The Resurgence of Vaccine Preventable Diseases at Home and Abroad

Measles, whooping cough, and other vaccine-preventable diseases are on the rise around the world, and cuts to foreign aid, coupled with growing vaccine hesitancy, and persistent gaps in vaccine access are fueling outbreaks in poor and wealthy nations alike. Global health experts discuss the drivers of these outbreaks, the solutions that can advance vaccine equity and better public health worldwide, and a new vaccine-preventable disease tracker from Think Global Health, developed in collaboration with ProMED.

BOLLYKY: Great. Welcome to today’s Council on Foreign Relations meeting on “The Resurgence of Vaccine Preventable Disease.” My name is Tom Bollyky. I am the Bloomberg chair in global health, the director of the Global Health Program here at the Council on Foreign Relations. I will be presiding over today’s discussion.

Cuts to foreign aid, growing vaccine hesitancy, conflict, persistent gaps in vaccine access are fueling outbreaks of vaccine-preventable disease around the world in poor and wealthy countries alike. The United States is in the midst of its biggest measles outbreak in more than three decades. Canada’s measles outbreak is actually even larger, rivaling those in Afghanistan and Kyrgyzstan. Across the Atlantic (sic; Pacific) Ocean, Japan is seeing a huge resurgence in whooping cough with nearly 80,000 cases. And as the New York Times just reported this week, there’s a large diphtheria outbreak, or several outbreaks now, in Somalia, Sudan, Yemen, and Chad.

Today we will have a discussion of the drivers of these outbreaks of vaccine-preventable disease, and the solutions that can advance vaccine equity and better public health worldwide. We are so fortunate to have three truly perfect speakers for this conversation.

To my immediate left, Seth Berkley, currently senior advisor to the Pandemic Center at the School of Public Health at Brown University. But of course, between 2011 and 2023 Seth served as the CEO of Gavi, the Global Vaccine Alliance, and that was a time period in which the organization—if I have done my math right, and Seth will correct me if I’ve done it wrong—supported the vaccination of roughly 800 million people over the course of his tenure, of course mostly children. His leadership was equally significant in cofounding and spearheading COVAX, which facilitated the distribution of over 2 billion COVID-19 vaccine doses to 146 nations.

On our screen we have Heidi Larson, and it’s good to see Heidi up there. She is the director of the Vaccine Confidence Project, the chair of the Global Listening Project. She is a professor of anthropology, risk and decision science at the London School of Hygiene and Tropical Medicine. Heidi is really the world’s foremost authority, in my view and I think most others, in the analysis of social and political factors that affect the uptake of health interventions and influence policies.

To my far left we have Bill Moss, who is the executive director of the International Vaccine Access Center, professor of epidemiology at Johns Hopkins University Bloomberg School of Public Health. He is a pediatrician by training with a sub-specialty in infectious diseases. He has done groundbreaking research that spans both the U.S. and the global context, and we’re lucky to have him here.

Before we launch into the discussion, please note that this event memorializes the release of not just one but two exciting new resources. To go from the institutional perspective first, kudos to Allison Krugman and Nsikan Akpan on the release of the new Vaccine Preventable Disease Tracker—you see it on the screen there—on CFR’s Think Global Health site. It is to monitor these trends in vaccine-preventable disease. It’s really an incredible resource done in collaboration with the International Society of Infectious Diseases ProMED Program, and it tracks the outbreaks of nine diseases featured on CDC’s routine immunization schedule. It will be updated weekly and actually has data covering from 2000 to 2025. I really urge you to check it out and share it with others. It, like this event, enjoys generous support from Bloomberg Philanthropies, so we’re grateful to them for that.

And last but far from least, we have this week—published this week Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity, Seth’s book. It is, I can attest because I have read it this week—it is a terrific read for those looking to understand the history of vaccines, Seth’s career, the multiple intersections that career has had with expanding global access to vaccination. It also includes a robust defense of COVAX, which I think for many in the public but even within the global health community will be provocative and engaging. And I really think it’s worth your time, so well worth checking it out.

With that segue, let me turn it over to Seth. Seth, talk a bit about the circumstances that led to Gavi’s creation, the approaches that it used to address the problem, and what the long-term legacy of those approaches have been.

BERKLEY: So, thanks, Tom, and it’s really great to be with all of you and to have a chance to have this very important discussion.

So one of the things the book tries to do is go back and tell the history, and it’s really the history of vaccine access, because if you go kind of to the mid-’70s less than 5 percent of people in the world had access to even one dose of vaccine, and if you fast-forward to right before the pandemic that number had jumped to about 90 percent of people had access to the routine immunization system and at least one dose of vaccine. And this is an incredible story. We saw a 70 percent reduction in vaccine-preventable diseases. We saw a concomitant drop in under-five child mortality of over 50 percent. So this is from a public health point of view really extraordinary.

And Gavi is one of the things that played an important role, but I track UNICEF; the Task Force for Child Survival; the Children’s Vaccine Initiative, which people may not have heard of but played an important role as an experiment; and then Gavi, which the goal was really to engage with industry—because they are critical to this exercise, and there was some distrust between public sector and private sector—to bring them in and then to try to drive forward access to vaccines. And Tom already mentioned the number, but the other thing that happened is, you know, there were over 700 new vaccines launched from Gavi. And these were vaccines against diarrhea and pneumonia, the two largest killers of children; but also two cancer vaccines for, you know, liver cancer, hepatitis B, and cervical cancer, HPV; malaria vaccines; and then a whole set of stockpile vaccines for outbreaks.

