MS. DIANE REHMThanks for joining us. I'm Diane Rehm. International efforts over the past 14 years to vaccinate children against deadly diseases have saved nearly 6 million lives. But still, 22 million children, most living in poor countries, do not have access to basic vaccines. In the U.S., measles cases, considered virtually eliminated here, have hit a 20-year high.

MS. DIANE REHMHere to discuss ongoing vaccinations, efforts against deadly diseases, Dr. Anne Schuchat of the Centers for Disease Control and Prevention, Susan Dentzer of The Robert Wood Johnson Foundation and joining us by phone from Geneva, Switzerland, Dr. Seth Berkley of The GAVI Alliance. That's an organization working to provide vaccines to children in the developing world.

MS. DIANE REHMAnd throughout the hour, I'll look forward to hearing from you. Give us a call at 800-433-8850. Send us your email to drshow@WAMU.org. Follow us on Facebook or send us a tweet. And thank you all for joining us.

MS. SUSAN DENTZERGreat to be with you, Diane.

DR. ANNE SCHUCHATIt's a pleasure to be here.

DR. SETH BERKLEYGreat to be here.

REHMGood to have you with us. Susan Dentzer, I'll start with you. We seem to have a two world problem. First of all, talk about what's going on in the developed world and especially in this country.

DENTZERWell, as we know, particularly with respect to vaccines, they have been one of the most beneficial and cost-saving interventions ever developed to improve human health and to fight infectious disease and probably the greatest if not one of the greatest public health stories of all times. And you can see that still here in the United States.

DENTZERThe vast majority of children are fully vaccinated against any of a number of infectious diseases. The vast majority of adults. But we still have issues. We still have problems and, in particular, you see it in the measles outbreak you were just discussing. Most of those measles cases involved people who were unvaccinated here in the United States, many of them children under 20 who traveled overseas, became exposed to measles and brought it back to the U.S.

DENTZERSo we still have that phenomenon and we still do have a certain amount of so-called vaccine refusal, which is people objecting to getting vaccinated for either medical reasons or philosophical reasons or what have you.

REHMAll right. And before we go further into that problem, Dr. Berkley, talk about what's happening in the developing world with the availability and the receptance (sic) of vaccines.

BERKLEYWell, in general, we don't have that problem, which is we don't have people who say I don't see the disease. I'm not familiar with the disease and therefore we don't need that vaccine. In fact, in general, in our countries, when people know that these vaccines are available, they line up. They'll travel great distance to get those vaccines 'cause they want to protect their kids. And these diseases are real.

BERKLEYPeople are dying of them around them. Their relatives are dying. Their neighbors are dying. And so they see these diseases. And what's happened has been a remarkable change. In the past, in the '70s, less than 5 percent of children in the world were vaccinated. There was a big push to get some traditional vaccines up and my organization, GAVI, was established to try and get the newer vaccines, the really miraculous vaccines that exist today that really cover some of the largest killers of children.

BERKLEYFor example, diarrhea and pneumonia, two largest killers of children, about 30 percent of child deaths are now targeted by very good vaccines. These would not have been made available in the past given the cost, given there wasn't a market and GAVI's job was to do that and we're now bringing 11 vaccines forward, new vaccines to people in the developing world and trying to get coverage levels up.

REHMAnd to you, Dr. Anne Schuchat, talk about why we are seeing this outbreak of measles here in the U.S. Susan Dentzer spoke a bit about people traveling to developing world countries, coming back infected. But is there more to it than that?

SCHUCHATYou know, we're so lucky that rates of vaccine-preventable diseases are very low here in the United States, but these diseases are still all around us and really just a plane ride away. Some people have forgotten what measles is, but there are about 20 million cases of measles around the world and a very large outbreak going on in the Philippines with about 40,000 cases.

SCHUCHATSo what happened here in the U.S. this year is that we've had lots of people traveling back from the Philippines and elsewhere, some infected with measles. And when the measles virus finds a family or a community or school where many people haven't been immunized, it can spread. So what we've seen is 17 outbreaks around the country and a very large outbreak in Ohio that's primarily affecting the Amish population, which had not been vaccinated.

SCHUCHATThey are accepting vaccines now and we're seeing things get better there, but they're just one of many communities that have chosen not to vaccinate.

