CDC Telebriefing on Investigation of Human Cases of Novel Influenza A (H1N1)
June 26, 2009
Operator: During the question and answer session today, you can press star 1 to ask a question. Today's conference is being recorded. At this time I'll turn the call to Mr. Joe Quimby. You may begin.
Joe Quimby: Hi, good afternoon to everyone. With us today is Dr. Anne Schuchat, the director of National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention here in our headquarters in Atlanta. Dr. Schuchat?
Anne Schuchat: Thank you, good afternoon, everyone. We've just completed 2 and a half days of our Advisory Committee on Immunization Practices, a lot of which did focus on the novel H1N1 influenza virus and so what I want to do this afternoon is briefly give you a situation update about what is going on here in the United States, a little bit about the Southern Hemisphere and provide a few pieces of information related to vaccine planning.
The novel H1N1 influenza is continuing to spread here in the United States and around the globe. What we're seeing is varying by region in the United States and in different countries. The key point is that this new infectious disease is not going away. In the U.S., we're still experiencing a steady increase in the number of reported cases. Of course, reported cases are really just the tip of the iceberg. The number of new cases that were reported to us this past week was actually the largest number we've had reported since the beginning of the outbreak. Today, we're describing the 27,717 lab-defined cases have been reported to us here in the U.S., including over 3,000 hospitalizations and 127 fatalities. There were more than 6,000 of these cases reported to us within this past week. W.H.O. is now reporting almost 60,000 cases of this new virus in more than 100 countries and they report being aware of 263 deaths. Here in the U.S., 12 states are reporting widespread influenza activity, those include Arizona, Connecticut, Delaware, Hawaii, Maine, New Jersey, New York, Pennsylvania, Rhode Island, Utah and Virginia. And you'll notice some of those states have been having widespread activity for a while and some of the states that had widespread activity a while ago, like Texas or California, aren't actually on that list right now. It's very unusual for this time of year to still be having so many states reporting regional and widespread activity and that's just one feature that helps us know that what we're seeing this year is quite different than what we usually see with seasonal influenza.
In terms of the virologic testing that's being done, the new H1N1 virus is now making up more than 99% of all the typed isolates we're testing here in the U.S. with our collaborating laboratories, so virtually all the of the influenza that's circulating that's getting a diagnosis is this new strain right now here in our summer months. We're also tracking milder illness, outpatient visits for what we call influenza-like ill this and this is now returning below the national baseline but in -- at the national level, but two of our ten regions of the country are still above what we think of as a baseline for this time of year. Those two regions are New England and the New Jersey/New York area, regions 1 and 2, where they're still seeing more influenza-like illness than you would expect to see at this time of year. Those regional numbers can mask outbreaks of clusters at smaller geographic areas and we know some communities are still coping with outbreaks of this disease. Influenza-like illness increase during week 24 in 6 of the 10 regions compared to week 23. That's unusual. Usually this time of year, things would be going down instead of going up.
As you may have heard yesterday, we at CDC are estimating that those reported cases are really just the tip of the iceberg. We're saying there have been at least a million cases of this new H1N1 virus in the United States so far this year. That's really not a perfectly accurate estimate. It's just a number, a ballpark figure, that we think for sure there's been more than a million of these new infections. We know we're not tracking every single one of them. There have been community surveys in a couple of areas looking at influenza-like illness in areas where we know there's a lot of the strain circulating and in many of those communities, they're reporting proportions of about 6% of their community members having had an illness that's consistent with the new virus. I want to just briefly next some clinical features. We continue to say there most of the impact of this new virus is affecting younger people compared with what we see with the seasonal flu when, of course, seniors, people over 65, are so greatly affected. We're seeing high rates of illness among people under 50. The highest rates are in those under 25. When we look at hospitalized cases, nearly 80% of people who have been hospitalized in the U.S. and reported to us have been under 50. The median age of hospitalized cases is 19 years old. When we look at the most severe outcomes, the people who have died, the age is a bit older. The median age of those who have died is 37, still quite young for anyone to be dying of an infectious disease, but a bit older than the hospitalizations and the average cases.