There was also a big effort to build better systems. And I’m sure we will talk about it, but it’s absolutely critical to have a delivery system because vaccines don’t deliver themselves. And what’s really important is that system is also the system that you use for medical countermeasures in pandemics. It’s also an intelligence system to reach out to places that otherwise would be dark. Given that vaccines are the most widely distributed intervention, if you don’t have vaccines you don’t have anything. And so that last 10 percent, the so-called zero dose, are absolutely critical to reach. And it turns out today about 10 percent of the population, 50 percent of the child death is occurring in those groups and two-thirds of them are in poverty. So this is a great, you know, measurable group you can target your—you know, your work on that deals with equity and builds greater global health security.

So maybe I’ll stop there and I’m sure we’ll come back to it.

BOLLYKY: Great. Well, let me ask just a quick follow-up question on that before I turn to Heidi and Bill.

So, when I think about barriers to vaccine, you think about barriers to administration, which you mentioned—how do you get the vaccines to people and make them accessible; you think about barriers of supply, and you mentioned the—all the new vaccines introduced through Gavi; and then you think about barriers to demand. And I’m curious, during your time at Gavi, how much did you think about demand creation or addressing the barriers to demand globally for the vaccines that Gavi was distributing pre-COVID pandemic?

BERKLEY: So fabulous question. Of course, I’m afraid to say anything in this area since I have the world’s greatest expert there on the other side of the screen, and I’m sure Heidi will jump in. But let me just give some general points which I think are interesting.

And that is that prior to the pandemic, you know, in a sense we had a bigger problem with—there’s always been hesitancy, by the way, hesitancy from the first smallpox vaccine. We had woodcuttings that showed horns growing out of people’s heads, you know, because it was made from cows. There’s always been misinformation and challenges, but that has really changed. And prior to COVID, developing countries appreciated vaccine more because they saw the diseases. They saw people that had died. They saw people walking, you know with limps after polio, et cetera. And you know, frankly, vaccines work really well, so people didn’t see the diseases in places like the United States and Europe and others, and so they didn’t have the same appreciation.

That has changed with COVID completely, and part of it is also the new tools that allow disinformation to spread at the speed of light. But also, there were attempts to use disinformation to destable, you know, regimes. There were Russian bots, Chinese bots, you know, North Korean bots. But there was also misinformation from the U.S. Defense Department, as an example. And this is a real problem in terms of creating an environment of vaccine hesitancy. And there’s been some recovery, but also the heavy partisanship that’s now occurred makes it really difficult.

Because when you have political leaders, and you have people that have positions of authority saying things that are clearly not true and not based on data, that spreads at the speed of light. And all of a sudden you’re not now trying to argue with some local misinformation. You’re now arguing with disinformation. And people say, well, what do they know that we don’t know, you know? And it really changes the dynamic. So I think this is an increasing challenge now. And given the loss of trust in institutions and in government agencies, et cetera—experts, all of that—it’s going to make it much harder to tackle. But we must tackle it, because at the end if you don’t have science, if you don’t have, you know, data, you’ve got nothing. And I think this is something that I’m sure we’ll get into.

BOLLYKY: Great. Well, and, as you said, we are very fortunate to have one of the world’s leading experts on this topic. Heidi, obviously, you started The Vaccine Confidence Project. You’ve been tracking these issues for a long time. Post the pandemic you’ve started this Global Listening Project. Talk a little bit about how you’ve seen vaccine confidence issues evolve in the pandemic and afterwards, and what your Global Listening Project is finding from the surveys and listening you’re doing globally now.

LARSON: Thanks, Tom, and Seth. And, actually, great to see the full panel here. Also, Bill. Yeah. It’s a rocky, rocky world right now when it comes to vaccines. How did it—how did my focus on it start? Well, I was in UNICEF on the launch team for Gavi. And it was really during the first five years of Gavi., I had this dual role of supporting the launch of Gavi and the Advocacy Strategy Task Force, but also within UNICEF, the point person on introduction of new vaccines and strategies. And it was during those five years, 2000 to 2005, where I just saw a growing increase of our country field offices calling us and saying, you know, Houston, we got a problem. People were hearing things that we never heard before. People questioning, not wanting.

And what struck me was all the different countries. And it wasn’t anything you would read in a newspaper. You would read—you wouldn’t read it in an academic paper. It was really what we heard from the field. Also with Gavi we had some resistance to some of the early vaccines because some countries were struggling with the—with the very basic ones they had. And the idea of adding something else was challenging. You know, as you’ve heard, that’s initial—some of the initial anxieties have been overcome.

But I think one of the things, in terms of what’s changed the environment, in terms of, you know, the enthusiasm in that initial change, as mentioned, between the early ’80s, and that huge global push to get global acceptance of the basic vaccines, we kind of took it for granted that people loved vaccines. And we kept adding more, and more, and more. And one of the reason that we’ve heard from a lot of the public is, whoa, whoa, you know, how many can we handle? And from government, whoa, whoa, how many can we support? I mean, that’s been an evolving process and a dialogue.

But during those five years I got particularly concerned about these questions. I did manage to put one question in the joint reporting form that went out to countries, because the biggest question that UNICEF, WHO, and colleagues were asking me when I said, I think we got a problem brewing here, how much? How big? Has it changed? Is it any different? And I realized we had no benchmark. We had no—we had anecdotal evidence. So that’s when I added that one question, to try to get an initial metric. Have you had to manage any negative media about vaccines in the previous year?

