Sept. 25, 2009 -- Weekly 2009 H1N1 Flu Media Briefing

NOTE: This is a rough, unedited transcript and transcription errors may appear

Operator: Welcome.  Thank you for standing by.  At this time I would like to remind listeners that your line is in listen only mode.  I will now turn the line over to Glen Nowak. 

Glen Nowak: Thank you both for joining us today both in person and online for our weekly update on the n1h1 virus.  I will turn the podium over to dr. freedman. 

Thomas Frieden: Good afternoon.  What we'd like to do today is to tell you what we know and what we don't know about what's happening with h1n1. What's happening with vaccine preparations and production.  What we do know is that h1n1 is spreading widely throughout the U.S., particularly in the southern states, but in most of the country h1n1 activity is now widespread.  We also know that so far there's been no change in the pattern of disease.  So most of the people who have become ill with h1n1 have had disease similar to disease in the normal flu season, moderate illness.  It has affected disproportionately young adults and children, people ages 5 to 24 and although people sometimes think of the flu as a mild illness, in fact, having the flu is no picnic.  Even in an average case, it can knock you flat on your back for a couple of days.  You can miss school and work, have some difficult days and in severe cases, it can put you in the hospital and tragically some people have died with h1n1 and we will inevitably see death in the future.  Our challenge is to minimize the number of people who have become severely ill or who die from h1n1 influenza.  So far, the laboratory studies show that there has been no significant change in the genetic makeup of this circulating h1n1.  That's ready good news.  it means that the vaccine we have coming off the production lines shortly is a very good match, in fact, an excellent match with the virus that continues to circulate, which suggests that it's likely to be highly effective in preventing illness.  It suggests so far the disease is not widely to become deadlier.  But what I'm going to describe is first what we know and then what we don't know.  We know a lot about what's happened so far.  We can't predict what's going to happen in the future.  Influenza is perhaps the most unpredictable of all infectious diseases.  We know that although millions of people have gotten sick with h1n1, the overwhelming majority of them don't need testing or treatment.  however, if you're severely ill, such as having trouble breathing or you have an underlying condition like heart disease or lung disease, diabetes, women who are pregnant, it's important to get treated promptly because treatment in the first 48 hours is most helpful.  That's a challenging message because it means that on the one hand we're encouraging people to contact their doctors or do self-care in most cases, but in certain cases to get care promptly.  One of the real challenges about dealing with h1n1 this season.  We know there is plenty of Tamiflu Oseltamavir available.  Although it's important that it's used carefully.  People who need to be treated are people who have underlying conditions or who are severely ill.  It should not be used generally for prevention and it should not be used for most mild average cases of influenza.  That way, people who really need it will have enough to go around and we won't have as big of a risk of resistance, because resistance, we know, does develop so we have to preserve that drug for when we really need it.  We also know that although we've seen widespread disease, we've seen relatively few school closures and that's consistent with what CDC recommended last month, to minimize the disruption to learning and to communities when h1n1 is present.  Common sense measures can reduce but not prevent the spread of influenza.  the most important is to stay home if you're sick.  If you have fever, stay home for at least 24 hours after you have no fever when you're off all fever reducing medications.  Also, of course, cover your mouth when you cough or sneeze or wash your hands frequently.  Those are some of the things that we know about influenza.  There's a lot that we don't know, as well.  We don't know and only the future will tell if h1n1 influenza becomes more deadly in the weeks and months to come.  We don't know whether the fact that it's beginning to trend down in some areas suggests that it will completely go away in those areas.  We don't know if it does, whether that will be over weeks or months.  And if it does go away, we don't know whether it will come back this season.  We also don't know whether we will have another flu season.  The other circulating flu viruses such as h3 are present in many parts of the world.  Just because we're having an outbreak of h1 doesn't mean we won't have an outbreak of h3 later on this year.  Only time will tell.  so the basic take home message is for those of us in public health and health care are to monitor intensively, to see whether the virus is spreading in different ways, whether it's becoming deadlier and to be ready to adjust our approach if it does and for the public to stay home if you're sick, cover your cough, wash your hands and if you are at risk of serious illness and become infected or ill to get treated promptly and as soon as vaccine becomes available, to get vaccinated.  And that brings me to what we know and don't know about vaccine.  Vaccine is by far our best tool to prevent influenza.  It prevents both the spread of influenza and serious illness from influenza.  We know that the new h1n1 vaccine will be available in significant quantities by mid to late October.  And we know that some vaccine will be available before then.  We know more good news that a single dose is quite protective of people age 10 and above.  And we know that although people understandably have concerns about the safety of vaccine, that there is every reason to believe that this vaccine will be safe.  It is being produced just as seasonal flu vaccine is produced.  last year we gave over 100 million doses of seasonal flu vaccine being made by the same manufacturers in the same factories with the same mechanisms with the same safety precautions as every year's seasonal flu vaccine.  And really the fact that it's acting in the clinical trials very much the way seasonal flu vaccine acts gives us every reason to be confident that there's every reason to think this will be a take vaccine.  I have to hesitation getting the vaccine and I think that is the case for all of us working on the vaccine response.  