Measles: Your Questions Answered with Dr. Frank Esper

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and today we're here to talk about measles. In 2018, 372 individual cases of measles were confirmed in 26 states and the District of Columbia. This is the second greatest number of annual cases reported. This year so far, there's been six active outbreaks in 2019 and most are in New York State. Is that correct?

Dr. Frank Esper:  That is right.

Nada Youssef:   All right, and to bring you expert advice and to answer all your questions about measles today and to take your questions live, Dr. Frank Esper, pediatric infectious disease specialist here at Cleveland Clinic Children's. Thank you so much for being here today.

Dr. Frank Esper:  Yeah, it's very good to be here. Thanks.

Nada Youssef:   Thank you. And before we begin, please remember this is for informational purposes only and it's not intended to replace your own physician's advice. So, first of all, it's been all over the news, measles, can we start by talking about what measles is, how you catch it? Symptoms? Just overview.

Dr. Frank Esper:  Yeah. Measles has been around for a long time. And really what it is, it's a cold virus. It comes from an entire large family of cold viruses. That family includes things like croup, as well as a mumps and other common viruses that we see that come every year. So it comes as a cold virus and it does things that ... The same symptoms that cold viruses do. It shows up, it causes cough, and it causes congestion and it causes a little bit of red eyes. And that's generally how it all begins. The difference though, is with measles is that measles, unlike a lot of these other cold viruses where it just stops with those types of symptoms, measles can then go and cause a lot of other problems. And so measles is one of the more severe cold viruses and that's one of the reasons why we took it upon ourselves to really try to stop that back in the 60s with the vaccination program.

Nada Youssef:   Sure, sure. Okay, well the outbreaks are preventable, but they keep happening.

Dr. Frank Esper:  Yeah.

Nada Youssef:   Why is that?

Dr. Frank Esper:  The outbreaks themselves are something that we've actually eradicated outbreaks here in, or at least ... I'm sorry, we eradicated a transmission of what we call it endemic measles, where basically homegrown measles no longer happens here in the United States. And the reason is is because since 2000, we were able to eradicate it with a very vigorous vaccination campaign along with pushing other types of ways to prevent viruses spreading. So good hand washing campaign and things like that, good sanitation, et cetera. And so since 2000, we stopped homegrown measles. And then since then, we have prevented it. For the last 19 years, we have prevented measles from taking root again here in the United States, but we still see these outbreaks. We see a dozen outbreaks on one year, 10 outbreaks on another. And in the worst outbreak season, which was in 2016, we had about 20, 20 plus outbreaks.

And what we do, what's happening is that we're still getting peppered with measles from outside the United States. And so people who are coming, who are travelers, and as we know, the world is getting smaller, travel is on the rise. And so people from places around the world that have measles still are bringing that measles into the United States. And the vast majority of that does not cause an outbreak. It's only when a person who has measles from outside the United States comes into the United States and is able to transmit that individual, or transmit that virus to a person who doesn't have very good immunity to measles. Whether that's because they didn't get vaccinated or it's because their immune system was suppressed.

And then if that person is surrounded by other individuals who do not have immunity, then you start seeing these larger outbreaks. What the most recent outbreak that we got in New York state is actually from a person who is originally from the United States, but they weren't vaccinated. They went to a country that has an outbreak going on right now in Israel. And then they brought the measles back to their community and then it spread around their community.

So it's not just travelers from outside the United States, it's travelers from inside of the United States going to outside the United States and then bringing the measles back. And what's preventing it though from taking root, from having persistent measles, is because of the great vaccination campaign that we still maintain here in the United States.

Nada Youssef:   Sure. So it seems like when you travel outside the United States are some vaccinations that you should probably take care of. Measles should be on that list then?

Dr. Frank Esper:  Oh, absolutely. So we have to understand the measles is still all over the world. And there are really big outbreaks that happen every so often in countries. The main ones right now is in Israel. And then there's a big one in Ukraine. A few years ago, it was the Philippines. So it changes. It could be an Asia, it can be South America, you never know. So measles is still out there, but the measles in the United States, we don't see. But when we, or when someone is about to go traveling for an extended period of time, here at the Cleveland Clinic, but a lot of other places, we actually have a whole area of what's called travel medicine, where we prepare you for the types of infections that you might encounter.