And 25 percent of the field countries in 2003 said that they were having challenges managing negative media around vaccines. And that was enough, along with what was going on in northern Nigeria and the fact that rumors, not even an adverse event, were shutting down the polio program in northern—in Kano state, and that it had a global knock-on effect, was enough to make me say, we’ve got to get some metrics around this. (Laughs.) Which is why I launched The Vaccine Confidence Project in 2010. And we developed a Vaccine Confidence Index.

So we have a lot of data in terms of trends. And it’s been ups and downs with different things, but as already mentioned we had a dramatic drop during COVID. The Global Listening Project, just to clarify how that fits in, in 2021 I was lucky enough to get a MacArthur Award that let us expand our listening on trust to multiple interventions, masking, control measures, overall trust in government, trust in compliance in a state of crisis. So we were able to expand to a much broader mix of who did you trust, who did you turn to during that time. And it really helped us give us more contextual data.

So in 2023, just picking up to—up to more current times, in the UNICEF State of the World Children’s Report, we contributed to a chapter that really put the data out there. And it was fifty-two out of fifty-five countries where we had pre and post data where there was not a significant drop in confidence. But when we turned to our Global Listening Project data, which gave us much more contextual stuff, we really saw that it wasn’t really—we recognized that a lot of the research on trust was very individual. Was like, do you trust your health worker? Do you trust science? Do you trust government? But not looking at it as an ecosystem.

And trust, in itself, is not the problem. There’s a lot of people that have trust in the current administration. And it’s really—it’s a matter of who you trust, what you trust. Our challenge is there’s a lot of people who don’t trust vaccines. But they have a huge amount of trust in other things. Sometimes I feel like we spend—there’s a huge issue with mis- and disinformation. But we can’t just focus on that. We have a significant ideological drift, and emotional, I would say, manipulation going on, that if we’re only focusing on the facts and fixing the facts we’re going to miss this broader thing.

So our challenges are big. The good news is that there are a lot of people in the world who, over the last decade in particular, have become much more not only conscious, but trying to be more proactive. During COVID, on the one hand, we had that drop in confidence. But there were very valuable efforts going on that I think, at a hyper-community level, hyper-local level, that we can harness. And I think we’ve got a lot of work to do. (Laughs.) But, yeah, I think it’s one of the things we’re all here and working on.

And also, to—I think we need to put the U.S. in a global context, because there are a lot of regions that are kind of rising to the occasion, to give a broader support to vaccines. But nothing is isolated in any country right now. So really look forward to the conversation. Thanks, and sorry if I rambled too long.

BOLLYKY: No, you were terrific. That gave us a great sweep. The story I see emerging from the two of you is that we’ve seen a lot of progress globally in increasing vaccine access, but it has been accompanied, particularly since the emergence of COVID-19, with a deterioration of vaccine confidence.

To turn to you, Bill, one thing I often hear in talking to U.S. officials about the measles outbreak is that what’s going on in the U.S. is just another example of what’s happening globally. There’s nothing unusual happening with the U.S. measles outbreak. There are measles outbreaks happening in other settings. Speak to that. Help us connect this conversation from the global to the domestic. Is what we’re seeing in the U.S. unusual?

MOSS: Yeah. Thanks, Tom. And I’m honored to serve on this panel with Seth and Heidi.

So there’s no doubt that measles cases in the United States, which are due—which can—which are due to importations, are going to reflect what’s happening globally. But what’s happening in the United States is not solely a reflection of what’s happening globally. So let me just kind of maybe unpack that a bit. So one of the best measures of the quality of an immunization system are outbreaks of highly contagious infectious diseases. And measles and pertussis are the best examples of that. In the United States here, we had 35,000 pertussis cases in 2024. That was a fivefold increase from 2023. This year, they’re still elevated above pre-pandemic levels, but lower than what we had in 2024. But I’m going to focus on measles. And in the immunization community we often refer to measles as the canary in the coal mine. That’s the disease that kind of finds the pockets of the unvaccinated or the under-vaccinated.

And so this year, as of October 28, we’ve had 1,648 measles cases here in the United States, 12 percent hospitalizations, three deaths. Not surprisingly, 92 percent of those cases were unvaccinated or had unknown vaccination history. And that’s a problem because Texas doesn’t report the vaccination status of the cases. But only 4 percent of cases had one dose of measles vaccine, and 4 percent had two cases. But it’s important to think about—so that’s the current situation with measles in the United States and the unvaccinated. What I find interesting, actually, is the age distribution of the cases. About a quarter are in children younger than five, about 40 percent in children five to nineteen years of age, and about a third over nineteen, or over twenty years of age. What that tells me is that this is a problem that was long in the making.

If this were a very recent problem, we would just see cases in younger age group. But we’re seeing measles cases kind of across the age spectrum. So this is really, in some communities, a longer-standing problem. It’s also important to put the current outbreak in historical context. We have this year the most measles cases in the United States since measles was declared eliminated in the United States in the year 2000. You have to go back to 1992, when there were 2,126 cases of measles. And that was the tail end of a very large measles outbreak from 1989 to 1991, where there are 55,000 cases here in the United States. So, yes, this is of concern. And I’ll talk about some concerns. But, you know, historically, you know, we’re not where we were, you know, thirty years ago.