we know that it's particularly important that certain groups get vaccinated, people with underlying conditions, diabetes, heart disease, problems breathing, pregnant women, health care workers, people who care for infants and kids who are in school.  And that's one of the reasons why you'll be seeing, over the coming weeks, cool located vaccine clinics, something we don't usually do in a normal influence season.  We also know that seasonal flu vaccine is available.  It's in large numbers, more than 50 million doses are in the system.  That's more at this stage of the year than in any previous year.  And there are lots of myths about flu and flu vaccines which make it difficult to get people vaccinated every year and will undoubtedly make it difficult this year.  First, you cannot get the flu from the flu shot.  There's no way.  It is a killed virus.  You can get a sore arm, but you can't get this flu from it.  Second, flu is not necessarily a mild illness.  Many people who do have a mild viral infection, a cold, think it's the flu and think it wasn't a big deal.  Flu makes you pretty sick.  You feel bad and if you've got an underlying problem or you're unlucky, you could get very sick.  So we need to take the flu seriously.  Also when seeing a doctor, even if someone has mild illness, they can get vaccinated at that time.  Now, the flu vaccination program for h1n1 is going to be challenging.  In a normal flu season with lots of time for preparation, the years, even decades of practice, working with provider groups and others, we vaccinate about 100 million people over about four months.  What we're looking at now is vaccinating as many people as want to be vaccinated in as short a period of time as possible.  And there are enormous logistical challenges to doing that.  the production challenges of getting the vaccine out of the factories, the transportation challenges of getting it in controlled temperature vehicles transported to warehouses, stored in warehouses, distributed along with needles, syringes and other kits to about 90,000 locations throughout the united states.  We know that each state is different.  They'll have different strengths, different resources, different community resources that they can call on to help with vaccination.  And we know also that misinformation spreads more rapidly even than the flu.  So any rumor has a risk of creating concern and we need to deal with that as it arises.  In order to support states, localities and territories and tribes for this vaccination program, the federal government is providing nearly $1.5 billion to help with vaccine planning and administration, is providing free vaccine and we will have enough vaccine for everyone who wants to receive it.  We won't have it as soon as we'd like, but we will eventually have enough vaccines for everyone.  We're providing needles and all the other equipment needed to vaccinate, technical support and guidance.  There's a real challenge here and there was a choice to be medicine and a dilemma.  We have some vaccine coming in early October.  The bulk of the early vaccine will be in mid to late October.  The choice was between having vaccine stack up in warehouses until we have enough to distribute substantial quantities everywhere or getting it out as soon as it was available to us for distribution.  And we think the only right answer, the only ethical answer is to get it out as rapidly as possible particularly since we have flu spreading widely.  What that means is that in the coming weeks, there is going to be some roughness.  It's going to be a little bumpy because in different states there will be different levels of preparedness and readiness and planning.  There will undoubtedly be places where people want to get vaccinated and can't in early to mid October particularly.  But that's a better option than just sitting on the vaccine.  It doesn't all come out in one big drop.  it comes out batch by batch from five different factories and we felt that the only responsible thing to do was to get that out as rapidly as possible, knowing that that would mean that these first couple of weeks of October are going to be rough, a bit rough, in terms of there being a demand for vaccine that can't always be met.  We do know that by mid to late October, there will be lots of vaccine available and that will be continuing to receive substantial amounts of vaccine every week for the rest of the year.  We don't know what the update will be.  In the past, it's been difficult to get people who clearly would benefit from vaccination to get vaccinated.  And one of the challenges here is making sure that people who could benefit from it have every option to get vaccinated because doing so is the best way we have of reducing the amount of illness and death from influenza.  We also don't know which states are going to have particular problems.  We're working very intensively with states and localities to help them with preparations, to facilitate, if there are logistical difficulties, to help them overcome those.  The bottom line is that vaccination is our best tool to prevent flu, that it's very likely to be highly effective this year against h1n1.  We wish we had had it sooner, but we ensured that all the steps were followed and given the technology that exists today; this is as fast as it can be produced.  It's particularly important for some groups.  We know that there will be differences between different states in how ready and the approach states take to vaccinate.  Some states are planning very comprehensive school located vaccine programs.  Other states are planning less extensive school vaccinated programs.  This is an unprecedented effort and though we wish we had a smoothly functioning system, that's not the easiest thing to have happen.  This is not an ideal time to have had a pandemic.  we have a public health system that has had decades of underfunding and neglect and on top of that, the fiscal crisis has meant that there have been layoffs, furloughs, hiring freezes, difficulties getting purchases and contracts in place and the health care system is not well set up to coordinate, to have information systems that work particularly effectively or to prioritize prevention and vaccination is really the -- an ideal example of a preventive intervention.  It's going to be a busy and challenging few weeks.  But the good news is we have a vaccine.  it's likely to be highly effective after a single dose for people age 10 and up and it's going to be rolling off the production lines, rolling into warehouses and from there, do doctors' offices, clinics, health departments and two school located vaccine programs in the coming weeks.  Thank you very much.  And we can take a few questions.  We'll start maybe in the room. 