We think it's important for everyone to be aware of this new virus that's circulating in so many parts of our country and the world, but it's particularly important for those of us who have underlying health conditions. We might think of these as big problems because they're just part of our day-to-day life, but people with asthma, people with diabetes, heart disease, people with chronic lung disease and, of course, people who are pregnant night to be especially concerned if they develop respiratory symptoms, fever and a respiratory illness. You've heard us talking about obesity and sometimes we talk about what doctors call more bid obesity or extreme obesity. That's showing up in our lists of people who are hospitalized with this condition and among some of the deaths that we're seeing. We want to clarify that. We think that people who are severely obese, the extreme obesity or what doctors called more bid obesity are people who also have chronic lung disease. The heavy weight that people are carrying around can compromise the lungs and can put you at risk for influenza, so it's not really a new risk factor for influenza, it's just a repackaging of that chronic lung disease that we've always known was a risk for influenza.
I want to mention a particular feature that we've been hearing about this past couple weeks and that's outbreaks of influenza occurring in summer camps. Earlier in the spring, we were talking to you about outbreaks in schools and now, the state health departments are letting us know about a number of outbreaks in summer camps that are affecting people, both children, teenagers and adults associated with these camp communities. It's quite unusual to have this many outbreaks of influenza in camps, but it's not actually that unexpected given the continuing spread of this virus and the fact that when at-risk people congregate in close quarters, it's easier for things to spread. We are aware of 34 outbreaks of the novel H1N1 virus occurring in 16 states around the country and this is an important issue for public health and for parents to be aware of. Camps have taken a number of steps to reduce illness among their campers and their staff. They're isolating sick campers from others. Some have delayed sessions or sent kids home who were ill. Some have actually closed for the summer. And we want to make sure people know that we have guidance about Congress with this new virus in the summer camp setting that's on our website at www.cdc.gov. Of course for camps that are catering to children with medical conditions, that's a particular concern because those children are so vulnerable.
Next I want to briefly mention the Southern Hemisphere. We talked to you a lot in the weeks that passed about our keen interest in what would happen in the Southern Hemisphere as influenza continues to circulate because the Southern Hemisphere, of course, is going into their winter season, their flu season. There are reports of this new H1N1 virus circulating at the same time as the seasonal H3N2 influenza viruses and other influenza viruses in the southern Hemisphere. They're outbreaks of the new virus that have been reported from several countries. There's significant numbers or cases that have been reported in particular from Australia and on Argentina and Chile and in some of these places we have heard reports that the health care settings are actually having difficulty coping with the numbers of people coming in, so just as we saw some challenges here in cities around the country in the U.S., some of the Southern Hemisphere countries are also having that type of challenge with the onslaught of these new cases of illness. We do expect that this new strain is going to continue to spread in the Southern Hemisphere and intensify over the weeks ahead and we are continuing to watch this closely. We'll be watching for changes in the virus. We have not seen any changes in the virus that are important as of this point. We'll also be watching for changes in disease patterns. We've mentioned that people over 65 don't seem to be getting this illness or getting it in very great numbers here in the U.S. We'll be watching to see whether older people start to get this virus in the Southern Hemisphere as the flu season progresses. Those kinds of concerns have not shown up yet but we're continuing to watch. We'll also be continuing to watch the virus to see if it develops resistance to the oseltamivir type of drugs. We haven't seen that yet but it's the kind of thing we'll continue to look for.