So what’s driving this? And it’s really multifactorial. And we can have more discussion about what’s driving that. But one of the best indicators that we have of measles vaccine coverage are the annual surveys of kindergarten students that are done by the CDC. And we have seen a slow and steady decline in measles vaccine coverage among kindergarten students here in the United States. It’s now, in the most recent year, ’24-’25 academic year, 92.5 percent. And so that’s still high. We’re still doing reasonably well. And a large part of that are the school vaccine requirements that drives that high coverage. But we’ve also—so we’ve seen a slow decline in kindergarten coverage.

We’ve also seen in an increase, not coincidental but correlated, you know, with non-medical exemptions here in the United States, where it went from 3.3 percent to 3.6 percent of students into 2024-25. So this—I’ll come back to this, but this is an area of concern, the non-medical exemptions. Medical exemptions for kindergarten students have been very constant over years. But we’ve seen this uptick in non-medical exemptions, which include religious and philosophical exemptions.

So what are—what are the big concerns? One is, I think we’re likely to see more frequent and larger measles outbreaks globally as a consequence of funding cuts to global health programs. That may lead to more frequent and larger outbreaks in the United States, driven by more frequent importations and, basically, larger susceptible—pools of susceptible. It’s really clustering of children who are un- or under-vaccinated. And then I’ll just add, there are kind of two major concerns that I have.

One is the increased legislation that we’re seeing at the state level in trying to relax school entry vaccine requirements. And so a lot of us are kind of tracking this legislation, but that’s of concern. The second is the undermining of the Advisory Committee on Immunization Practices, and specifically the undermining or targeting of the measles, mumps, and rubella vaccine. So we’ve seen, as you’re all aware, you know, a complete change in the—in the makeup of ACIP and undermining of the rigorous processes that they’ve undertaken. And we’ve seen the MMR vaccine specifically targeted with, first of all, a recommendation around the MMRV, so the measles, mumps, and rubella, and varicella vaccine.

That has led to kind of the beginning of a fragmentation of vaccine policy and recommendations here in the United States. The advisory—of the American Academy of Pediatrics kind of came out with their own recommendations. So we’re seeing this fragmenting. And that’s very important, because states rely—have relied—traditionally have relied on ACIP for their policy for school entry checks, insurance coverage, provider practices, vaccine purchasing. And now we’re seeing that whole system kind of fragment.

BOLLYKY: Great. Terrific. So I want to—we’ve talked a little bit about how the global affects the local, or the U.S. I want to turn to Seth and Heidi to talk a little bit about how the local is affecting the global. How do the trends or the conversations we’re having in the U.S., or rising vaccine hesitancy, or the views of some officials on vaccination—how are they starting to affect global vaccine policy? Obviously, it has had a direct impact on U.S. support for Gavi. So maybe you can speak a little to that, Seth. And then, Heidi, you had that terrific piece in The Lancet talking a little bit about how what’s happening in the U.S. is projecting out globally. So maybe we can start with you, Seth, and then turn to Heidi.

BERKLEY: Yeah. So just a word on—because Bill, at the end kind of hinted at this. He didn’t go directly into it, but it’s really important. Is, you know, you can’t put a wall up and stop infectious diseases. And, you know, and there’s—whatever demonization goes on, who’s transmitting them, the big Disney World outbreak that occurred, you know, a while ago was actually a Swiss tourist that that was the index case. And the important point about that is, you know, anybody can carry a virus. And there’s massive numbers. You can’t stop any travel, you know, if you really wanted to do that. So what Bill said is absolutely right. If the rest of the world has much worse outbreaks, you’re going to see more risk at home. And it’s important for people to understand that, because there’s a humanitarian purpose to help the rest of the world but there also is a self-preservation that is absolutely critical in terms of being able to do this.

And I think we have to think about the fact that some of the recommendations now, and this is your point of local going out, first, on what happened with Gavi. So Gavi has had support—bipartisan, you know, bicameral support—forever. During the first Trump administration, Gavi, you know, got a 5 percent increase. It was the only health agency that got it because people believed in this. Strong support from the Evangelicals. Support from everybody. And this time, we had a surprise because replenishment came up, it was already pre-agreed and approved by the House—because you have to do that if you’re going to get a multiyear grant—that there would be a contribution from the U.S.

And, lo and behold, at the replenishment, the secretary of health gave a video and in that video said that they were stopping all support—so even though it was already approved and, and, you know, done, they were stopping all support. And there was an accusation of safety issues that were being done because we were using a whole cell pertussis. And the issue was that this was killing more children than it was helping. And, you know, the scientific data that was put forth was not real. And the people who even had put that original hypothesis together tried to repeat it and found they couldn’t repeat it. And yet, here we are in this circumstance. And another thing that happened, of course, was the thimerosal controversy, which is a preservative that’s used. It’s a mercury-containing preservative, but it uses ethyl, not methyl, and doesn’t build up, and doesn’t cause problems, and has been known to be safe. And it’s only used in a small number of vaccines, but what you need to do in large campaigns, multidose vials, et cetera.

So, you know, this is all happening. At the same time, we’re saying we’re getting rid of mRNA vaccines because, you know, they’re horrible, they’re unsafe. And then they turn around and say, well, we need more whole killed vaccines because they’re tried and tested. So we’re not even consistent in what we do. And what that does, though, is it spreads this—you know, this nervousness, because the question you get all the time, and I’m around the world talking to people about this, is: What do the American administration know that we don’t know?