REHMAnd in fact, how is the measles virus transmitted?

SCHUCHATMeasles is one of the most infectious or contagious agents out there. If you're infected with measles virus, you can cough or sneeze and it can infect others. But what's really troubling about measles is you don't even have to be in the same room as a person with measles. A child can enter a pediatrician's office with measles, go so the doctor, leave, two or three hours later, another family can come in and if a person hasn't been vaccinated, they can get measles 'cause the virus can persist airborne for a couple hours. It's extremely infectious.

REHMNow, there's another vaccine that some people are resisting and that is the whooping cough vaccine.

SCHUCHATYeah. The whooping cough situation is complicated. We're having a lot of whooping cough the past several years and we think there are multiple things going on. If you haven't been fully vaccinated against that disease, your about six times more likely to get infected than if you have been well vaccinated. But the vaccine for whooping cough isn't perfect and we do see some cases in people who've had the vaccine.

SCHUCHATOur most important message for whooping cough is for pregnant women to be vaccinated in their third trimester with the TDAP shot, which includes whooping cough, so that their baby will be healthy and not develop whooping cough in the first couple months of life. It can be fatal in babies.

REHMWhat I understand is sort of shocking. More than 8,000 cases of whooping cough have been reported, most of them in California.

SCHUCHATCalifornia's declared an epidemic of whooping cough this year. A couple of years ago they did as well. What we're learning is the whooping cough vaccines that we're using here in the U.S. are good, but they're not great and their protection wears off after several years. So babies and young children really need to get all the recommended shots and we want pregnant women to get vaccinated, too.

SCHUCHATIt's a complicated story.

REHMDr. Anne Schuchat is director of the CDC's National Center for Immunization and Respiratory Diseases. I hope you will join us with questions, comments, 800-433-8850. Send us your email to drshow@WAMU.org. Follow us on Facebook or Twitter. In measles cases, you're back to California. There are 60 apparently fairly wealthy families who have refused to vaccinate their children. What's happening?

SCHUCHATYou know, the demographics of who isn't vaccinating are very interesting. We do find affluent, highly educated people who've decided not to get their kids vaccinated. But I want to remind listeners that 99 percent of toddlers have gotten vaccinated. Most people are in the system. But when we look at who isn't vaccinating, there are a lot of different reasons, but some folks feel like these diseases are gone.

SCHUCHATThey're not a risk anymore. Some people have questions about the safety of vaccines. The MMR is safe and very effective. There were concerns some time ago about a possible link with autism. That's been completely disproven. Vaccines don't cause autism. So we know that some parents still have questions. They need to talk to their doctors to make sure they're comfortable, but I strongly recommend vaccines to protect your kids from life-threatening diseases.

REHMI gather the third biggest outbreak of measles in this country is in New York City.

SCHUCHATThat's right. New York City is another place that's been battling measles. In fact, there's 20 states that have had measles. Important for folks to know that the public health system in this country responds to every possible measles case and investigates and looks for contacts and tries to make sure everyone's vaccinated. We've eliminated homegrown measles here in the U.S., which means we don't have continuing circulation for more than a year, because of this strong public health response and because we have high rates of measles vaccination.

SCHUCHATBut when pockets of people decided not to vaccinated, they put their own communities at risk. And what we saw in California or New York City is some of these communities where like-minded people have decided not to vaccinate.

REHMSo is that outbreak in New York City and in California being contained?

SCHUCHATYes. We think that the New York City and California outbreaks have been contained. The one in Ohio is continuing. There are nine counties involved, but the health department's responding very aggressively there and the community leaders have stepped up to get their families vaccinated.

REHMAnd Dr. Berkley, I know you wanted to add something.

BERKLEYSo, you know, just to remind people that the viruses and people travel and you can have dinner in Nairobi, breakfast in London and lunch in New York and that's before these diseases appear. And so even if those children aren't traveling to other places, they can have contact with people. But let me also point out one other myth that exists about these vaccines and that is, well, if I get the disease, I live in a great treatment place and there's not going to be a problem.

BERKLEYCertainly, in our countries, that may not be the case, but a lot of these viral diseases don't have treatments. If you get hepatitis B, for example, you got onto potentially some people have cirrhosis and necrosis of the liver, other complications from measles and other diseases.