Lastly, I want to say a few things about vaccines. We've told you in the past that vaccine development is going on in the U.S. Five manufacturers are working on this particular strain of influenza, making candidate vaccines that can be tested in clinical trials that will be happening over the summer months. And then, as many of you know, the CDC hosted our regular advisory committee on immunization practices here in Atlanta the past couple days and we had two sessions devoted to the novel H1N1 virus and really, the pandemic planning in general. It's too early for decisions by the ACIP about who might get this new vaccine that's being worked on or for specific target groups to be clarified. It's really important that we have open and candid discussions about the planning and that's what went on here in Atlanta. A very thorough set of presentations about vaccine development, virologist, about the guidance is important pandemic influenza vaccination that are being developed over the last few years, re-evaluation of that guidance in light of the scenario we are seeing today. Were heard about the plans for tracking vaccine effectiveness and vaccine safety and about the public health issues related to implementing immunization program against this new virus, a pandemic virus. It was a good meeting with a healthy set of discussions.
I want to let you know a few of the features of the discussion. Although we haven't made decisions about actual vaccination and who will be vaccinated should a safe and effective vaccine be developed and available, it's very important for states and communities to begin intensifying their efforts on planning to administer a vaccine should such be necessary in the fall. So, we want to do what we can to help states and local health departments and the partners within their communities move forward in that planning. We want states and communities to be ready to offer and administer the vaccine should one become available against this novel H1N1 virus and to help with that, we expect to be providing specific planning scenarios to states and communities that they can use in trying to understand which populations they'll need to be reaching. While the CDC and our partners have not finalized those planning scenarios, based on what we're currently seeing with respect to the virus and the epidemiology, we want states and communities and health care providers to be thinking about how they would be able to vaccinate younger people, pregnant women, people who have underlying health conditions like diabetes and answer ma that put them at higher risk from severe complications from this new influenza virus so the idea that this virus has been greatly affecting young people including school children, pregnant women, babies, and adults, particularly younger adults with those underlying conditions, those are the kind of populations that the state, local and health care providers can really begin thinking about. That action doesn't mean we've finalized any vaccine recommendations. Of course, we'll be looking to the advice of the advisory committee on immunization practices and other stake holders as well as the public as we move forward in our plan, but it's very important for planning to go on and to move forward expeditiously because if we do need to vaccinate, we'll need to have good plans in place.
So, in some way, this influenza virus, this new H1N1 virus that the W.H.O. has declared to be pandemic, is not going away. It's continuing to cause illness, deaths and outbreaks here in the U.S. and it's causing illness in the Southern Hemisphere in great numbers. The government and public health are busy taking steps to be ready to respond to this virus as we see what happens in the fall and to be ready for a great increase in the illness and outbreaks that this virus will cause. We want communities and families to also be thinking ahead about how they can ready themselves to cope with this virus should increased illness and community outbreaks occur. Coordinated planning is important and this is a partnership really between government, the private sector and the public and it's also important that we coordinate between the federal, state, local and really community levels and those are the kinds of efforts that we're going to be focusing on over the weeks ahead so, I think I'll stop with that and answer questions that you have.
Joe Quimby: Operator, ready for questions.
Operator: Thank you, just tell me if you'd like to ask a question, press star 1. Again, press star 1. And one moment, please. Our first question comes from David brown with the Washington Post, you may ask your question.
David Brown: Yeah, thanks a lot for this. Some people around here in Virginia, which is one of the states with widespread flu activity, are wondering why, when they take a kid to the E.R. with a 105 fever, headache, you know, seems pretty sick, get tested and they're positive for influenza, there's no further testing to nail down that it's the novel H1N1. Can you sort of explain a little bit more why definitive diagnosis is not useful in -- at this stage in the epidemic or when it is useful?