And one last point I’d make, and this is where we’re going to even see more of this happening. So, you know, there was a Truth Social post a couple of days ago. It said directly—it talked about some of the autism issues and other things. But it said directly, no American should get MMR anymore. They should get a measles vaccine, a mumps vaccine, and a rubella vaccine. So we go from two vaccines to six vaccines now. So whether you like that or not, that’s what, you know, officially was said. But here’s the problem, there is no MMR vaccines—(laughs)—that are approved in the United States. So if you’re a parent who’s listening to this, what do you say? Oh, my God, do I stop giving the vaccines? Do I take the vial and divide it up three times? What do I do? Because it’s not—and the reason I emphasize that is because disinformation in an issue of social media spreads around the world at speed of light and is going to create all kinds of confusion and concerns.

And, yeah, so I just—and lastly, I’ll just say—and I know we’re not talking about COVAX and COVID vaccines, but one of the comments on these issues are, you know, if we have concerns about safety of mRNA vaccines, I’m not sure I would say mRNA is the best vaccine since sliced bread but it’s the fastest vaccine. And if we have another pandemic, it’s the one we should be moving forward. But what do you do if you have concerns? You do more research. You don’t pull the research out and stop it. And this is going to create, again, uncertainty and concern around the world from, you know, what’s happening here.

Although I noticed that Moderna opened a factory in the U.K., and, you know, what we may see are companies beginning to move and offshore their processes. And, again, that’s going to create some confusion. But all these vaccines, by the way, aren’t only looked at in the U.S. You know, COVID vaccines were looked at by 200 countries’ different regulatory agencies and had looked for safety issues. You know, and so there’s real track records here. And, ultimately, we got to get back to the facts here.

BOLLYKY: Great. Heidi, talk a little bit about what we know, and some of the evidence you’ve drawn out in that Lancet piece, about we know how what’s happening in the U.S. might be impacting other countries, in terms of these vaccine concerns.

LARSON: Thanks—yeah. Thanks, Tom. The Lancet piece on the crisis of credibility, and it was really looking at the global cost of the misinformation, just reflected back that we already, during COVID, when we looked at trends—because we, in addition to a lot of survey work in The Vaccine Confidence Project, do a lot of social media monitoring and analytics, and had really a lot of information on trends and swarms, as they are, on social media globally. And really, so much of what we see that lands in other countries, the source is the U.S. And not just misinformation. Again, I mean, some of it is very much ideology, religion, evangelism, going against certain things for different reasons. I mean, if it’s related to fertility concerns or related to other things, these things spread through networks—networks of like-minded belief systems, networks of different aspects.

And even before COVID, in our very first global monitoring—global mapping of vaccine confidence in 2015, we redid the same global survey in 2018. And in the first survey, we saw that France—Europe in general was the most skeptical region in the world when it came to vaccines. I think if we had disaggregated the U.S. into states, it probably would have been similar to Europe. But France globally had the highest level of skepticism. I think 41-42 percent of the public said that they did not agree with the statement that vaccines are safe. Three years later, we looked at our global map, which had a heat map. And we saw that Africa, which was pretty confident in 2015 overall, in 2018 there was a whole swarm of negative hesitancy.

And we recognized that it was primarily in the French-speaking countries, Francophone Africa. And it really struck us. And then later, we saw different trends. Poland had some growing organized antivaccine groups. And we started to see the impact on the Polish community in different countries in Europe. So the diaspora is by language, because there’s, you know, people these days are hyperconnected, as we’ve been talking about. They’re like viruses. They don’t need any passports. And they go in swarms. And that certainly hit us, struck us. But I think what’s growing in complication now, with AI, is it’s not just text that is traveling. It’s images. It’s videos. It’s voices that are not necessarily real.

And that is creating a whole other new level of challenge for us. We saw, for instance, with the HPV vaccine in Japan nine years suspending the proactive recommendation of HPV vaccine because a few girls had what was deemed as more of an anxiety reaction. And that video, through YouTube, got sent around the world. It was voiced over in English, subtitled in multiple languages, you know, went to Denmark, went to Ireland, which questioned and pushed the EMA to reevaluate the HPV vaccine. That video went, subtitled again in Spanish, hundreds of girls, between 4(00) and 500 across in a section of Colombia started fainting, having all these reactions.

So we see this contagion of misinformation that, through multiple mediums, not just text-based, can travel—can travel quickly. So I think—and Google Translate now is—and multiple modes. We need to raise our game a bit. And what we’re increasingly looking at is the phenomena of what we call fertile ground factors, because the same pieces of misinformation can land in three different countries or three different settings and have totally different impacts. In one country it will fizzle and die. In another country it will disrupt a program. And another it will shut down the whole program. And I see that particularly in Africa and in lower-income countries, there’s a different kind of shock value that can totally shut down a whole state in places where you don’t have this fertile ground resilience that Finland, for instance, is like 95 percent for thirty years in DTP3. And some countries have much more resilience. So I think we really need to work on that resilience piece.

The other just last point on this, and one of the issues that happened—phenomena that happened during COVID, is when we were looking at these swarms of questioning and mis/disinformation, or anxieties before COVID, it was largely parents groups, moms groups, people—maybe young girls looking for HPV information. More clustered around people actually looking for something related to a vaccine that they were looking for. During COVID, because everybody—every part of the population was looking online about vaccines, it exposed them to what a lot of people told me they had no clue what was going on online about vaccines before COVID. They just took it for granted. But it exposed—like, it bit the apple.