Mike Stobbe: Mike Stobbe from the AP.  Doctor, you said flu activity is trending down a little bit.  Could you talk a little bit more about where it's trending down?  And I have a follow-up question. 

Thomas Frieden: we've seen a couple of states, including Georgia where we are here at the CDC where we still have very high levels of flu, much higher than after average flu season, but a little bit less high than last week.  What does that mean?  Well, it's not clear whether that trend will continue.  It's not clear whether if it does go down, it will come back up later.  in New York City in the fall where I was health commissioner -- I'm sorry, in New York City in the spring where I was health commissioner we had an initial wave and then it went way down and then it came back much stronger.  So we are in uncharted territory.  We have not had a flu season that's continued like this through the summer or started this early in the fall since, perhaps, not since 1957 where there was somewhat of a similar pattern in the summer and fall.  And what that means in terms of the future, only the future will tell.  That's why we're monitoring so intensively on a weekly and even daily basis to see what happens with activity.  But we're going to have to look day-to-day, week to week and month to month for what those trends do in the future.  Operator, do we have any questions on the phone? 

Operator: at this time if you'd like to ask a question, please press star 1 on your touch tone phone.  Please record your name and I will announce your question.  If your question has been answered, withdraw your request by pressing star 2.  Our first question is from Miriam Falco from CNN.  Your line is open. 

Miriam Falco: hi.  Thank you for taking questions.  I have two.  Number one, you addressed the fact that there won't be that much vaccine available at the beginning.  What are you going to do when either people who really want the vaccine and you'll have too many people asking for it or you may not have anybody show up because they're afraid of it or whatever?  How are you helping the health department specifically in all the states to deal with this?  You're saying there's not going to be a shortage of vaccine, but at the beginning there will be if there is high demand.  Then I have a follow-up. 

Thomas Frieden: it's going to be primarily a question of communication at various levels.  With the initial vaccine, much of it will be the LAIV, the flu spray, and that is, unfortunately, something that is recommended, indicated only for people who do not have underlying health conditions and are under the age of 50.  So it's not for everybody and that is a lot of what's going to be out first.  There are certain groups that make a lot of sense to give it to first, such as health occasion workers or people who care for infants under the age of 6 who are otherwise healthy.  The flu shot for h1n1 will be coming a little later and the exact time of that we'll only know as we get closer.  We ask people to be patient, to understand that we're getting out the vaccine as quickly as possible and to recognize that there will be times when it's not possible.  Seasonal flu vaccine is available.  They can both be given together, but people can be vaccinated now against the seasonal flu and there's plenty of seasonal flu vaccine in most places.  You had a second question? 

Miriam Falco: it is about your recommendation, parents of children under six months should get a vaccine right away, but why did you not recommend the that the parents of older children also get vaccinated since all children are in the high risk category? 