Anne Schuchat: Yes, thank you. Of course, parents want to know what's wrong with their children and I think we've been paying so much attention to this new virus that it's very understandable that as an individual family, you'd want to know whether that's what your child has. We have to step back and think about the implications of that answer and also the epidemiological needs the public needs to know what's going on and the reality that tests are not an unlimited capacity right now. Fortunately, we don't have a simple test that can be done at the bedside that differentiates this particular virus from other viruses. Fortunately, we have a new test that can be done in state and public health laboratories that can differentiate this new virus from other viruses but there's really not the sufficient number of those tests or the capacity in terms of the people to do those tests to test every single person who has an influenza-like illness. I mentioned earlier we're estimating more than a million people probably have gotten this infection, but with don't typically get a laboratory answer on every single person with influenza each year. Now, for clinicians, it's very important that they recognize influenza-like illnesses and that, if people are at high risk for complications, that we think it's important that they offer antiviral medicines to treat those illnesses, so that's one reason why you want to know what's going on but it may not help you to get a lab test back several days from now in terms of an antiviral treatment. We think it's also very important to look at the types of viruses that are circulating in communities around the country and that's one of the reasons we do virologic sampling. We do virology testing of influenza-like illness. Not every single one of them, but a sample. So what we're trying to do is make sure we have very good, accurate, timely information for the country and for specific regions, but not, unfortunately, the capacity that every single individual child or adult with an illness that may be this new one. Next question?
Operator: Thanks, next question comes from Fergus Walsh with the BBC. You may ask your question.
Fergus Walsh: Yes, thank you very much for taking my question. A couple of points. I just wanted to check in the UK, everyone who's suspected of having the H1N1 virus is offered antivirals and I wanted to see what the policy was in the U.S. And secondly, just one quick clarification on what Lyn Finelli was saying yesterday. I've got a quote here where she was talking about people over 65 and I just want to check this because she said, it seems to be deadliest to people 65 and older with deaths in more than 2% of elderly people infected and that kind of jumped out to me because I thought very, very few people over 65 were getting it. I just wondered if you could clarify that for me, please.
Anne Schuchat: Yes, thank you. In the U.S., our antiviral recommendations are based on the observation that the vast majority of people who get this new virus have illness that is mild and clears on its own or they have illness that gets better. It's not mild, you can be quite miserable in bed for a few days, but it doesn't lead to complications in most people. On the other hand, pregnant women, people with underlying medical conditions like asthma and diabetes, can have a much worse outcome. They can get pneumonia. They can have severe hospitalizations and, of course, some of them are dying. So, the strategy here in the United States is to focus the antiviral treatment on people who have those conditions that put them at much greater risk of a complication. Babies, people who are pregnant, have those underlying conditions. Now, I want to clarify the issue about people over 65 because I think these numbers can get very confusing. Very few cases that we are seeing are occurring in people 65 and over. Very few hospitalizations that we're seeing are occurring people 65 and over. In fact, there are only 6% of all of the cases in one of our hospitalization series occur in people over 65 and that was in only 15 people in that one series. In that same series, 35% of the hospitalizations were occurring in people 18 to 49. Now, when you have a very small number, the proportion that died may not be that accurate. So, I think what Dr. Finelli was trying to say was that we have a -- the majority of our cases are in the very young. Our hospitalizations are in young people. Very few people over 65 are getting this, but if they do get this, their chance of dying is a bit greater. Now, that's not really that surprising that, in the rare times when somebody over 65 gets this virus, between their age and the many other medical conditions that they may have, they may have a worse time of it, but in terms of our really putting our arms around the problem, this is much more of a problem in younger people with very low rates of disease, hospitalizations and so forth in the oldest population. I hope that clarifies things. Next question?
Operator: Our next question comes from Daniel DeNoon with WebMD. You may ask your question.
Dan DeNoon: Thank you. Dr. Schuchat, can you elaborate a little more on the experience in the Southern Hemisphere, particularly the overwhelming of some health care institutions. As we heard at ACIP, there's a lot of concern at the local level and even at the state level of a lack of funding that makes us a good bit less prepared than perhaps we'd like to be. Are these situations in the Southern himself steer analogous and are there lessons to be learned for us in.