And the other phenomena that was happening was that it was converging with anti-government control, anti-GMO, far-right movements. Where they merge together is being about government-driven, government-controlled initiatives. So it totally pushed this—pushed the swarms to be across a number of different interest groups, which puts us at a new level. So it’s a pretty serious landscape. (Laughs.) I think part of the problem is, as a public health community and scientific community, we’ve been extremely anxious and concerned about going into that space because of the nature of it. And we’ve kind of rolled out the red carpet for it to be owned. And we need to be there. And we need to do it in a real quantum-shift way.

BOLLYKY: Great. I want to ask Bill one last question, and I’m going to turn it over to the audience. I put that out there so people can start to think of your questions. I will call you on the order that I see your placard. And just a reminder that today’s event is on the record.

Bill, you talked about some of the way that vaccine concerns are being memorialized in policy in the U.S. or undermining some of the infrastructure that existed around giving scientific guidance on the adoption and use of vaccines. Do we see any trends in that regard globally? Do you have any sense of whether or not this is shifting school policies in other nations, shifting how other nations are issuing their guidance in terms of vaccination?

MOSS: Yeah. Obviously, many, many countries, you know, have their own, they’re called NITAGs, National Immunization Technical Advisory Groups, that advise on immunization policies. They traditionally have relied very much on the World Health Organization as the body that provides global guidance on vaccines. So I don’t know of specific examples of countries—Heidi may know—you know, of countries outside the United States shifting their vaccination policy, their school vaccination policies, as a consequence of what’s happening here in the United States. But it’s still pretty—it’s pretty new here in the United States with this—I think this kind of more surge of legislative action to try to relax some of the requirements for school entry checks.

Many countries—I work a lot in Zambia. We actually have—are doing—have recently conducted a project to try to get them to do school vaccination checks as an opportunity to provide vaccination for children who have missed vaccinations. It’s not a vaccination requirement or mandated vaccines, but there’s great enthusiasm to do that. It’s just another opportunity to identify those children that Seth referred to, those zero-dose children, those children who’ve missed out, at school. So, again, as Seth alluded to this as well, in countries where the they see the burden of vaccine preventable diseases—they see measles, they see diphtheria or pertussis, and know about the important consequence—it’s much easier to get that public buy-in. With the caveat of what Heidi referred to, there’s still—there’s still vaccine hesitancy there.

BERKLEY: Just wanted to add one other point, which is, you know, we talked a lot about misinformation and the spread. The disinformation problem is a real problem. And we all are aware of the case when we were looking in Pakistan for Osama bin Laden, there was this issue of trying to do a campaign to see if one could get some, you know, serum to look at the DNA of people to see what happened. And after that, there was an enormous set of critique on doing that. And there was a never again should we do this, because even today we’re seeing polio workers being killed, we’re seeing, you know, the effects of this. That, by the way, spread to Nigeria and other places. So it was really a big problem.

And, you know, one of the things I cover in the book was that all of a sudden it’s back again. And there was an effort in the Defense Department to use a misinformation to say that the Chinese vaccine, Sinovac, in Muslim countries was grown on pork, and was—you know, was not efficacious. And the idea was they wanted to, you know, drive people away from the Chinese product. But, again, the effects of this are—have such a long tail. We don’t know what the tail will be, but it really has this effect on trust, that Heidi talked about. And, you know, how we get to a kind of a global agreement that vaccine should not be used as this tool of this disinformation, because, you know, you can’t control what happens afterwards and try to put the genie back in the box, if I want to say that proverbially.

BOLLYKY: Mmm hmm. Great.

So we have some questions online. We’re going to have some in person. I’m going to take them in groups of two because we’re going to have many. Please make your question sound like a question. State your name and affiliation. And we’ll try to keep our answers short so we can get to as many as possible. Why don’t we start with Jamie and Devi online?

Q: Wonderful. Thank you. My name is Dr. Jamie Garden. I’m affiliated with Mount Sinai Hospital in New York City, as well as the WHO in Geneva.

Thank you. This has been a wonderful panel. And I really appreciate the discussion about the concept of trust here. As a physician, we have previously enjoyed a role in society where we’re generally trusted by our patients. I’m wondering what you guys would advise. I’ve encountered multiple times where I’m talking with families about vaccination and things that we know the science behind, and why are they going to listen to me when the president or the secretary of health and human services is telling them otherwise? What would you advise in terms of, you know, on a micro-level, combating this level of distrust that we’ve previously sort of taken for granted that we have with our patients and with the people that we’re physically injecting these into?

BOLLYKY: Great.

Devi.

Q: Hi. Yes. Devi Sridhar from University of Edinburgh. Thank you for your insights. And congratulations, Seth, on your book, and, Heidi, on your brilliant paper.

So I guess mine is linked, in a way. Which is social media is the main way people get their information. The more followers you have, the more credible people think you are. Popularity has overcome expertise, I would say. Like, take Joe Rogan, who I would argue is the biggest health influencer, though I wouldn’t say he has the right expertise. And so my question is, in these spaces—I guess, Heidi, you mentioned we need to go into these spaces—if you say anything in support of vaccines you get a major backlash. This is abuse, death threats. It’s vicious. Whereas if you’re vaccine hesitant, if you talk about—you know, and a lot of podcasters have recognized this—you get a cult following. It’s lucrative. You get lots of acclaim, and all of a sudden. You get invitations that you thought you’d never get before. So the incentives are kind of backwards. So I guess, what do we do about it? Because I don’t really know what we can do about the wild west of social media, where it’s about popularity not necessarily what’s true and not true. Thank you.

BOLLYKY: Great.

So we’ll move to—two questions on intervention. So why don’t we start with you, Heidi, and then move here to the room. We have about ten questions, so let’s keep short answers, and then we’ll work through all—as many as we can. Go ahead, Heidi.

