting to in the hands of other community residents. Created by another community group actually in New York State. And then we got it in the hands of our folks down here in New York City. And the last is immunization action, which is an organization that promotes immunization. So that's another great resource that everyone has access to and can use. So thank you. Any questions? And honestly, we want questions. So if you have a question and you're like, well, then our doctors, you're not going to know, still ask it. Because honestly, we've been asking the hard questions and trying to get answers. And you're our first presentation. So we want to make sure that we pull these questions and get answers for them for other community presentations. Also, test for fighters. So if you can get your search, do they give you any information? So at the Fluke Green Clinic, I don't know if they do the titers test. I want to say the other locations that we mentioned, the local health and hospitals locations and the federally qualified health clinics. These are actually full blown clinics that are partners in the communities. They will have clinicians that will be able to do a titers test if necessary and make the assessment of whether a booster is required or not. Great question. And I like that. I didn't hear that. Oh, yeah. The question was how are we enforcing vaccination in the communities where they have already stated, this is my belief. This is my religious belief. Some people feel it's religious. People combat it instead. So yeah, if they said this is my strong belief, religious or not, like how are we combating it? And honestly, the best we can do is information and peer to peer. So if, say for example, it's like a mother's circle and you're the one mother who's like strong and wrong or just strong and you're like, everybody has the right to their own beliefs. So you're strong in that belief that you have to appear. These other mothers and like, look girl, my kid plays a dear kid and I really need you to do this thing. So it's kind of like here, peer to peer community to community. We are. We also met with a lot of religious leaders to say, like, can you actually tell your followers? Like in mind you also the box community is not all the same. Like there's different sex. So we don't want to act like everyone's the same. But tapping into those religious leaders to kind of disprove the statement that this is a religious kind of thing. For that community specifically, because I can't speak for all kind of religious backgrounds. It's not in the doctrine. And so really trying to push that. Right. And then working with local like religious affiliated organizations or actual like community based organizations that work with that population and supporting them to get information out. But some of them, they've even gone as far as like, you know, we support it. We're concerned about this in our community. We want to do a vaccination event. And, you know, they asked us, what can we do to help as the health department? We know that there's a mistrust of government because we are a government agency and of, you know, of us as well too. They would never come to us and ask us for a vaccine vaccination event. But if I went to a community organization which helps them with their day to day, you know, things, you know, they can potentially hold the event. They will bring in their own community doctors. What we would do behind the scenes would be basically supplying the vaccine because we manage the chain of vaccines that are kind of supplying it to me. We're also furnished them with any additional resources as well too. Maybe connect them with another partner that brings in the needles and the swabs and everything like that. And they can do that and then bring in somebody that can actually touch for titers or actually check the city wide immunization registry to see if somebody has been vaccinated before as well too. Please. So it may be too early to tell but I was just wondering from these sort of increase in rates of vaccination, have people started, you know, because of the outbreak itself and they know that the outbreak is happening. Are people now going back on their stance on those? I think there's there's a lot of people that have been on the fence and you know, with the misinformation that's out there and they were waiting for more, you know, more guidance from us as well too and also from their religious leaders and other organizations. And yes, so as I mentioned before, since the start of the outbreak in like September 2018, we've seen an increase in that community of about 20,000 vaccinations, which is great. Since the order itself, which was back in April, from that time till now, it's about an increased about 2000 vaccinations. So, you know, I would like to believe that the mandate help though we want we want to make sure that folks understand that, you know, they're making the correct and right decision by choosing to vaccinate and kind of going on beyond what's, you know, the misinformation out there or any misconceptions about their, you know, the religious exemptions or anything like that as well too, so. I have a question. I live in Ruffin County and I know that this is one of the first places that have affected. And I know the government was imposing fines on the schools if they were allowing children to come to school unvaccinated. So that's