REHMDr. Seth Berkley, he's CEO of the GAVI Alliance. That's an organization working to provide vaccines to children in the developing world. Short break, right back.

REHMAnd welcome back. If you've just joined us, we're talking about efforts to vaccinate children against deadly disease like measles, whopping cough and indeed polio. Here is an email from Heather who says, "There's a very large pediatrics practice in Toledo, Ohio that just announced they will no longer accept children who have not been vaccinated. Do you see this as becoming a trend," Susan Dentzer?

DENTZERI don't know that it has become a trend but certainly one could see that developing for just the reasons Anne described earlier about the ready transmissibility of many of these conditions. We should also point out there are court cases now involving in instances where families have opted out of vaccines for their children for either religious or other reasons. There have been court cases about whether school districts could then require children who have not been vaccinated to stay home from school in the event of outbreaks. And those have been upheld.

DENTZERSo I think the prevailing tide of opinion is that the herd, if you will, which is all of us, needs to be protected. And this herd immunity needs to be reinforced by essentially enforcing some of these restrictions.

REHMTell me about some of the studies in regard to these vaccines and the concerns about aftereffects, Dr. Schuchat.

SCHUCHATYeah, the concerns begin with a study that reported a possible link between MMR and autism. That...

REHMThat is the measles vaccine.

SCHUCHAT...the measles, mumps and rubella vaccine. That study has been retracted and discredited but the myth has actually persisted. There were lots of questions because of the age when children do present with autism. And of course autism is a terrible condition, very difficult for families. But there have been more than 20 studies of that question and the link has not been shown. The issue has really been disproven.

SCHUCHATMany of the autism leaders and researchers have really moved on to other issues that are more promising because we do want to get answers to that terrible condition.

REHMDr. Berkley, what about polio in developing worlds? What's happening there?

BERKLEYWell, we're in the final stages of an eradication campaign. Polio, a terrible disease. You know, generations ago, we would see outbreaks that would occur that would paralyze large numbers of children. Parents were terrified that we take our children to the pool, for example. Remember...

REHMOh, I remember the iron lungs truly.

BERKLEYAbsolutely. And I dated a girl once who had had polio as a child. With 350,000 cases a year, that's down now to a couple of hundred. But this goes back to what we were talking about. As long as it exists somewhere, it becomes a risk. So there are now three countries left that it's never been eradicated. And these are called endemic countries, and that's Nigeria, Afghanistan and Pakistan.

BERKLEYAnd what we've seen is outbreaks that keep occurring from these countries. And even in countries that have very good immunization coverage, we see the virus appearing. So Israel, for example, recently had in their sewage wild polio virus. Luckily nobody got sick because they were well immunized. We just saw the first in sewage in Sao Paulo, Brazil.

BERKLEYSo that shows us that these viruses continue to travel and that's why we have to keep immunization coverage up. But also, we have to finish this job of eradication because only by finishing it will we, at the end of the day, protect children everywhere.

REHMHere's an email from Tina in Cincinnati, Ohio. She says, "I have educated friends who would never refuse other vaccines but who believe you should not vaccinate against chicken pox vaccine. They believe it's better to expose children and build up an immunity. Would this make individuals more susceptible to shingles later in life? Are there ever life-threatening consequences from chicken pox?" Lots of questions there, Dr. Schuchat.

SCHUCHATYeah, chicken pox used to be fairly universal. And while most people got a rash and recovered, some people could have life-threatening illness or even die. Adults in particular have a worse time with chicken pox. We've seen a huge reduction in deaths from chicken pox, hospitalizations from chicken pox and outbreaks of chicken pox in the era of vaccinating.

SCHUCHATI had friends who wondered, oh do you really need the vaccine? And then as they watched their children go through a miserable condition, they felt really sorry that they hadn't vaccinated their children. So we are now enjoying high rates of chicken pox vaccination and very low rates of disease. I again strongly recommend that vaccine for parents to make sure their kids are protected.

REHMWhat about the question of the connection which we know exists between chicken pox and shingles later in life?

SCHUCHATThat's right. The chicken pox virus is very unusual because it goes silent in the body or latent. But it can come back and cause a very painful disease, shingles. We have seen a shingles vaccine be licensed now for seniors for people 60 and over in fact. And that is having moderate affect but we don't have high uptake yet of the shingles vaccine in adults.