LARSON: Thanks. Just picking up on Jamie’s. On the trust issue, I think I just recently did a piece in Nature. And we call it, “Science’s Biggest Problem is Not Loss of Trust, it’s Loss of Influence.” And, again, you know, trust in doctors and trust in scientists is still high, but trust in a lot of other things is getting higher. So I think what we need to do is really work at getting kind of an ecosystem of trust, and working with family members of—family is huge. And if we can maybe get other members of the family engaged, or other—through other networks, or through schools, find ways to do that, because it’s an issue. Because there’s a lot of trust for some people in what is disinformation right now, or misinformation. And we have to remind ourselves, though, that we’re calling it misinformation. They’re not calling it misinformation. We’re framing it as being antivaccine. They don’t—they’re not antivaccine. They’re recommending different types of vaccine, or more science. So we have to step out of the way we’re looking at things and try to engage in ways that they’re considering. This isn’t an easy fix, so I don’t mean to make it sound at all easy. (Laughs.) But it’s some of the things we’re learning.

And with Devi’s point, I think our problem as a scientific and—or, challenge as a scientific and public health community, is we’ve got—we’re very emboldened in our information, but we are very specific about it in ways that the alternative information is emboldened, with very little evidence. (Laughs.) But I think that what we need to do more is make it relevant. I’ve heard more and more people say, we don’t want you to—we don’t need you to simplify complex science. Just make it relevant to our lives. And somehow, we can’t be out there in a campaign mode on social media. We need to be out there embedded in other interests that people have, and work it into their—whatever the group or interest group it is, and make it part of their belief system. If it’s a mom’s group, what else are they caring about? And work it in. If it’s a different type of group, we need to work with that. At least, that’s what we’re trying.

BOLLYKY: Great. Thank you, Heidi.

Anything, Bill, did you want to add something quick?

MOSS: Yeah. I could just add, very briefly to Jamie’s question. You know, I think physicians and primary—and healthcare providers are still very—their advice is still very much valued by parents. And I think listening and understanding what the concerns are. And, you know, some people talk about what’s called the movable middle on vaccines. You know, those for whom healthcare providers can make a difference in their decision making.

BOLLYKY: Great. I’m going to—if it’s alright, I’m going to go to go to questions because I think we have about nine, and eight minutes left. So we will not get to all of them. But I’m going to take them in groups of three to get to as many as we can. Again, keep them short, and we’ll keep our answers short.

I have Kenneth, then Julia, and then Amy.

Q: So my name is Kenneth Oye. I’m at MIT and I also sit on the NIH advisory committee that was just disbanded. (Laughter.)

The question really picks up on some points that Seth and Bill were making. You talked about how vaccines were victims of their own success, OK? The consequences of not getting vaccinated are limited by herd immunity and by the effectiveness of vaccines in addressing the diseases, and without the horrible demonstrations, smallpox, polio, the case for getting vaccinated is diminished. My question to you really is, under what circumstances would you see a reversal in those attitudes caused not by social media and the things that we’ve been emphasizing, but by a change in fundamental circumstances—a resurgence of the stuff that we really don’t want to see?

BOLLYKY: Great.

Amy.

Q: Oh, yes. Thank you. Amy Stambach, University of Wisconsin-Madison. I’m an anthropologist. I’ve worked quite a bit in South Africa during the COVID years and so on. And I’m also a fellow with a senator who works on the Global Health in Africa Subcommittee.

My question—I have one question. I’ll leave it to one. In addition—this is for Seth Berkley. In addition to the replenishment funds—you know, I sympathize—(inaudible)—that those weren’t forthcoming—how else does the U.S. government support and fund Gavi? What other financial support do we offer? Thank you.

BOLLYKY: Great.

And then I had Julia—or, Julie. Forgive me. I said Julia, but it meant Julie.

Q: Am I Julia? Yeah, Julie. No worries. Hi. I’m Julie Fischer, Georgetown University, and also formerly of an advisory board to the CDC on readiness and resilience—or, of a former advisory board.

I would love to get back to this question of building resilience and creating ground that is less fertile. I think one of the challenges is that we hear a lot of suggestions on countering disinformation and misinformation, or providing more scientifically valid information, that is very individually focused. What individual clinicians or experts can do to work with small groups of people to voice, counter to what is a very global push of information on the other side. So I would love to hear more about how we can look at, how do you engage people who have the technical vocabulary to talk about these things and take away some of the concern? Decoupling the evidence and information from issues about politics and ideology and identity politics, particularly, that make this so difficult for scientists to wrap their heads around how to get engaged? What are the ways to build that resilience and build a corps of scientists or technically trained people who have the vocabulary and the comfort to deal in these areas?

BOLLYKY: Great.

Why don’t we go William on the first question about is there such a thing as a good epidemic—(laughter)—or a good crisis. Seth, obviously, to the Gavi question. And then Heidi a little bit on whether scientists are good messengers in terms of building this resilience.

MOSS: Great. So thank you, Kenneth. It’s a very interesting question. And I hope we don’t need to get to a big outbreak, you know, in order to convince people. But, you know, I think about the outbreak in West Texas, the measles outbreak in West Texas. And I think there were some people—I don’t want to over generalize—but there were some people who recognized that as a crisis, and there was an up—you know, some members of the community got vaccinated. But there were also members of that community, and I think about the interview of the first child who died—with the parents of the first child who died, who, even after the death of their child, said in the interview that they would not have had their child vaccinated. So there are—it’s complex. And it will move some people, I hope, but not everyone.