the one way they were trying to continue the spread. But my other question is, this is college and I know there was some rule saying if you were born before 1936, you don't need to have the MMR vaccine. But if you were born after that, you need to have proof that you got the vaccination. Now that we are seeing an increase in measles, even after 77 years old, I'm wondering, is the health department rethinking that policy? I think our language has actually changed to just follow up with your doctor and see if you have, if you're immunized to your point. We do have, if you're 66, you're definitely born before 57. So, yes, our language has definitely been to see your doctor. If you're unsure of your immunization or if you're immune to measles, follow up with your doctor is the language. We know everybody's situation is different. I don't know if folks know that if a woman's pregnant and she was previously vaccinated, pregnancy is considered a medical condition. It can actually change her immunity. Generally when after they have given birth, if their breastfeeding or not depends, they would basically have to consult their obstetrician slash pediatrician to see when they potentially would follow up and if they need to be retested to check what their immunity is as well. Scenarios are a little bit different, but yes. Generally anybody between, you know, 1957 to probably like the like early 1980s probably only got received the one dose of MMR. And, you know, if you're not sure about your immunity and your vaccination history because the record keeping was kind of, you know, not so great at that time, the recommendations go to see your doctor. If they can't look up your vaccination history, they can do the titers test, check your immunity and see how that is. And then they would suggest whether or not you need the booster. Anybody after born after mid to late 1990s, their records were actually computerized and it's uploaded into citywide immunization registry. So there's a citywide immunization registry. And our doctors and local doctors can basically go into that and check based on, you know, person's name and the date of birth. If you happen to be an ID NYC holder, if you have an ID NYC from the city, you can also access that information as well too based on that information that's associated with it. So I know that some of the schools have been closed down because they didn't enforce a policy of subjecting the vaccination history to a student. And I'm wondering, was that received well by the community? So I think they were given warnings. We had actually instituted school exclusions, I want to say sometime like late November. And they all received communications, which, you know, we want to make sure that people are fully aware of what's going on. So you operated such and such daycare or such and such yeshiva or something like that in these zip codes. If you have students in attendance with either religious or medical exemptions. So either one, you are to exclude them from attending school until we officially declare that the outbreak is over. We want to make sure that we clear your school or the zip code to go ahead and let students kind of back in. And what we do is that, you know, since we want to oversee, you know, childcare in the specific realm, our inspectors go and check these locations on a day to day basis anyway to make sure. And, you know, one of the things that they were checking was attendance records. We know it's tough. You know, the school sometimes, you know, mom or dad drops the kid off or throws him on the bus and the bus drops him off. And, you know, it didn't talk to the school an hour or two later to figure out, hey, this kid was not supposed to be here. They need to be sent home. But if that kid happens to be sick or infectious, that becomes a very kind of difficult issue. So, you know, it's, and I want to say that the community understands that this is a necessary component of the response. Some may or may not agree with it because they may think it's a little bit of a heavy-handed approach. And it's an inconvenience when you shut a school down or you shut down a daycare that somebody's childcare. And that means I, as a parent, have to take time off now to, you know, pick up my kid because of somebody else. And that's where Jackie had mentioned the kind of peer pressure. You know, you, because you have this religious exemption or this issue of not vaccinating, you're affecting me where I had my kid vaccinated. But because of all this, it caused the school to get shut down. And that's how we were kind of sending our message. It's not probably the best way from an enforcement standpoint, but it does send a message. And we continue to inspect schools on a weekly basis, on a daily basis, in the most part. And, you know, we find schools, some of them are really large, thousands and thousands of kids. And we spend several hours there, a day going through the attendance records to make sure everything's going to compliance. So yeah, I just want to add to that. Like, I think the greatest challenge in this response is how do we, you know, enforce this? How do we like, you know, put the peer pressure on? How do we ensure that the safety of all communities are, you know, at the forefront of our decisions, but also make sure we're not stigmatizing this community and also making sure that we're not kind of in bad