SCHUCHATWe don't know yet exactly what will happen 40 or 50 years after chicken pox vaccination in terms of the shingles rates. Many experts think we won't be seeing so much shingles once people who have been vaccinated as children age. But we really need to wait for a time to see whether that will be the case.

REHMInteresting. All right. And here's another email from Ann who says, "As a woman in my 20's with many friends starting families, I'm shocked by those opting to not vaccinate their children. One of the concerns I feel is not discussed enough is that new doctors have not encountered many of these diseases outside of textbooks and thus may misdiagnose or mistreat an illness," Susan.

DENTZERThat could well be the case. And of course it's the fact that so many of these disease have been largely eliminated, which reinforces the belief among many people that vaccination is not necessary. I think it's important to point out though that by and large, as Anne keeps saying, and it's true, most people are getting vaccinated. Most children are getting vaccinated. It's also the case though -- and I think the CDC has said this -- the number one reason that children do not get vaccinated is that their doctors do not make the arrangements for them.

DENTZERSo in areas of the country where we have seen doctors stop vaccinating children for usually financial reasons -- and this should get us into a conversation about the high price and the rising prices of many of these vaccines -- it's very hard for some of the small pediatric practices now to stock the vaccines because they are so expensive. A total course of immunization now for children in the United States exceeds $2,000.

DENTZERMost of those, of course, are covered now in insurance plans due to the Affordable Care Act and the requirement that they be paid for at no cost sharing to the individual. But the mechanics of stocking these high-priced vaccines are hard for some small pediatric practices. So making sure that there's access to vaccines, that doctors are recommending them, that is a piece that we still have to continue to push on in the United States.

REHMDr. Berkley, you've still got 22 million children in third world countries who've not received vaccines. Is that in part because of cost?

BERKLEYWell, first of all, let me just say on your previous point about physicians, my wife's a physician. Before we moved to Geneva she ran the intensive care unit at Columbia Presbyterian, a big teaching hospital in the U.S. She's never seen a case of tetanus, never seen a case of measles, never seen a case of whooping cough. So that's an example of a doctor incredibly well trained, you know, in a tertiary sense and not having seem them.

BERKLEYSo that is a true issue and something to pay attention to going forward. Obviously we don't want to see the diseases but we do want physicians to be educated and understand the magnitude of these diseases.

REHMExactly. Surely.

BERKLEYSo in terms of the number of unimmunized children, actually that is the number that are not fully immunized with the basic vaccines. Probably half of those children are receiving some immunizations. And so we have two different problems. One, are children who have access to no vaccines. And that's a very small number now but obviously they're children that are isolated in very rural areas or some have some other stigma or more and more in urban slums where they come in for employment but they don't get registered and they, you know, fall out of the system as a result.

BERKLEYThen there are children who, you know, travel far, work hard to get vaccines but come back maybe and the vaccine's not in stock and therefore they don't get their full course of doses. And for that what we're trying to do is improve supply chains and work to make sure that there are incentives in place for people to fully immunize our kids.

BERKLEYBut, I mean, the remarkable thing is the number of children around the world -- more people have access to immunizations than any other intervention.

REHMBut Dr. Berkley, considering the fact that the rate of disease in this country has gone down so far, what did that do to the incentive for companies, corporations to continue to produce these vaccines for children in third world countries?

BERKLEYWell, that's the remarkable story. So because we purchase vaccines for 60 percent of the world's population, we've created a real marketplace. And it's done two things. One is we can go to a company and say, listen we'll put in an order for multiple years and for very large volumes. And they then change their economics. So they go from being a low-volume high-cost producer to a high-volume, you know, medium-cost producer. And what that's able to do is, you know, make the vaccines affordable for countries. And we've had very large drops in prices, sometimes 90 percent, from the prices you just heard about.

BERKLEYWhat we've also done, and this is the second important part, is we've created a marketplace for other manufacturers to come in. So we now have large numbers of manufacturers from middle income countries that are entering the marketplace. And they're producing vaccines at a lower cost, making it cost effective for countries. And that's important for sustainability because although we subsidize vaccines, at the end of the day there's no free lunch. Every country pays something. If you're very poor you pay little but as you get wealthier you pay more. And we want it to be sustainable.