Anne Schuchat: I think the situation in the Southern Hemisphere is evolving and we are looking closely with partners in those case and with the world health organization, pan-American health organization, to support the effort and also to get as good information as we can. Now, remember that we have had some challenges here in the U.S. with lines in emergency departments and it being difficult to get into your doctor's office to be seen, and when we have the respiratory season, that can happen anyway. I think what may be going on in some of these Southern Hemisphere countries ask, as the virus is recognized and people are trying to figure out, do I have it, is my illness that I may or may not usually go seek health care for something that I really need to seek health care for, there's probably what we think of as the worried sick. You know, people who are ill who might not usually have sought health care who may be seeking health care. On the other hand, there probably are more illnesses and so, as we work together with people in Mexico and as we worked in communities here in the United States, it can take some time to tease out true increases in severe disease, mild or moderate disease, and then an increase in the illness that's presenting to health care. We've had to make some changes in our recommendations here at the national level, as you know? Some of the affected cities, they really changed their warnings which people they suggested call their doctor or go to the emergency department which people needed to be alert for the illness requiring medical shift and I believe in the Southern Hemisphere countries, there's a little bit of that going on. Now, there are, of course, some areas around the world are people are having particular problems trying to handle severe illness in places where there may not be enough life support for those kinds of illnesses, but that's not as well confirmed at this point and I think we're really in early days trying to tease that out. Next question?
Operator: Next question comes from Helen Branswell with the Canadian Press. You may ask your question.
Helen Branswell: Thank you very much. I was hoping I could ask couple of questions if I could. The first one is, did the CDC have an estimate as this point of how many people who die have underlying conditions? We had earlier heard maybe as many as half of the people who were dying were previously healthy, but increasingly, it seems like all of the death notices, almost all of the death notices have reference to underlying conditions. And the second question I wanted to ask is are you doing any sero surveys in parts of the U.S. to try to get a better handle on how many people have been infected in this wave?
Anne Schuchat: Yes, thank you. The vast majority of the fatalities that we hear of or that are officially reported to us do occur in people with underlying conditions. It's not 100%. It's more on the on order of three-fourths of them at this point. We're continuing to track that and get additional information. We're up to 127 deaths have been reported to us, but we don't have that underlying condition information yet on all of them. But it's the majority but I think it's important for people to recognize that we do have some reports of deaths in people who don't have any underlying conditions, so most of the people who are dying are those with another condition, but as I said, they tend to be relatively young and I don't think that they were thinking of themselves as ready to die. So, this is a serious virus, one that we are taking quite seriously. You had a second question I'm trying to remember.
Helen Branswell: Serology.
Anne Schuchat: About the serology, right. We are working on serologic assays and we are doing, in the midst of serologic surveys, there's a number of ways that those assays would be evaluated. We're working with Mexico on understanding the, what we call the bottom of the pyramid, people who might have had milder illness are really asymptomatic illness but have been exposed and infected with this virus without actually knowing it. We're doing that in some of the areas here in the U.S. that have been affected. We've actually got some projects going on in the households where people have had an illness to understand what kind of spread there is in the family, both symptomatic and asymptomatic spread, so there's a number of settings where we're trying to understand really how much infection is around a particular case or an outbreak that we're seeing. This, the ser logic testing is rather complicated. It's not a quick type of test. So those tests are -- those studies are ongoing, but we don't expect to have results in the days ahead. They're something that we're working on quickly, but they won't be results we'll be able to share within the next several days for sure. Our next question, please?
Operator: Thank you, next question comes with Betsy McKay with the Wall Street Journal. You may ask your question.
Betsy McKay: Thank you, Dr. Schuchat. I had a question about the mild end of this disease. In other words, how mild do you think the presentations of this disease could be and as part of that, who are some of these 1 million or more than 1 million people do you think, or do you have evidence that there could be people out there who are -- may have only one or two symptoms like a sore throat or a cold but actually have novel H1N1 or there are people who may actually be asymptomatic but are carrying the disease?
