we started seeing protests this increase in some of our communities including having two deaths and that in justice a reminder to folks you know we as long so we always talk about the the the numbers of cases that are reported as being a tip of the iceberg and this is another one of those issues where it's not easy night i think you're absolutely take it tight you know how hard we're working and i think the structure of this presentation is really going to show how much good work is being done by and our other epidemiologists in our communicable disease epidemiology group and how much we're dependent on that data to help us understand what's going on and to figure out what you do so chess is going to walk through and show you i detail the d that we how on our surveillance and he's reporting and then i'll give you some information about our communication efforts are specific efforts to help the writer community understand what's going on and give them any additional information they need and then what we've been doing washington state you saw it less than five hundred cases per year we began to have some peak years through a decade of the ninety's where we had over eight hundred he says and then here was six hundred cases and then we did have a new technology for diagnosing protests as introduced in the late ninety's which is a political race chain reaction or a v c r which detects the d n a as opposed to having to grow out the bacteria which is very hard to grow and so we did see that ability to better diagnose the disease and play tonight we continue to have a little bit higher annual average rate of reporting until in two thousand and five we had a thousand cases in this state as marriages a thousand cases in the whole country nine hundred seventy six and then we just sort of cruise along again considerably higher and then out of this is from our weekly update that we post every week i have a whole choices we twenty and we just put out the statistics for we twenty three yesterday pound this week oh i just calculated the numbers and oh it's going down on the most recent week but if you look at that same week we twenty three weeks later it's got over two hundred cases reported in  come in and on and this is kind of an interesting process that our we've been doing for the last two and a half years we've been helpful lady and soner free software our baseline an epidemic threshold epidemic is so spectacular that it's leveled everything out and all the previous cases look like they're just kind of reading along as a norm and then i did mention that we have this process called case classification it's part of surveillance nationwide and we have criteria that are established nationally of what is a confirmed case and what is a probable case and then we also have got more rapid diagnosis and earlier treatment and what we're starting to see over the past few years is p c r positive cases that don't meet the case definition for reporting is confirmed cases and you can see this year we have about one hundred fifty additional cases that are lab confirmed that we can include them in our count so it's just kind of an interesting phenomenon and that's due to our new technology so i wanted on this graph each of the year is two thousand five through two thousand and eleven our annual rate disease and this so you can see that two thousand and five when we had the thousand cases in the state we had a really high rate in infants of two hundred cases one hundred thousand infants that has come down over the last few years and fortunately in the gray area that this year year to date that's not an annual rate in the gray area lots and lots and lots of protests it's not being reported i'm especially in the hold her own adolescents and adults to diseases milder in sometimes it's not recognize or sometimes it's just not i'm serious enough to make them go in to be seen by a health care provider so it doesn't get diagnosed but they're still contagious so the median age of our cases the last two years is eleven years big dig out and i just  records that if you see their ninety eight ninety two ninety three ninety four ninety five at that time i think the whole health care community wasn't as aware that this is a disease of all ages it of our disease in infants and in two thousand and twelve you see that we still have higher rates in under one than we are also seeing quite a bit of disease in school age  counties that didn't report in texas last year and then you if you move to this year you can see that we have considerably more disease certainly along the i five corridor but we also have some h and then i just wanted to give you a summary of tarsus infant deaths over the last two decades we had two deaths in the ninety's one death in the early two thousand and two deaths in the late two thousand and ten we have had two deaths in each of the past two years and looking at all of those deaths together all of those all the deaths that we have documented in the last two decades were under one  age eight if there were two months of age or younger approximately even distribution male and female own but we did see a higher our number of deaths in hispanic or then this last slide i just want there are some things that want to tell you about it because it's really important to understand this information comes from surveillance data it is not medically dog documented vaccinations i what we give him with her case reports and that is variable between counties all so it's important for you to understand that on our case reports for two thousand and ten  this year twelve percent of all ages have no vaccine permission forty nine percent of adults have had no information so with that said what we did was take a look at the cases for which we did have information and we started with seven month olds because that would put them after the ages at which they should have had the first three doses so by seven months we're expecting them to have three doses on board and then we looked at other cases up through eighteen years of age and what we are seeing is that in two thousand the hope would have been ten eleven we had about sixty four percent of cases up to date for purchases containing vaccine according to the c i p schedule and this year about sixty one percent and then if we just drill down a little bit on some of the ages that would concern about the seven year olds should have the polls childhood series and then there is another recommended vaccine on telly age eleven so looking at seven to ten year olds the proportion of pieces with four more doses was a one percent in the last two years and i'm seventy recommendation of age eleven and twelve we try to look at ages thirteen through eighteen leaving out the ages