So it's not just measles, although that's one of the first things. The first things we do when we hear that you're about to go abroad is we check to see, did you get the measles vaccine? Do you have any problems? Have you not received it? When was the last time you received it? Et cetera. But also things like malaria, things like Japanese encephalitis, types of prophylaxis to make sure that you don't get infected, typhoid, et cetera. That you don't get infected when you go and then you don't bring that infection back.

Nada Youssef:   Bring it back. Right, right. So before I go on my cruise with my kids, should I come to a primary care physician? To infectious disease specialist? Who do I talk to? 

Dr. Frank Esper:  Usually you'd start with your primary care physician. A lot of times they do then refer you to an infectious disease specialist. Here at the Cleveland Clinic it's infectious disease. And we have very, very good and very available travel. The main thing though is that you have to understand that when you get prepared for a traveling abroad, don't do it the day before you leave. It doesn't help you then. You want to talk to your physician a couple of months or at least a four weeks plus before you travel. Because then if you do need vaccines, if you do need prophylaxis, we can get that on board so that you are safe on day one of your trip.

Nada Youssef:   All right. And when you start getting vaccinated, is effective right away?

Dr. Frank Esper:  No.

Nada Youssef:   It takes a few weeks?

Dr. Frank Esper:  It takes a couple weeks. It takes at least two weeks, preferably four. That's why we try to do is we try to meet these people a couple of months beforehand, make sure that we get their vaccines. And sometimes it's a vaccine series. If you haven't never seen this vaccine before and you just supposed to get two vaccines, we'd like to get both of those vaccine in before you leave, but definitely at least one.

Nada Youssef:   Okay. Good to know. I'll make my appointment. Okay, so what defines an outbreak?

Dr. Frank Esper:  That depends on the germ we're talking about. But in this case, we're just going to focus on measles.

Nada Youssef:  Yes.

Dr. Frank Esper:  For a measles outbreak, it's three cases. That's not a lot, if you think about it, but that's because we're not supposed to see any cases. Our preference is zero. If we see three cases in the same community or the same district within a one month period of time, that's how we define that, "Okay, this person is an outbreak." So a lot of times, you can just see three cases and it dies there. That's fine. It's still considered an outbreak, but it's not a bad outbreak. Whereas we've seen some outbreaks where it's 75 plus individuals from a community. We saw that back in 2016 ... I'm sorry, 2014, where we had a lot of outbreaks within Amish communities and things like that. Then, they can actually get pretty big.

Nada Youssef:   Okay. So we've talked about some of the symptoms. You said it's kind of like a harsh cold?

Dr. Frank Esper:  It's a bad cold at the beginning. Cough, runny nose, red eyes. That's where it starts off with. Then what the really, the hallmark though is when you start getting the rash and the rash starts at the head and then just kind of flows down and it's this bad, lacy, red, raised rash that just kind of starts, it doesn't hurt so much.

Nada Youssef:   Itchy?

Dr. Frank Esper:  But people feels miserable. Sometimes it's itchy, yeah. But people just feel miserable because usually they have a high fever too. The rash though is important because that's when it hallmarks. When are you contagious? And it's really for the most part centered around that rash. Technically you are contagious because someone gave it to you when you have the cough and the runny nose and the cold stuff. But what we look for when we have to say, "Who got exposed?" We look for the people who were exposed four days before that rash happened up to four days after the rash happened.

And you have to understand that four days before the rash happened, you don't even know you have measles. You have cold, maybe it was a bad flu, but for the most part, you didn't think it. "No, this isn't measles." And then next thing you know, uh-oh, now you have measles and you think about all the people that you might have exposed during that time. So that's one of the reasons why measles is so tricky. It's so insidious and it's able to spread so well because you are infectious before you really know you have it.

Nada Youssef:   Right. So then I will know I have measles once I get the rash?

Dr. Frank Esper:  Once you have the rash, that's when a lot of people bring their children or themselves to their physicians. And then it's the physicians that are able to take a look at it. A lot of times, it's just eyeballing it. We can see the rash, we can hear the story, we talk about the vaccinations that you did, or the exposures that you may have had. And then we could probably piece it together there. But a lot of times we have to do really sophisticated tests of your blood or swabbing your nose, looking for the virus itself. And that'll take a few extra days, but a lot of times a good physician will be able to see it. They'll be able to say, "Okay, I think this is what it is." Sometimes they refer back to infectious disease to confirm their suspicions. But a lot of times it's that rash. When that rashes happens is when people start saying, "I need to go to the doctor."

Nada Youssef:   So then to reiterate, you said you are contagious four days before rash and four days after.