BERKELY: So, just on that point, I think it really is a—it is going to happen, I mean, is the point. And during COVID we had the same thing. We had people on their deathbed saying, you know, I don’t believe in it. I wouldn’t get vaccinated. But at the end, I don’t think most people want their children to die or to have severe, you know, morbidities. And so it will take time, but that shouldn’t be how we have to get there. So I think you’re right, but it’s horrible to think about that.

You know, Amy, it is an important question because replenishment cash matters, but this trust issue matters enormously. And the U.S. was the largest development donor in the world. And so it supported health systems. It supported delivery mechanisms. It supported laboratories. I mean, the measles laboratory system that existed around the world to do testing for it was supported. And so we’re seeing surveillance go down. We’re seeing these other factors go down. And this is going to have a dramatic effect on health. And, most importantly, when you talk to people I think people understand—they don’t want to talk about COVID—but I think they understand that that pandemic preparedness is a government function. And we’re going the opposite direction now in terms of dealing with that. And I think that’s important. And I just published a piece that made the point that more Americans died in COVID than died in all wars—this is U.S. military—in all wars since the Civil War. And, you know, the point is you can’t have global security without having health security. And, you know, meanwhile we’re cutting all the money for global health security while we’re increasing the money at 12 percent increase for defense to a trillion dollars. It’s just not making any sense.

Q: Agree completely. Can I just ask a yes/no question?

BOLLYKY: No.

Q: Oh, no.

BOLLYKY: I’m sorry. (Laughter.) We have a long list of people. So I don’t want to be unfair to them.

Q: I understand.

BOLLYKY: Heidi, quickly on the scientists as emissaries.

LARSON: Yeah. And, Julie, I’m happy to follow up offline on this because I know a minute is going to do no justice to this. But just—I just strongly believe that we need to get more partners with science. And we expect a lot of scientists to be great communicators. And it’s not always what they either want to do or are good at. And I think that we need to get more partnering, and working with scientists to make it—make it relevant. And I don’t think we should be thinking about decoupling the facts from the context. Our problem is we’ve not done enough coupling of the facts in context.

BOLLYKY: Great.

We have two minutes so I’m just going to pull Lyric from online, if you could ask it in just twenty seconds or less. And then Eileen in person. And then we’ll do the best we can.

Q: You got it. OK, Lyric Hughes Hale with EconVue in Chicago.

My question, everything that we’ve been talking about so far has been about the demand side on vaccines. What about the supply side? China has recently threatened not to supply rare earths. We are just as dependent on China for pharmaceuticals. Who’s working on this problem right now? Because during COVID we had issues. I was personally involved in some of them. It was not just masks. It was reagents and so forth that were really needed to fight COVID. And, let alone, you know, biologics. So I just thought we should touch on that side of things today.

BOLLYKY: Got it. Thank you, Lyric.

Eileen.

Q: I keep wondering what the—I’m Eileen O’Connor. I’m actually an attorney who worked on the vaccine and autism cases and then worked at Rockefeller on vaccine availability around the world. And we did work on this confidence issue as well.

So what I wanted to ask was, they have used litigation. The initial experts have used litigation to actually—and are still using it now on Tylenol, for example. Can we use—what are your views on using litigation for—against people who might be injured eventually or are injured? I know you have some who don’t wish they were, but are injured, and also doing discovery to get the profit motive behind the antivaxxers? There is massive profits that they’re making. And then secondly, just quickly—

BOLLYKY: No, no, no, no.

Q: OK. (Laughter.)

BOLLYKY: So let’s start on the issue of how much do we rely on China for vaccine components and vaccines, to Seth, very quickly. And then, I mean, ask, actually, Bill, if you can talk a little bit about what you know on the litigation side, maybe. And then we can finish up from there.

BERKLEY: Yeah. I mean, you know, the issue is we’re less reliant on China for vaccines than we are for API and drugs, where there is a big challenge. That being said, of course, we need diverse supply chains. And it’s one of the things coming out are lessons learned from COVID to make sure that there are big supply chains. And one of the reasons, just in a sentence, is because biologics, as living things, you can’t change anything because you can’t say it’s chemically pure, like you can with API. So if you change a filter or you change the reagent, you got to go all the way back to try to redo it. And that’s a problem.

MOSS: Yeah, it’s a complex question, Eileen. And I’m not sure I’m going to be able to do it justice very quickly. But I’m not—I’m not aware of specific litigation, and maybe Seth is, you know, on the pro-vaccine side, which is how I understood the question.

Q: Yeah.

BOLLYKY: I think anti—oh, pro-vax? Bringing it on—

MOSS: Yeah, bringing it on, yes. I mean, I could—I could imagine that. I’m trying to think if there’s a case where, you know, some immunocompromised person or person who couldn’t get vaccinated is then exposed to a vaccine preventable disease. That might be a situation.

BERKLEY: There has been a little of that. But, you know, we’ve ended up with this warfare going on. And I would hate that to be the way we make our policy. But you might have to get there, given the financial, you know, issues that are in place.

MOSS: Yeah.

BOLLYKY: Great. This has been a very rich discussion. Again, read Seth’s book. It’s terrific. Take a look at our new vaccine tracker. Thank you to Sidney (sp) for organizing this event. Thank you all for being here. And please join me in thanking our three terrific speakers. (Applause.)

(END)

This is an uncorrected transcript.