REHMDr. Schuchat, let's talk for a moment about what happens when a child gets the measles. I can recall having the measles at age 7 or 8 and being put into a dim room with shades drawn, the thought being that blindness could occur with measles. Is that a myth now put aside?

SCHUCHATOne of the reasons for the dark room was that the light may both your eyes when you have an infection like measles. So measles will begin with a fever, runny nose, sore throat, cough. But it will actually involve a whole body rash that starts at the head and goes down. Most people recover from measles but it can cause serious complications. My uncle actually had encephalitis from measles as a young child, really a terrible condition. It can cause pneumonia, dehydration and death.

SCHUCHATSo measles is serious. It can also cause a long term problem of encephalopathy that is rare but is sort of like a latent viral problem, so measles is devastating. It's particularly devastating in developing countries where more children do dies from it.

REHMDr. Anne Schuchat of the CDC and you're listening to "The Diane Rehm Show." We've got a lot of callers. I'm going to go to the phones, 800-433-8850. Let's go to, let's see, I cannot see a comment here. Let's try Warren in Delray Beach, Fla. Hi, you're on the air.

WARRENThank you, Diane. It's cloudy today. It's more like Dull Ray Beach, Fla.

REHMOkay.

WARRENListening to this, please allow a former medical proofreader to offer a slight correction and a little bit of an origin story. Most of the medicines being discussed would be, as Dr. Berkley was saying, more in the way of inoculations or immunizations. The original vaccination -- term vaccination, I'll tell you how that originates. Edward Jenner in the latter half of 18th century England, who had been a smallpox victim himself, observed that milkmaids who had contracted a similar but less virulent illness called cowpox, were immune to smallpox.

WARRENSo he got an idea and he took matter from a milkmaid's pock from her hand and he injected into someone and then observed that -- they got but one pock and then the immunity -- notice I said the immunity system, not the immune system -- because no system is immune --the immunity system took over and not only made that person immune to cowpox after that but smallpox as well.

REHMHave you heard that kind of story?

SCHUCHATThat is a -- all historical...

BERKLEY...is actually -- that's the true story. And the other thing is it was a young boy who received it. So from an ethical point of view today, that would be something that we would certainly not do. But it did prove it.

REHMAll right. And to Jason in Baltimore, Md., you're on the air.

JASONThank you. It's a pleasure to be on your show. I was curious about the long term effects of a natural immunity gain through actually contracting the diseases -- all the diseases that you mentioned back in the '50s and '60s when I grew up. Parents would swap kids around and catch each other's diseases to get that immunity, especially, as some of your guests may elaborate, boy children with mumps. So I'm wondering how effective and long term lasting compared to injections those (word?) immunities might be for chicken pox, mumps, measles, you know...

REHMThat's interesting. I can remember the same thing.

SCHUCHATThat's right. Before we had vaccines almost everybody got all of these diseases. Some people got them at young ages and some people got them older. You know, people know that President Franklin Roosevelt was a polio victim. He was 29 when he got -- or 39, I believe, when he got polio and had lifelong paralysis. But children who developed polio infection didn't all have mild cases. Some of them were paralyzed. And so there was almost a Russian roulette at the time in terms of what age are you going to get these illnesses. And is it safer to get them as a young child than as an older person.

SCHUCHATVery important to say that vaccines are much more effective than the natural infection in protecting you and keeping you healthy. There's some infectious diseases where the natural immunity is long lasting and, you know, it's very unlikely that you'll get another infection with measles after having had measles. But there's some where natural infection isn't that good either. So with whooping cough, you can get whooping cough multiple times.

REHMWhat about mumps?

SCHUCHATThe mumps virus is one where you can have long term -- or you can have substantial complications. Men can have orchitis or a testicular infection, which is very, very painful. And that was why the young boys were aiming for mumps at an early age. But it can also cause problems at a young age as well as the older one. And the mumps vaccine is combined with the measles and the German measles or rubella vaccine.

REHMDr. Anne Schuchat. She's director of the CDC's National Center for Immunization and Respiratory Disease. We'll take a short break. More of your calls when we come back.

REHMAnd welcome back. Time to go right back to the phones as we talk about diseases that can be prevented with vaccines. Let's go to Raine in Raleigh, North Carolina. You're on the air.