Dr. Frank Esper:  Up to four days. And that's the standard. There's ... Nothing in life is ever so set. I mean some people getting transmit a little bit even before that or a little bit after that, especially if you have an immune system that may not be as vigorous because you have medications on board or cancer, chemotherapy. Then their symptoms and their contagiousness can actually be a little more prolonged.

Nada Youssef:   Sure. And there's a crazy fact that I found online, I'd like to read it here. So a person with measles can cough in a room and leave and then hours later, if you're un-vaccinated, you can catch the virus from the droplets in the air of the infected person that left behind. And the vaccine, the beauty of the vaccine is that most people who get the proper doses will never get sick from measles, even if they're exposed. Is that correct?

Dr. Frank Esper:  Yes. For the most part. Now, nothing in life is ever 100% either. But this is, again, tells you how tricky this virus is. It's not just you touch a hand of someone, or shake a hand, or contact with an individual who is infected. It's able to just basically ride the currents of the air in the room for a few hours and then still can be breathed in by someone who walks into the room a couple of hours later. And that can lead to transmission. This is one of the reasons why it is so infectious, much more infectious than a lot of other cold and flu viruses that we deal with. But it is something now with the vaccine, it's one of our best defenses to prevent infection, okay? And that even that vaccine is good as it is, is still not 100%.

You get one dose of vaccine, the one dose of vaccine is effective to 93% of individuals, but because 93 wasn't good enough, we talked about a second dose after that. And so we get typically, the recommendations from the Centers for Disease Control, from the American Academy of Pediatrics, we get two doses. Once when you're about 12 months of age or so, 12 to 15 months of age, the other around four to six years. And that second dose moves it from 93% effected to 97% effective. It's still not 100.

Nada Youssef:   Right, still not 100.

Dr. Frank Esper:  Still not 100. So you could not ... It's possible that you could be one of those 3% who just does not respond to the vaccine. But those 3% who are not responding to the vaccine are protected by everybody else who did respond to the vaccine. And you're basically encased in a nice little protective bubble to prevent spread.

Nada Youssef:   Sure, sure. Okay, so there are a substantial number of individuals who cannot receive the vaccination due to underlying reasons. Maybe like a weakened immune system, you were saying, developing cancer, children under age. What would you recommend for these groups?

Dr. Frank Esper:  Yeah, I think it's very important that we understand who's at risk for more severe disease and who's at risk for getting the infection to begin with. We can't give this vaccine ... I'll take that back. We typically don't give that vaccine before 12 months of age. However, if you live in an area that's undergoing an outbreak, or you're about to travel to a country that has an outbreak, we can actually give this vaccine safely at six months of age or about.

Nada Youssef:   Oh, okay, six months.

Dr. Frank Esper:  So if we do give it at six months of age it doesn't count. You still have to get another vaccine at one year of age. But you can't get it even younger. The people who are at most risk of really getting bad, severe disease are individuals who are very, very young, under a year of age, older adults, basically anyone over 20, which is like everyone, for the most part. It's a bad disease for a lot of people. And those people who have a immune system that's just a little bit less robust. It just can't fight off a vigorous, bad virus like measles because of chemotherapy, because of steroids, or because they were just born with an immune system that's just not reactive as much.

And those individuals can have very severe disease. When we talk about what's severe for measles, we just talked about how it just starts off as a cough and a cold. But 1 out of every 10 will then go to an ear infection. And I think, as a father of five here, I can tell you how bad ear infections can be. But then 1 out of every 20 go to pneumonia. And so when this virus gets into your lungs and it really causes a really, really bad pneumonia, a lot of times your immune system will be able to handle it. But if you have one of those immune systems, because you're just too young or you're under the influence of particular medications that suppress your immune system, that pneumonia is really, really bad.

And then about one out of every thousand people, the virus gets out of the lungs and it gets into the blood and it gets into the blood, it goes to the brain. When he gets into the brain, it causes brain swelling. And that's the most severe complication that we see from measles. That's what we worry about the most. One out of every thousand, it seems like that's pretty uncommon, but when you multiply that back in the pre-vaccine era where everybody got measles, I mean, basically it was universal.

 By the time you hit adolescence, you had measles at least once. So you multiply one out of a thousand of that. That's how you lot of people. A lot of people would die. And so it's one of the reasons why this was one of the first targets for vaccination and control. But you get that one out of a thousand people, is pretty bad with brain swelling. 1 out of every 20 can get a pneumonia, about 1 out of every 500 to 1 out of every thousand people will die. And that's just too much.