partnerships. Right? Because we've had, in some cases, in parts of the agency, longstanding relationships with schools, with rabbis, with other community partners. And this is not easy for them, right? Especially if they're like, we are overwhelmingly vaccinated and we feel like this is unfair, right? So I do want to be completely transparent and say it's not easy to do this. And it's also a very delicate dance when we're trying to think through enforcement, but also information, combating misinformation and ensuring that communities are not stigmatized. So that was the difference between pie and peach. And why did you think it was necessary to change from peach to pie? So peach was actually not something we promoted. Peach is a parent organization that oftentimes can connect with parents who don't believe in vaccination. So they kind of tagged themselves to some Orthodox Jewish parents, specifically mothers who didn't believe in vaccination, and then put out this extremely long and detailed document that said, this is why you should not vaccinate your child. So then a nurse who's from the community said, oh, no, this is not, this is not cool. I don't believe in this. I know that this is bad information. So she took it upon herself to literally combat every point that was made in the, in peach and created pie. So, so, you know, peach versus pie is like a cute kind of thing, but it definitely targets the anti-vaxing misinformation. And I don't think you remiss to say that. And it's a good recognition that the women in this community are actually the ones leading the fight. Absolutely. So this nurse, she's a pediatric oncology nurse. I forgot if she's a pediatric oncology nurse, but she's an oncology nurse. She's from the community, so she's Orthodox herself. She's organized mostly with other clinical nurses from the community and basically, you know, leading the pro-vaccination movement to counter this misinformation. And they know that the anti-vaxing groups are targeting the moms because the moms in this particular community are the ones basically running the household. They're the ones conducting the childcare and everything as well, too. And so, you know, they've been leading this fight. And you know, we need to recognize that we're actually trying to support them in whatever way we can. We help them actually do some printing of the documents. They gave us permission to actually, you know, post it on our website. We set up other resources as well, too, as far as, like, recording on my phone. And we're like, who listens to a recording on the phone? But apparently when a mom is busy, she doesn't have time to sit down, read something off the internet or print a matter. She will actually turn on her phone, have, you know, there's hotlines in this community as she turned on her recording. And while she's taking care of the kids, doing something else and prepping dinner, she's listening to, you know, recordings. So we put this resource together as well, too. So, you know, part of the work that we're trying to do is understanding, you know, we are so diverse in the city and figuring out what works in the community and what doesn't. And the last question I have. Oh, somebody else wanted to. So the, if you actually go to the health department website, there's a very long list of zip codes that have, that have cases in them. And these four kind of zip codes are actually the most impacted in terms of they have the highest count. And it's been pretty much between Williamsburg and Borough Park have the highest case count. And every case count we see every, every case count we have per week, it's typically in those zip codes. But it is, it's not only in those zip codes and those four zip codes because it was overwhelmingly the case count was so large, the order went out to try to control that those four zip codes. But if you look on online and so here we go. Yeah. I will say this is like my like bullhorn message that the zip codes one one two zero five one one two zero six one one. One one one two one one two four nine one one two one one two one one two zero five one one two six are actually bedside. Clinton Hill, Fort Green, and then one one two zero six is actually overwhelmingly Bushwick. So really kind of pay attention to the zip codes. And I know a lot of the languages that where is my where is my where is my where is my where is my where is my where is my where. But since I'm in Brooklyn, I want to inform people properly that it's actually the areas that are in fact. Yeah. And we also need to be clear too that there have been a handful of cases outside of the Orthodox community. So again, this affects everyone, you know, misinformation is not just in that community. It's everywhere. And so folks are either delaying or not getting vaccinated. They risk the potential and I will go ahead and recognize we just announced this yesterday. There's four cases now in Sunset Park, you know, two of the cases without getting into too much PPLs because the privacy concerns is that they were non Orthodox, right? The potential link for exposure was that they probably had some kind of interaction in the communities that had the larger cases. But they're not Orthodox and they had a religious exception from getting vaccinated in the attended public school. And so it's not just in the Orthodox communities, but it's everywhere as well too. And what happens is that to