RAINEHello Ms. Rehm and panel. I wanted to possibly clarify something. I don't know -- I heard a panelist say that the age for the shingles vaccine is 60-years-old. I don't know -- I know it was designed for 60-year-olds in -- 10, 15 years ago when it came out. But at some point, it was also then changed to 50-years old. I had shingles at about age 57. My husband was 58. He promptly went to his doctor, got a script, went to a chain pharmacy and got the shingles vaccine at 57, covered by our insurance. A year after I had shingles, I was able to also get a script, go to the pharmacy and get the shingles vaccine.

REHMDr. Schuchat, do you want to...

RAINEMy understanding is age 50.

REHMYeah. Do you want to comment?

SCHUCHATYeah, thanks. Let me clarify. You're correct that the FDA approved the vaccine for 50 years and up.

REHM50 years.

SCHUCHATThe CDC Advisory's Committee on Immunization Practices has recommended it routinely for people 60 and up. And that's because of the, essentially, when the risk increases and how long we think the vaccine will last for.

REHMOh, I see.

SCHUCHATBut, certainly, people in their 50s can get shingles. People even in younger ages as well.

REHMHow long does the shingles vaccine last?

SCHUCHATWe're still learning about that. It was only first licensed in 2006, so we're really only eight years into the national use of the vaccine. But we aren't sure yet whether it will be long lasting or whether subsequent vaccinations will be useful or not. You know, it's a silent infection that comes back and a new infection, so the vaccine issues are complex.

REHMRaine, do I understand you had another question about how long these vaccines are viable?

RAINEI do. That's because I was a Peace Corp. volunteer in West Africa from 1978 to 80 in health. And at one time, I transported the vaccines in a cooler from the capital up to my post, six, eight hours away, by car. And I was told that these vaccines had to be kept above a certain temperature. The car breaks down, whatever, the vaccines go bad. I don't know, I wonder, has any research been done or I hope there's been improvements in transportation of vaccines. I...

REHMAll right. Dr. Berkley.

BERKLEYWell, first of all, it is still true that vaccines get transited in a cold chain. And the bigger risk now has been that vaccines don't get frozen. Because some vaccines are quite sensitive and if they get too close to ice and people have been creating new technologies that allow you to transport vaccines without any risk of freezing. But the other thing that's happening is we're beginning to test vaccines and try to make vaccines that are more heat stable. So, recently, a meningitis vaccine, that's really been remarkable, used in North Africa to try to deal with meningitis, has been shown to be able to be out of the cold chain for at least four days.

BERKLEYAnd so, what happened is people transported in the cold chain and then for the last mile, when you have to be out, you're able to use it at ambient temperature and that makes it much easier. But of course, at the end of the day, we are strengthening cold chains in these countries, but we also really like to ultimately have vaccines that are heat stable.

REHMRaine, I'm glad you called. Thanks for your question. Here is an email from Mike in Jordan, New York who says, I'm guessing the research and development for childhood vaccines is long past. Why are they still so expensive? Big pharma always claims that R&D is a big part of cost, but that being over long ago, what's the reason now? Susan.

DENTZERWell, it certainly is true that many of the vaccines now commonly used were developed years ago, and so the caller raises an important question. The costs presumably have been recouped. But pharmaceutical manufacturers and vaccine producers are keeping some of the prices high. Seth laid out part of the rationale here, which is that rich countries should pay more toward this so that these prices can be lowered in poorer countries. And a certain amount of that makes sense. Does it explain all of the high prices here, particularly for newer vaccines? No. And it's also the case though that there are lots of, and this point was made earlier, there are lots of other conditions that we're still developing vaccines for.

DENTZERSo, and we should continue to develop them. We now have the HPV vaccine, because we know now the correlation between the Human Papillomavirus and cervical and other cancers. There are going to be additional conditions like that, that we continue to see a viral or bacterial link to, that we're going to want vaccines for. So we need to keep the research enterprise robust. How we do that and what price level vaccine manufacturers have to continue to exact, particularly in the rich countries, is going to remain an element of debate.

REHMDr. Schuchat.

SCHUCHATYou know, vaccines are probably the most cost effective intervention that we have. Prices are high here in the US, but we know that for every dollar we put in to vaccinating children, we get three dollars in direct medical savings back. 10 dollars back as a society. We know that some private clinicians are struggling to be able to afford...