Nada Youssef:   Wow. So when someone cannot take the vaccination due to the number of reasons that I gave, or maybe a religious reason or whatnot, how do you make sure to protect yourself against measles, especially the complications that can be fatal?

Dr. Frank Esper:  Yeah. The best way to protect yourself against measles it is to have vaccine. The next best way is to make sure that you don't get yourself exposed to people who are sick with measles. And so for example, if you didn't get the measles vaccine, you may not want to travel to areas that have the ongoing outbreaks. And the Centers for disease control actually list where all the outbreaks are worldwide, so they can tell you that if you're going to this country, is there a measles outbreak? And they will say yes and they keep that up fairly regularly. So you'll be able to at least find out from there whether or not you should at least hold off on your travel plans at that point in time, or talk to a doctor about getting vaccinated before you go.

Nada Youssef:   Okay.

Dr. Frank Esper:  The other ways to prevent, remember, it's a virus like a lot of other cold viruses. Washing your hands absolutely does help. So preventing ... Good hand washing. Coughing, if you are infected, for people who are infected to stay away from others who aren't and to cough into your sleeve is always a good thing.

Nada Youssef:   The elbow.

Dr. Frank Esper:  But as we just said, even with all that good cough hygiene and good hand hygiene, remember, the virus likes to live in the air and no amount of hand-washing is going to prevent you from breathing in that particular air.

Nada Youssef:   You literally, all you get it is breathe it in.

Dr. Frank Esper:  That's why the vaccine is our best defense against the measles itself.

Nada Youssef:   Sure. Okay, and you said for vaccinations, you get it at 12 months of age and then between four and six.

Dr. Frank Esper:  12 to 15, yeah.

Nada Youssef:   12 to 15.

Nada Youssef:   So how long does this vaccination last?

Dr. Frank Esper:  The vaccine, this is one of the types of vaccines, we talk about vaccines a lot and there's so many out there right now, it's hard to keep them all straight sometimes. But you need to think about, as an example, the tetanus vaccine. People say, "Oh, you need to get your tetanus vaccine every 5 to 10 years and you keep doing that over and over again." Well, this vaccine, it's not like we get our measles vaccine every 5 to 10 years. This vaccine is very unique. It's very, very good. And one of the reasons it's good is because that what we did is that this isn't a dead protein vaccine like the tetanus, but this is actually a live vaccine. So this is actually live measles that's been basically kinda of chopped and edited so it can't cause problems. It can't cause disease.

If it does cause disease, usually it's a very, very mild rash. But for the most part, it's what we call it attenuated or basically very, very weak. So it's a weakened strain. We give a shot, it's able to replicate once, twice, maybe three times. Your immune system is able to react to it. And so not only do you make antibodies against it, but you actually make a good cells that actually stay with you lifelong.

Nada Youssef:   Sure. And then, so is there a treatment for measles or for the rash?

Dr. Frank Esper:  The answer is no. For the rash, for the measles, there is not a treatment. But what you do do is that for individuals who have bad ... We have a fire drill going on.

Nada Youssef:   Yeah, of course there is.

Dr. Frank Esper:  I apologize for that. It's not a measles drill, it's a fire drill. The answer is that this is something that what we do is that if you've had bad nutrition, so there are individuals who have really poor nutritional, more so around the world, from Southeast Asia, South America, places like that. Africa, we give them vitamin A, because vitamin A actually prevents the worsening of symptoms if you have the measles. But that's for individuals who have low vitamin A to begin with. Pretty much everyone in the United States, drinking your vitamin A milk and things like that. We're pretty much fortified pretty well. So a lot of times we just support you until your immune system is able to respond to the vaccine.

If you get exposed though, there's other ways to prevent exposure. For example, if you are one of those individuals who can't get the vaccine, or you are immunocompromised, and you were exposed to someone who had the measles, and you know this was the measles, we can actually give you a whole bunch of everybody else's antibodies to protect you. And if we're able to do that right after your exposure, within a couple of days after your exposure, we can actually use their antibodies to protect you from developing the disease. And if you've never gotten the vaccine and you got to exposed, you can still get the vaccine up to three days after you were exposed to prevent you from, and it helps prevent you. It's not 100% but it helps prevent you from getting the vaccine ... Or getting the disease.

Nada Youssef:   So it's hard to know that you're actually exposed to measles, but if you have been, you have up to three days, you said?