Thomas Frieden: children under six months can't get the vaccine.  So as to protect them, we try to vaccinate the people around them who could make them sick.  Kids older than six months can get vaccinated and should get vaccinated.  We can take another question from the phone.

Operator: the next is from Julie Stenhuysen from Reuters.  Your line is open. 

Julie Stenhuysen: again, with I just wanted to confirm.  Basically are you saying that flu mist is the first vaccine that's going to be available?  And that that vaccine will not be -- cannot be used in people who have underlying conditions, so is that part of why you have such concern about, you know, the first couple of weeks being pretty bumpy? 

Thomas Frieden: there are a couple of reasons.  we know that although we'll have on the order of 40 plus million doses of various types of vaccine by mid October or late October, in the first couple of weeks of October, we're going to have much less than that.  So there will be times when there are people who want to get vaccinated and can't be.  and while we would have wished, perhaps, that the vaccine was available first for those at highest risk of serious problems, as it happened, the flu mist vaccine grew faster and will be available sooner.  So that is just the way it happened in terms of the production.  But yet much of the initial vaccine will be the flu mist and people with underlying conditions are not recommended to receive the flu mist.  Another question in the room? 

Mike Stobbe: thanks.  Yeah, Mike from the AP again.  Doctor, could you talk a little bit more about -- you said there would be some variation from state to state.  I think this week it was said 8,000 jobs have been lost at local health departments.  Are there certain states, and which states, are least prepared right now and which are best prepared?  Could you at least talk about the characteristics of the states that are well prepared versus not.  Each state has their own resources and challenges.  and some states, many states have been very creative in thinking about how they're going to vaccinate, how are they going to get kids vaccinated in schools, consents signed by parents, consents back using a back to school packages, using PTA meetings, using a variety of means to get large numbers of kids who have consents received for vaccination.  there are other states that have been very creative in using private vaccination programs, whether they're commercial pharmacies or visiting nurse associations, which will be able to vaccinate large numbers of people.  There are states that have been very creative in working with the private sector, identifying health care providers who can vaccinate in large numbers and making sure that vaccine is available widely throughout the state.  There are lots of different possibilities.  One of the more important is the school-based vaccination programs.  We know so many kids do get sick from flu and not only is that a problem for the children, but they end up spreading flu widely in the community.  So if you protect kids, you probably protect not only the kids, but the community, as well.  And school located vaccine programs can reach a lot of kids quickly.  Some places are vaccinating others in the community at those school-located clinics.  so there are different options, different patterns, different approaches and we're both supporting those and learning from them so that we can all understand what works best, what works better for a flu vaccination.  On the phone? 

Operator: the next is from tom mow, Los Angeles times.  Your line is open. 

Tom Maugh: hi.  There were two potentially concerning reports this week.  I would appreciate it if you would address them.  One is the paper showing that flu mist is not effective against seasonal flu as the decibel vaccine and the second is the so-called Canadian problem.  Can you talk about those? 

Thomas Frieden: so taking them one at a time, a very carefully done study in the new England journal of medicine showed that for one particular mix of flu mist and one particular season of flu, that flu mist was a little less effective than the flu shot.  There are other scientific studies that suggest that for children, for example, the flu mist is a little more effective than the flu shot.  And for this flu season, with this flu vaccine, all betts are off in terms of which is better.  Any time you try and make a prediction about flu, you have to stop yourself.  You can make predictions about flu, but you're likely to be wrong.  I will anticipate and say I do think it's likely that both the nasal spray and the injectable flu vaccine for h1n1 are both likely to be quite effective against this year's h1n1 strain because the match is so close for both and because the flu mist spray that's being used is just a single type of flu virus.  It's not mixed with others which might be one of the reasons why there's some problems with or slightly less effective than some flu mist.  But the great thing is that we know that both of them are effective and both of them will be available in the coming weeks.  In terms of the media reports coming out of Canada, there are reports that the -- in some analyses, people who received the seasonal flu vaccine were more likely to get h1n1 infection.  We have looked at our data at the CDC nationally.  I have looked carefully at the data from New York City where we had a very large outbreak and lots of information about what vaccine was received.  The Australians have looked at it and published their information.  And in none of those data is there any suggestion that the seasonal flu vaccine has any impact on your likelihood of getting h1n1.  It doesn't protect you at all and there's no suggestion from any of the other data sets that it increases your risks.  If data is published in the scientific literature, but all means, we would love to see it.  If there's preliminary data, we would love to see it.  But nothing that wove seen suggests that that is likely to be a problem.  On the phone. 