your question about where we see expanding and differences, if the misinformation is there for people to continue not to get vaccinated, if we do not be surprised to see these numbers start to grow, and spread it to other communities as well too, that's why it's incumbent upon us to let people know. Don't be complacent. Don't take this for granted. Folks here in this room, you probably had to check your vaccination history before you entered into school. But if people are concerned, legitimate, just for your overall safety, go and speak to your doctor and find out and that's what we're telling everybody. Even if you've moved in Staten Island or up in the Bronx, which we have one case up in the Bronx, this person that is in the Bronx, they never confirmed through case contact. They confirmed that they never entered into any of these other areas before. But you know that Fox is connected to Westchester and Rockland, so they're probably some of the interaction there, but was never actually formally confirmed for that as well too. So this is a human being. This is a wrong human being. Then there was a discussion, like, did they have to, like, what conflict? That's a good question. So under the New York State regulations, there are two types of exemptions that somebody can file for not having vaccinations. The medical one is pretty straightforward and generally has to become signed off by an MD, a medical doctor saying that so-and-so has this type of conditions because of such it's preventing them from being able to vaccinate under our recommendation and it gets submitted to a school, be it a public school or a private school, and it's incumbent upon that school to keep it on record so that they know in case anything kind of happens. For the religious exemptions, the flash quote-unquote philosophical one, it's like, it's against my religion and that's all some I can say. Sometimes some people will have doctrines and we know certain religions do have an adoption to say that, but it's very, very far-of-view. It's generally also incumbent on the actual childcare providers of the school, the daycare or the app school program. If they choose to accept it, you know, they just have to keep a record of it and basically so that in case something happens in the school or there's an outbreak in the area, you can go to them and say, who are your unvaccinated kids and what are their exemptions and you need to exclude them so we actually have an awareness. There's talk and conversation now about changing that. California did away with that like a year or two ago. They no longer recognize philosophical slash religious exemptions whatsoever. There's also talk of the federal level for that, but that's obviously a much more difficult, larger conversation. We have to see if anything kind of happens here locally, but we have an outbreak here in New York City. We have an outbreak up in Rothland as well too. Two of the larger outbreaks we compromised when we comprised the vast majority of cases overall for the United States. That's kind of leading the conversation right now. Yeah, I mean, there's a couple of things. One, anybody can always call 311 to find a location that's closest to them that's convenient. So not necessarily in the outbreak area, anywhere in the five boroughs. Regardless of their documentation or background, access to healthcare, they have no insurance or little insurance. They generally can go into any of the public hospitals or any of the clinics and basically receive some type of service or follow-up or healthcare without fair reprisal or anything like that as well too. And we, at our clinics and most of the public hospitals they provide services in the language that a person's comfortable in. But some of the work that Jackie and the group, our community and partner engagement group is working on is that we know, let's say the orthodox community, it's not exclusively orthodox. If you ever go into any of their restaurants or businesses, they will have folks of other different backgrounds working for them and it's a concern. A lot of them don't know the vaccination background and we've heard about this. We're working actually with a group to try to see if we can organize not only an education form but potentially a vaccination form for them as well too because unlike the orthodox community which doesn't want services from us directly in that sense, these folks want these head to services where we're going to try to make something happen soon for them so that they know that they have the service available to them. Yeah, so I really think this is where our community partnerships are still paramount because again, through many cultures, many communities, through very legitimate reasons, don't always trust the government, right? And so it's up to, and it really has been up to our community partners who have come to us and said, just like you did right now, this is a group of people that I'm very concerned about. I have housekeepers who are working in these homes and are afraid to come forward. Like how can we get them the information in a way that meets them where they are and then we actually rely on our other community partners to support that need through vaccination events. So that's kind of where we are now actually is really trying to tap into those community partners and understand. And now we're actually trying to be a little more