Dr. Frank Esper:  Unfortunately, right. Right, you got three days. But unfortunately, you said, people don't even ... Are infectious four days before they know you're infected, and you only have three days. You can see that it's hard to play catch up with this virus. It's one of the reasons why the best thing for you to do is get vaccinated before the problem even happened.

Nada Youssef:   Sure, sure. So there is a problem of the measles outbreak right now in Washington?

Dr. Frank Esper:  Yeah.

Nada Youssef:   Just recently happened.

Dr. Frank Esper:  Well,  Washington was the big one that happened at the tail end of 2018.

Nada Youssef:   Yeah.

Dr. Frank Esper:  Back in the fall, and then now there's a new one that's happening in New York state.

Nada Youssef:   Okay. So how do we prevent that from ... This is from travelers coming from outside countries? Is that what's happening?

Dr. Frank Esper:  It's a little of both. So a while it's not completely clear. The one in Washington state was from a traveler who came in and then exposed individuals as part of their tourism. They just went to spots like basketball games and museums and things like that. And they could then expose individuals who went to those basketball games or those museums during that same time.

Nada Youssef:   Sure.

Dr. Frank Esper:  The one in New York state is a little more clear is that that was an individual who traveled, who was un-vaccinated from the get go. A small child, as I recall, who traveled to Israel, was exposed to individuals where there's an outbreak currently in Israel. Then brought back and developed symptoms after he returned.

Nada Youssef:   Wow. Of course.

Dr. Frank Esper:  And then spread it to a community that did not believe or did not have a very high vaccination rate. And then it's spread pretty much throughout that community.

Nada Youssef:   Wow.

Dr. Frank Esper:  The one good thing though is that, and a lot of times I get this question, it's like, "Hey, these outbreaks still are happening so the vaccine doesn't work." And the answer is we've had about 150 cases thus far this year, which is a lot. But there's a big difference between the 159 cases that we've had now because we do have a very good vaccination, and everybody is doing their part to be vaccinated, compared to what would be 15 thousand or 150 thousand if nobody had any vaccination. And then we would be basically be skyrocketing with numbers of cases.

Nada Youssef:   Wow. So most states are allowing exemptions for religious reasons. 17 states, including Washington and Texas, allow exemptions for both religious and personal or philosophical beliefs according to the National Conference of State legislators. Both Washington and Texas have seen measles outbreaks this year. So this led the whole state to reconsider the exemptions, the vaccinations. Do you have anything to say about that?

Dr. Frank Esper:  I would say this, that there is no federal policy on vaccinations at this time. So every state regulates their vaccinations on their own, which unfortunately leads to some differences between states. So the vaccine policy that we have here in Ohio is different than the vaccine policy that we only have 70 miles away in Pennsylvania or 100 miles away in Indiana. And so that can lead to, unfortunately, people don't necessarily ... They come and go through all the states and so that can lead to one problem. So there's no federal policy, it's a state policy.

It's also important to know that every state has a vaccination policy. Every state has a policy, especially for young children to be vaccinated before they go to school. And the reason is why is it always a talked about with school is because that's when you bring a whole bunch of children together. And when you want to bring a whole bunch of children together, we call children viral culture media, by the way. That's what they do. They just breed. And as a parent, again, parent of five, I know how well these viruses love children and then they bring them back home to me.

But so if we vaccinate before they go to school, before they get their big wallop of an exposure, that's how we protect the community, and we protect the children, we protect the children's family, and we protect the community at large. So every state has that type of vaccine policy. It's also important to know that while there is, I think 17 or so exemptions right now from every state for religious or philosophical, that's actually on the decline. It was like a 19 a few years ago. When California had their big outbreak with Disneyland, the Disneyland measles, again, what happens? A tourist comes to what? Yeah. Disneyland.

Nada Youssef:   Of course.

Dr. Frank Esper:  That's what a lot of tourists will do. All right, but they come from an area that it was having an outbreak. They were under vaccinated and they were able to spread it to other individuals who did not, or had a religious exemption or it gets spread into those communities. Then even California said, "You know, we need to stop this." And so they were one of the first states that are starting to try to pull back on those types of exemptions. And we're actually starting to see some push back. The keys though is in the state legislature. So it's not a federal issue. It's not congress, it's the state congress. And that's the people that if you were talking about who do we talk to in order to ensure good vaccination policy, it's your state legislatures.

Nada Youssef:   Okay, great. And I was reading some facts, but before I go on, I let my viewers know if you guys have any questions, we can take your questions live right now. Just type them in the comments section below and we'll ask a question live. So some of the facts that I read, there's been more than 150 measle cases this year in the US, is that correct?