Anne Schuchat: You know, the question about asymptomatic infection is one we don't have an answer yet for. That's where we'll use the serologic testing. We are expecting to see that. It would actually be surprising to me if we did not find asymptomatic infection. We know that influenza viruses can cause a range of spectrum, a range of illness from very, very mild or, as I said, even asymptomatic to much more severe. We have information on presenting symptoms for hospitalizations and the vast majority, of course, have fever and more than 80% have cough, but for the milder cases, there are other symptoms that we're hearing about. You know, of course, sore throat. There is some that we've reported about vomiting and diarrhea occurring in the milder illnesses, but what I'd like to stress is there's a range. Most people, of course, do have fever in terms of the symptomatic illness. Most of the symptoms are in the respiratory category, cough, shortness of Beth or sore throat, but, of course, there are some reports now of the nausea or vomiting, diarrhea-type symptoms in conjunction with confirmed virus. I think the important thing is that if you have severe symptoms or if you have fever and respiratory symptoms and you have one of those medical conditions like asthma, diabetes or certainly if you're pregnant, you need to check with your health care provider because those are signs that you might need treatment and testing. Next question?
Operator: Thank you, our next question comes from Beth Galvin with Fox 5 Atlanta.
Beth Galvin: My question was already answered. Thanks, I'll let somebody else go.
Joe Quimby: Okay, next question.
Operator: Thank you, next question come from Karen Zietvogel with AFP. Ask your question.
Karin Zeitvogel: Hi, yes. I was wondering if you could explain a couple of things about the 1 million estimate in the U.S. Is this because a lot of people are walking around as "the Wall Street Journal" journalist just ask with milder infections and just aren't going to get checked and do you do similar modeling because I believe you used the model to arrive at that figure for seasonal flu and if so, where would seasonal flu likely be at this stage because I know we have 36 million cases every year of seasonal flu.
Anne Schuchat: Okay. We are working with modelers to come up with some estimates. The million is actually estimating the symptomatic. It's not assuming that there's asymptomatic cases, but it is assuming that people are ill with this virus and don't seek medical care and then, of course, as we were saying earlier, many, many people who seek medical care are not tested and many of those who are tested don't get the test -- the additional testing that's needed to show it's this virus rather than another one. We think there's several features of the numbers that are different from seasonal influenza. You know, we say that each year, seasonal influenza viruses in the United States cause an estimated 36,000 deaths, over 200,000 hospitalizations and many million illnesses that don't require hospitalization and don't end up dying. Things that are different about this particular situation is that we have seen illness begin in April and continue to increase. We are estimating about a million people in the U.S. or more have gotten this virus at a time of year where people aren't really continuing to get the seasonal influenza viruses. And so, a big question that everybody really has is, what kind of illness, hospitalization and deaths may we see when our actual winter flu season begins? Will we see a greater number of illness, hospitalization and death from this new virus than we see from any of the individual seasonal influenza viruses? Will we see about the same apartment or will we even see more? And I think it's really important the say that season influenza viruses cause a lot of disease that is important and that causes a burden on our health system and, fortunately, we have vaccines against the seasonal influenza viruses so we strongly recommend use of those seasonal influenza vaccines to prevent the hospitalizations and deaths and outbreaks that we see. I unfortunately can't tell you today whether next fall we're going to see more of this new H1N1 virus than of the other seasonal influenza viruses. We are expecting to have the regular seasonal influenza virus to circulate and we are expecting to want to vaccinate against those rig viruses but as we mentioned, we are producing a vaccine and we are studying it this summer and we are beginning to work with state and local health departments to implement the planning that would be involved on to be ready to vaccinate against this virus should it be needed.
Joe Quimby: Operator, we have time for two more questions.
Operator: Our next question comes from Martin Enserink with Science Magazine.
Martin Enserink: Yes, hello. Thank you for taking my question. I wonder if you could elaborate a little bit more on that model. I mean, how do you get from 27,000 confirmed cases to that estimate of a million or more? And secondly, I think you mentioned the 6%. I wanted to ask you to clarify what that means exactly. Is that the attack rate among household complex or contacts in general? What is that number? And is that high or low compared to seasonal influenza?