proactive, I think, in saying, okay, well, we know that these are the communities, if you look at the who should not get vaccinated, right? Well, based on that list, where are those people in the zip codes and how can we make sure to tap into our community partners to say, what information do you need? What are you hearing and how can we come together to support getting your participants, getting yourself the information necessary. So that's a really good point. One last question. Can you talk to us about the different types of immunology? And I'm thinking as a child, my mom would say, go play with the kids' legs go because they had measles. So that I would get the measles and get my natural immunity. What is so different about measles today that we both want to entertain that thought? So I think that the event that you're talking about is what they call measles parties. So they used to have chicken pox parties, too. Somebody's found out that when somebody's kid had chicken pox, it was like, well, we want to expose it then we get the immunity. You're basically taking a huge gamut from being exposed to natural measles. And the reason why I'm saying that is because all the complications that potentially happen to it. Because one, it's a child, their immune systems, they're not up to stuff as an adult person would be if the adult was healthy. And not only that, you've developed, potentially developed, rarely complications afterwards from exposure to natural measles. Nobody who's been exposed to natural measles recoups from it. Anywhere from five or ten years down the road, they could potentially develop encephalitis, which obviously folks know as the swelling of the brain. That only happens with exposure to natural measles. If you do the vaccination, you don't have that chance of developing that as well, too. So we have heard about this happening in communities, especially among those who are anti-vax, because we have issued these orders that you can't come to school because you're unvaccinated. What will happen is that, well, I can't keep my kid out of school for like two weeks or a month. I need to go to work, and I need to have my kid in school by taking care of them. So they purposely find somebody who had measles, exposes their kid. They don't even seek any health care whatsoever. You just keep the kid at home until they've gone over it. They give him some Tylenol for the fever and the kid luckily recoups. Now they bring the kid back to school and the school's like, wait, wait, hold a second. I can't get your kid in. You're not vaccinated. Oh no, he got exposed, and he's immune now. Well, I need you to supply me proof. So what they do is now, they take that kid to a doctor. They get the titer's test to show the immunity, but the doctor's office reports to us that we did a titer's test for somebody who had no registry, no indication in registry that this person's been vaccinated. It's counted as part of our case count. So a lot of these numbers that you see here are coming in retrospectively. So the person's not sick anymore. They may have gone sick several weeks ago to several months back, but they're trying to either get around the system or some way or something like that, and we have these kind of checks and balances in the place that you don't figure out the numbers to the case count. That's how we're finding a lot of cases. And to add, it's just, I think that's a lot of the arguments that some folks make, but I think it's because it's incredibly contagious, kind of viral infection of disease. So you have the 21-day incubation period, and then there's four days before the rash and then four days after that, they're actually very, very highly contagious. So as a parent, how are you to actually know within that 21-day incubation plus, that's a lot of tracking. So there's really no way, not no way, but it's very difficult to make sure that that child is not infecting many, many other people because of its highly contagious nature. And there are some people who can't get vaccinated. So in addition to taking the chance of not getting these complications or just taking the chance of getting measles, naturally, you're also putting people at, like if I'm in chemotherapy, if I'm just had a baby, so now, because you decided to do this, you could be putting so many other people at risk because of how highly contagious it is. Which is why I think we're so strong on vaccination. So as Jack mentioned, you know, when you're in the hospital, you know, they're very insular, but they do travel around the virus community. Not just between, like, where you're sure, as far as the rockways, there's some in two gardens and flushing as well, too. And then all the way up to Rockland as well, too. But there are many different sacks, many different folks, Christianity, Catholicism, you know, and all those other things like that. They're all kind of running similar tracks, but have differences in some of the beliefs. In Crown Heights, when they had the initial in one case, their rabbis came out very, very strong and very staunch. They even issued a letter saying, folks in our communities, you need to get vaccinated, do it right now. Williamsburg, it's been tough for the rabbis to come out and do something like that. Most of them say, yeah, there's nothing in the law that prevents vaccination, but there are some rabbis that believe in anti-vaxxer and we had a