REHMExactly.

SCHUCHAT...to get the vaccines. We do want clinicians to be able to keep vaccinating people.

REHMSo how much pressure is being put on Pharma?

SCHUCHATWell, what I would say is it's a really complicated equation. We know that years ago when vaccines were very low cost, companies were leaving the industry. Vaccine companies couldn't make a profit on it, and they were getting out of...

REHMOr enough of a profit.

SCHUCHATRight. And then we ran into supply problems, where suddenly we lost a manufacturer. We had shortages, and of course, with shortages of vaccines, you can get increases in rates of disease. There's a really complex balance right now between the clinician, the manufacturers, the government and the insurers. The Affordable Care Act for privately insured individuals and the Vaccines for Children Program, for children who don't have insurance or who are Medicaid eligible, have really meant that the consumer shouldn't have to worry about the cost of vaccines.

REHMThat's here in this country.

SCHUCHATIn the US. Yeah. But the clinician often does have challenges stocking the vaccines for their privately insured patients.

REHMDr. Berkley, how do you and your organization negotiate with Pharma?

BERKLEYWell, first of all, we are interested, obviously, in reducing price for sustainability, as we talked about, but we are also very interested in supply security, which Anne just talked about. And we want to make sure there's multiple manufacturers as well. And so this price tiering that we've talked about, and by the way, I have an article this week in The Lancet on price tiering for vaccines. But this is how we're working out the balance. And the challenge for us is to get to a stable marketplace where there's healthy competition, multiple suppliers.

BERKLEYAnd then if one supplier does have a problem, then, you know, it's okay because the other suppliers can take up the demand. When we're with a new vaccine, you may not have that luxury. And that's where you have a problem. Of course, the companies have been very good to create these types of tiered pricing so it can be available across the world. And that requires, though, having this type of differential pricing.

REHMJerry in San Antonio, Texas, Susan Dentzer, wants us to emphasize the concept of herd immunity.

DENTZERAs we should. As we should. We know that if we vaccinate or immunize a large portion of the population, that portion of the population, a good part of it, is going to immune. So that if there is an exposure of some sort coming in from someone who is unimmunized, that disease, that condition will not spread. So, that herd immunity force is extremely important. It's why we have had so much success here in the United States in eliminating these diseases. And that's where the concern comes about about having too many people opt out of the system, because we would jeopardize that here immunity.

SCHUCHATYou know, and it's important to remember that not everybody can be directly protected with vaccines. Some of the vaccines are live viral agents, and so we can't vaccinate a person with leukemia or immuno-suppression. That person relies on others being vaccinated to be safe.

REHMI see.

SCHUCHATAlso, for something like measles, we don't vaccinate very young babies because the vaccine works best if you give it at 12 months or older. And so, with measles, those infants are really dependent on older siblings and neighbors being vaccinated so that they won't get the disease.

REHMJonathan in Clayton, North Carolina, who's listening on WUNC, says I live with a couple who are vaccinating their kids, but they're working with their doctor to follow an alternative vaccination schedule. Please comment on why some parents do this and what effect it could have. Anne Schuchat.

SCHUCHATI think it's important to say that the schedule that's recommended for use of vaccines goes through an enormous amount of scientific review. The CDC updates the schedule every year, as does the American Academy of Pediatrics, based on the newest information on safety, effectiveness, how many doses you need and so forth. There are a lot of shots that kids get in the first couple of years of life, and so parents are wondering, do I really need all those shots or doesn't that hurt?

SCHUCHATIt's important to know that when you delay or space out the vaccines, your kids are at risk for those diseases between the doses, so we strongly recommend people following the recommended schedule, which does have some flexibility in it, in terms of the ranges that are okay for getting the next doses.

REHMAll right. And let's go to Anne in Fort Worth, Texas. You're on the air.

ANNEThank you. I want some kind of information on these children who have come over the border, that are now being held in, down in south Texas. That they have been immunized and the time limit has expired before they disperse these children all over the United States.

REHMI think there are a lot of concerns about that, Anne Schuchat.

SCHUCHATYeah. The Vaccines For Children Program, which addresses children who are uninsured or Medicaid eligible, also addresses refugees and resettlement issues to protect the individuals and the community. So, of course, FEMA is in charge of this response to the unaccompanied children and I do believe there's vaccination involved with some of the resettlements.