Anne Schuchat: Right. I think that I will give you some answers and then what I'd like to say is that we have modeling in progress and so, as Dr. Finelli mentioned, a number of at least a million. That's actually a preliminary number that's not fully -- I expect it's going to be a bit higher than that when we finish the modeling. I want to mention that in New York City, they did a community survey that suggest the 6.9% of New Yorkers had experienced a flu-like illness during a three-week period in may when from their viralic testing they knew pretty much that most of that influenza-like illness was cause by this new H1N1 strain. They estimated from that about half a million New York City residents may have been infected with this new virus and had that kind of flu-like illness without getting a test or necessarily seeking care. We have carried out similar kinds of phone surveys of communities and we've also been doing some household surveys where there are individuals who are ill looking at the secondary rates in the household. There are communities not driven by the household that came up for the 6% estimate and that's not for the country as a whole, has is for a couple of places where we saw the outbreak really spread through a community. So, we don't know whether many, many, many or every community in the country will go through that kind of experience next year or not. Now, when you compare this to seasonal influenza, I think an important feature is that seasonal influenza is usually happening over weeks to months in a cold winter environment. And we don't know exactly whether what we've seen in the communities that were affected in the spring and summer is like what those same kind of communities would experience in a winter scenario. The attack rate of 6% is low for the seasonal influenza, but it's just a several-week attack rate. That New York City estimate was three weeks in the entire city of New York. So, I think that we believe the attack rates of this new virus, particularly in young people, may exceed the kind of attack rates that we see with seasonal influenza, but one other feature that's important is that we aren't seeing illness in the elderly, even in our household studies, we're really seeing the people over 65 in particular and probably people in their 50s are less likely to get ill with this virus even when they're in a family with somebody who has it. So, in seasonal influenza, of course, quite a bit of the severe burden, the hospitalizations and deaths, cur in the elderly. The attack rate in the high, highest in young people with seasonal flu, but the severe illness is highest in the seniors.
Joe Quimby: Operator, our last question, please.
Operator: That comes from Stacey Singer with the Palm Beach Post. You may ask your question.
Stacey Singer: Thanks for taking the question. I appreciate it up you had mentioned that you're asking communities to start preparing, I guess, for potential vaccination campaign. I'd like to hear a little bit about what that kind of a campaign would look like. Around here, Maxim Health Systems usually distributes the flu shots, the seasonal flu shots if people don't go to the doctors offices. Are we going to see, you know, tables at Costco and grocery stores and things like that or is it going to be different in some way? Thanks.
Anne Schuchat: You know, that's a great question. The plans that we have right now are that we'll be working closely with the state and local health departments and expect them to be working closely with partners across the state. They may be working with the private sector as you mentioned, the community vaccinators like you mentioned or with some of the private businesses. They may be working with occupational clinics that are typically vaccinating adults. They may be working with the department -- the schools and the department of education in the state to understand what are the best ways to reach school-age children, so I think that there'll be a variety of approaches and what we're trying to do is develop guidance that will help the states and their local -- state and local authorities in their planning and really to encourage communities to start thinking about this. We know that seasonal influenza is really important. The seasonal influenza vaccination campaigns have become a community thing. Many people are not vaccinated in their doctors' offices. They're vaccinated in other places that just work better for them, but the doctors' offices are an important part of the seasonal influenza vaccination campaign, so I think it's a point of intense planning that we're looking forwards in rural communities, there may be some solutions, different solutions in big cities. Some of the health plans may have an ability to reach a lot of their members and other areas where it's much more smaller, private health systems that are there, the public health system may really need to be stepping in especially with those community vaccinators. So I think we're at a point where we really want to understand how to reach people who want to be vaccinated and need to be vaccinated and make it as easy as possible for people to have access to a vaccine. Of course, this is assuming that a safe and effective vaccine is developed and available and that recommendations for its use are issued.
Joe Quimby: Thank you very much, Dr. Schuchat, ladies and gentlemen, thank you very much for joining from around the world. This now concludes our media availability.
Operator: This does conclude today's conference. We thank you for your participation. At this time, you may disconnect your line.
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