meeting with the rabbis in Williamsburg. There was one rabbi actually handing out anti-vaxxer information and because there's so much this kind of pervasive misinformation, that's where you're seeing much more cases in Williamsburg and we could see it on the community as well too. So that would mean, like, is that real? Because you don't want so much shows about it. Yeah, yeah, yeah. Yeah, you're talking about like, you know, TV shows, scenario, contagion, like, the outbreak thing. We have those things in place, so there's no number per se. I think it would be a concern of mixing up numbers plus spilling out into the public realm as well too. Like I said, we have a handful of cases that are not in the most documented and we see those numbers grow mixed in with the continued growth of numbers in the most documented as well too. There could be, a point, it's not a definitive number or it depends on what the actions are. We would institute some more strategic measures. We have a protocol called POD, which is point of dispensary. I'll give you the extreme version of it. Let's say somebody decides to release air racks into the subway system. Wherever that was released, wherever that was. We have a connection with the local DOE school. We would stand up a point of dispensary and it's like a basically an assembly line all, it's staffed by all DOH staff and you basically will come in. The CBC comes in, gives us a supply of Cypher Foxen or another antibiotic. You come in, you pick up the supply for yourself, your family or any neighbors and everybody either pre-exposure or post-exposure prophylaxis so that's a very extreme scenario. We've only done that in one or two other instances before but that's again, if somebody's willing to actually come and get medication or something from us will it ever come to the point where we actually close somebody down and give them the inauguration? I don't think so. It's been obviously talked about since demandating you to do so and we'll just issue a fine if we find out that you were doing so but yeah, I mean right now because we're under emergency affirmations this is kind of the initial layer there are other layers that we can kind of spin up very quickly to try to institute something like that if it gets to that point. No, it's a civil penalty. It's not a criminal penalty. So the final just basically accrued more. We do have folks, the sheriff's department serving the summoners but it's not a criminal penalty. It's basically it's just, you know, for some folks you know what, they said that they rather pay the fine and do it but they take to a great risk not only for themselves but for the community as well too so we're hoping that the message kind of gets across. Any other questions? Any other questions? Any composition going on between the U.S. and the civil law? So we actually arranged the phone call with our commissioner and the Israeli health minister they're very concerned. They have over 4,000 cases and they've actually had fatality. They've had some successes because Israel is a Jewish state they're able to actually institute these pods but at a local standpoint where people will actually go here it's different because in the most part I will only go to see my own doctors versus somebody else or a stranger that I don't know plus there's also like separation these kind of nuances women have to see men so they've had such successes with that what they've had difficulties is the contact tracing that's why they have so many more cases once we hear about a case we start calling a case patient to find out who is in the household how many people is anybody vaccinated what's their vaccination history what events they went to what schools they went to any other public locations they went to try to contact those people to make sure they're not sick or anything like that they have less of that kind of network in Israel and they're trying to get information from us to replicate it but it's tough because we're an international city we have so many different people traveling from all over the world there's outbreaks going on in Israel Ukraine, Europe China parts of South America as well too it's tough basically to see where a case may potentially come in from because that incubation period is so long haven't been exposed there when they're vaccinated then you get off a plane then it's two or three days later then start manifesting symptoms and they don't know and get sick or something like that and you may have potentially exposed a lot of people I can tell you for our outbreak patient zero was a child that was not vaccinated from here in New York City went with their parents and came back and basically started this whole domino we've heard of some but we don't I think the vast majority that we are aware of most of them have had their licenses stripped from them but we've heard some of the doctors take a more of a harm reduction if you don't want to get vaccinated that's up to you the vast majority of the doctors that we have interacted with they are pediatric doctors that are in the community just like no, you need to get vaccinated stop with this nonsense please make sure for the benefit of yourself, your family and the community overall so thank you guys thank you thank you thanks and we can stare out for a few minutes if anybody wants to speak to us for anyone thank you I'll be okay I'll be okay thank you