where it was man and then just looking at the school age kids who are of a nature should have one and what we had to or they had a vaccine given out after the age of eleven and looking at that information we see calculated that about sixty two percent of arthur g eighteen holes in two thousand and ten two thousand and eleven had those out and about sixty percent this year so far and with that being said i just want to point out that we do know that the protection from the vaccine when it's and if for example you're a ten year old and you have all of your doses that were recommended and you got that last dose sometime during the time you were four or five years old and now you're ten you've had five years passed since  you got your last dose so it's a little bit deceptive when people say that all the cases were vaccinated they weren't vaccinated yesterday many of them were vaccinated five or six or seven years ago we do know  nationally on the communications front we have just been really busy you're going to have several mats and this gives you a snapshot of some of the key things that we've been doing in addition to that i just wanted to highlight that we've worked with the association of question of businesses in fact recovered herself for letter to them after them to be aware of the situation to promote vaccination amongst their employees we've also provided a letter to the hospitals in collaboration with the washington hospital action along the same lines to make them aware of the situation and promote vaccination of health care workers we have a lot of information available on our web site if you haven't checked it out please do so in addition to postings about the p situation on our home page we have a twenty twelve protests with epidemic ph with some supporting pages the high that there is a specific website page that is dedicated to health care providers as well as information available for parents grandparents childcare providers schools and of course also a lot of information are coming out so as we have received calls and e mails and meetings and heard questions and realize the need for more information we've created a lot of information and that's most all that is available on our website in addition to the media and social media that you see here the radio by specifically we are continuing to purchase media and doing more work over the summer to on  bus boards and billboards to make sure the community is aware of the epidemic one additional thing and given that we have the state department of health there are also responsible for help professor professions like think we have included in the notices for health professionals license renewal information about the epidemic and a reminder that teac is important especially for healthcare providers that we're looking at all those ways that we can get the word out and the didn't we have to have shows that the adult community is fresh really is responding we look have looked at do that for our immunization registry and it looks like close to two and a half times the number of adults who got time and we provided some of that information last week in a news report for provider education one of the i think biggest things that we did was on the thirty a m we worked with c on a weapon our training and that how it was continuing medical education credits there were a thousand slots available for participants they were all filled prior to the training and most of the participants were from washington state we don't yet have final numbers but we're really proud of that i'm getting the word out and having our healthcare providers participate in that training we have provided special information education through a letter from a doctor peyser help opus or to the medical community we've done that twice so far and will probably be doing another update soon and then again providing surveillance information on their website through the weekly postings and tools and templates for schools and child care and health care providers to support their and then the last thing that i wanted to share is around vaccine access so i think everyone here has a we're through our conversations over the last several years about our universal and steve childhood vaccine program where we purchase and distribute all the recommended next scenes for all  who are from birth through the eighteen sylvette there is one standard of care in washington for kids regardless of their insurance status and we we're seeing continued ordering out protests continue various scenes for that population and we're not seeing we're seeing them about the same as previous years of just not surprising because we have good imitation coverage for travelers for sixth graders toddlers it's about eighty two percent the sixth graders  pursue reports it's about eighty three percent coverage but we've been concerned about how much access to that scene for adults who are uninsured and under insured there is good insurance coverage for  pete vaccine and we know that with a fully implemented health reform at the national level there will be a first dollar coverage so no co pays and deductibles for all routinely recommended vaccines from the  schedule but that's not completely in place yet and so we have been working with c d c and with the state i'm to find some additional money to purchase vaccine that we can give to i will help jurisdictions so that they can try to position that vaccine  as best in their community to make it available for adults who don't have access or don't have an insurance who would that would cover it and we've been seeing a good steady use of that vaccine we're also we're in the first bullet here that the sano a cost it cost me it cost me forty dollars per dose to buy it what it cost which is not in and which is not insignificant and it is very laborious to find out whether they're going to get coverage to do various insurance carriers and so there are a few insurance carriers that have actually been proactive and notified my daughters was one of them notified them that it's fully covered you know and yet many of the medicaid many of the  medical provider plans the only place they pay for it is at the pharmacy while our patients are not going to the pharmacy to get it no way no how it is going to happen and so and so it's caught it's cost in this large amounts of money to try and do this and a large amount of research by our by our route builders and our staff to try to figure this out ahead of time and so so i understand you're having conversations with the insurance carriers ask them to be a little more proactive ask them to be a little more proactive in as a communications with years ago by the way why did you your old mother will not go to  to which is rarely ever