REHMIs it your understanding that those children, who have come in to the country, will be vaccinated?

SCHUCHATMy understanding is that's right.

REHMAnd how do we know?

SCHUCHATFEMA would be the key source of information on that, but I know that the Health and Human Services is working closely with them in this response. We think that Americans shouldn't be worrying about infectious diseases being transported with these children. People need to know that tourists and travelers coming from all over the world can have infectious diseases on them and getting your families vaccinated is the best way to protect yourselves.

REHMAll right. Well, let's hope that those children are indeed being cared for, and let's go now to Martin in College Park, Maryland. And you're listening to "The Diane Rehm Show." Martin...

MARTINHi Diane.

REHM...hi. You're on the air.

MARTINThank you. Sorry about your loss.

REHMThank you.

MARTINWhen my kids were growing up, they all had to be vaccinated to go to school. And all the kids have to go to school. And as far as people coming into the country, they should be vaccinated before they're given visas. Or else they don't get a visa. That would really solve the problem. Again?

DENTZERWell, there's a hodge podge of laws and regulations around the US, particularly around the issues of schools, but almost all states will allow parents to opt out of immunizing their children for medical reasons. Anne mentioned the instances -- if you have impaired immunity, an auto-immune condition, you shouldn't be immunized. So there are medical reasons not to immunize in some instances. Also, almost all states will allow opt outs for religious beliefs. The whole question about how far this should go is greatly -- is very, very contentious.

DENTZERAnd in every state, there are proposals to tighten these restrictions and there are proposals to loosen these restrictions. 17 states also will allow opt outs for philosophical reasons. I just don't like the notion of the government telling me I have to do something. So, this is a function of having a very complicated country where the states are in charge, largely, of health issues like this, including many of these important public health issues. And so we will see these arguments play out, probably from now till the end of time.

REHMDr. Berkley.

BERKLEYThis is why it's very important to make sure we immunize all the children in the world and try to eliminate these diseases. Cause although it is true the best protection is to have high immunization coverage at home, as you've already heard, sometimes vaccines don't take, or some people can't be vaccinated. And the same thing goes with travelers. You know, the more you get rid of the diseases, the less likely you are to import. Now, with polio, we talked about earlier, recently, they've actually created a new emergency -- brought the emergency regulations to bear.

BERKLEYTalking about travelers in Pakistan going to other places, being vaccinated before they leave because of these worries of transmission. But it's very hard to standardize that across the world. So, the more we get rid of these diseases, the better off we are as a world.

REHMDr. Schuchat.

SCHUCHATYeah. You know, we used to have measles being imported from the Americas, but the Americas really stepped up their game and eliminated measles and rubella in this whole region. That's been great for the population of all of the Americas, and we know there's been great progress in reducing deaths from measles worldwide. You know, with the World Health Organization, UNICEF, GAVI and others helping with that. It really protects all of us when children are doing better overseas.

REHMNow I'm really interested, Susan, in your points about religious, ethical, moral objections to vaccinations. What do the schools do about that? Didn't you say earlier that indeed, the parents of children who'd been kept out of schools have tried to sue and have been overruled?

DENTZERYes. At least in some -- and including here in the District of Columbia, that has happened. But we can imagine there will be more litigation like this going forward as we try to juggle this issue of when are we going to allow to opt out of the system, and when are we going to require people to be part of the system? I guess, you know, to go back to a point Anne keeps making, if we look at the overall benefits of vaccination, there's an article in the Lancet this week that makes the point that we prevent, for every group of children who gets immunized on an annual basis, we prevent about 20 million cases of illness and 40,000 deaths.

REHMWow.

DENTZERSo that's a pretty powerful reason to continue to proceed to immunize...

REHMClearly education is key, and that's where the CDC comes in. And want to thank you all for being here and doing your part today. Susan Dentzer at the Robert Wood Johnson Foundation and on air analyst for the PBS News Hour. Dr. Anne Schuchat of the CDC and Dr. Seth Berkley of the GAVI Alliance. Thank you all so much.

DENTZERThanks Diane.

SCHUCHATThanks you.

REHMAnd thanks for listening all. I'm Diane Rehm.