Dr. Frank Esper:  Yeah. In 2019, yeah.

Nada Youssef:   Okay, so how do I know if it's an outbreak happening right now? How do I know if it's in Ohio? How do I know if it's in my school? How do I get this kind of critical news?

Dr. Frank Esper:  Well, that's something that the Center for Disease Control Tracks and your state health department also tracks. Everybody is on notice for measles, but you never know where it's going to happen. There are these small pockets of un-vaccinated or under vaccinated across the United States. We're trying to, A, educate everybody about the safety of the vaccine, trying to educate everybody about effectiveness of the vaccine, trying to educate why it's important to be vaccinated and how it helps yourself and everybody else around you. And so that is actually starting, I think, to take hold.

Although, we do see a slight bump in the number of un-vaccinated children across the United States. And so that just means that we have more work to do in order to get this kind of information out. That's kind of why we're here right now. Sure. But what we're trying to do is encourage everybody to talk to their physicians. It's important too to hear these types of information from places like Cleveland Clinic and the Centers for Disease Control. But the person who knows you best, the person who knows your family the best, your child the best, that's your pediatrician. That's your physician. We absolutely encourage you, for any questions, they have handouts, they have information, they have experience that they can talk to you about this vaccine.

Nada Youssef:   Great. Now, I have Janelle that actually submitted a question. She's asking, "Could I still get measles if I'm fully vaccinated?"

Dr. Frank Esper:  The answer is yes. Nothing in life is ever 100%, Janelle. It is something that is your best chance to prevent yourself from getting measles. And again, remember it's not just you, it's everybody else around you. A lot of people can get measles, but they don't get sick, but they can still transmit it. And so when you protect yourself, and I say this a lot about vaccines, you're protecting yourself. You protect your family, you protect your neighbor, you protect your community. This is an all in type of situation. The more people that we have that are protecting one another, the better your community is to prevent these types of outbreaks from happening.

Nada Youssef:   Great. And just like you mentioned, measles is still considered, what's the word you called it? It's not eradicated.

Dr. Frank Esper:  Oh, it's not ... There's no homegrown measles. So the only virus that we've ever eradicated, truly eradicated is smallpox. And that's the one where worldwide, we no longer see smallpox. Now we're trying our best to eradicate polio and that's the next one on the list that if we can really just get into certain areas that still have some polio, but the vast majority, we don't see polio here in the United States or even on this half of the world anymore because it's a great vaccination program. Measles is actually ... There is a worldwide push for measles eradication.

We've actually, in the last 20 years, seen a substantial decrease in the amount of measles outbreaks throughout the world and number of measles cases throughout the world. We used to have millions. Back in the 80s, there were millions of measles cases around the world. Now there's only hundreds of thousands. It's a lot, but only hundreds. I mean, we were down 10 fold. That should be good.

Nada Youssef:   Right. Sure, sure. All right, so with measles, with the outbreaks happening right now, I want you to kind of end the Facebook live with a message to people, to the audience, anybody who has kids, people who are scared to get vaccinated, maybe for religious reasons, but what do you have to say for our audience?

Dr. Frank Esper:  I think that what's important is to understand that there's a lot of information out there, and a lot of good information about the vaccine, about how well it works, about how safe it works or how safe it is. We test this vaccine for its safety and it's effectiveness every year, making sure that the vaccine matches the strains that are circulating. And it does. And this is something that if you have any questions, going to the Centers for Disease Control, they have a fantastic amount of information on there. Going to your physician is also a great source of information.

Unfortunately, there's a lot of other information out there that's not as robust. I would really focus on Centers for Disease Control, the National Institutes of Health, the American Academy of Pediatrics. Those are good sources of fantastic information. That's where you'll get the answers that you need as well as talking to your physician.

Nada Youssef:   Thank you. Thank you so much for your time. It's been a pleasure.

Dr. Frank Esper:  Oh, it's very good to be here. Thanks for having me.

Nada Youssef:   Thank you. And for more information about pediatric infectious disease or to make an appointment with Cleveland Clinic Children's, please call 216-444-5437 or go to ClevelandClinicChildrens.org/ID. And for more health news information, make sure you're following us on Facebook, Twitter, Snapchat, and Instagram, @ClevelandClinic. Just one word. Thank you. We'll see you again next time. This concludes this Cleveland Clinic Health Essentials podcast. Thank you for listening. Join us again soon.