Operator: the next is from Deborah Franklin, national public radio.  Your line is open. 

Deborah Franklin: yes, thanks.  We've been getting a lot of listener calls from primary care docs, wondering when they'll be able to get the flu vaccine.  Can you comment on that, whether the distribution system is different, very different with this vaccine than seasonal flu? 

Thomas Frieden: this is a very different distribution system from what we do with seasonal flu. We did that to try and make sure there was fairness and so we could try to get it out as consistently and rapidly as possible.  In a normal flu season and for seasonal flu vaccine this year, doctors, clinics, health centers, hospitals, employers place orders with the companies directly.  And whoever orders first, gets the most.  in this year, because the government is paying for all the flu vaccine and we want to ensure that -- especially when there's not enough to go around early on, but throughout the season, we can provide the h1n1 vaccines and kits to provide vaccination throughout the country equitably and rapidly, we are using a central distributor program and working through state health departments and the state health departments have electronic systems that allow them to register and have agreements with providers.  So if you're a doctor in a state, you should check with your state's health department or in some areas, local health departments.  And the program that has been used with the vaccines for children's program, which is a very successful program which has more than 40,000 doctors signed up and receiving vaccine, that same system is being used for this vaccine distribution.  We expect there will be about 90,000 vaccine distribution points around the country.  Doctors and other providers would sign up through their health department and then that will enable us that the vaccine gets to where it's needed pretty much throughout the same time in the country.  More on the phone? 

Operator: the next is from Brian Hartman, ABC news, your line is open. 

Brian Hartman: could you be more specific on the timing of distribution, when you'll start taking those electronic orders and what formula you use to how much goes to which state and what happens to it from there. 

Thomas Frieden: the formula is straightforward.  It's a population based formula, pro-rata, based on how many people live in each state.  At the end of September, we will begin taking orders and by the first week in October, a vaccine will begin arriving in doctors' offices.  So the first vaccine you would expect to see around the 6th of October.  On the phone. 

Operator: the next is from Elizabeth morning.  USA Today.  Your line is open. 

Elizabeth Weise: thank you so much for taking my call.  I had a quick question and then a longer.  In the flu mist versus the injectable form, do you know what the ratio is that will be available?  And the second question is, I heard various things about the morbidity and mortality for pregnant women.  what specifically are the dangers to pregnant women and given the data coming out of Australia and New Zealand, what are the numbers that we can give for that group in particular? 

Thomas Frieden: we know that for pregnant women, the risk of getting seriously ill is about six times the risk of serious illness for people who are not pregnant.  So pregnancy is a time when it may be harder to get deep breaths, when there's changes in the immune system.  And, therefore, it's particularly important that pregnant women get vaccinated and for pregnant women who are sick before the vaccine available, if we didn't get vaccinated, to see your doctor promptly before being treated.  Flu mist is likely to be around a quarter to a fifth of the total available vaccine.  It could be a little more since the production has gone quite well with the flu mist. 

Thomas Frieden: two more questions on the phone. 

Operator: the next is from Kelly Brewing ton, the Baltimore sun.  Your line is open. 

Kelly Brewington: my question has been answered.  Thank you. 

Operator: the next is from Diane Debrowner, Parents Magazine.

Diane Debrovner: I'm wondering about people who assume that they had h1n1 in the spring or summer, even if they didn't have a definitive test.  Are you still recommending at this point that they be vaccinated? 

Thomas Frieden: we do recommend that people who were ill in the spring get vaccinated.  Many people had H1N1 many people had colds or different viruses.  The safety would suggest to get vaccinated, even in places where there was lots and lots of h n 1 in the spring, like New York City where as much as 10% of all people may have had it.  That means that 90% of people didn't and in the small studies that we did, even at the height of h1n1 in the spring and the fall, most people with flu-like symptoms didn't have h1n1, they had something else. 

Operator: Miriam Falco, CNN, your line is open. 

Miriam Falco: just a quick question following up on the Canadian reports that were unpublished in an unnamed journal, I'm just wondering, where does it come from that having one vaccine can make you vulnerable to another illness?  I don't even understand the logic. 

Thomas Frieden: that's a very good question.  It's something that we haven't seen in any of our data, nor would there be a real explanation technically or scientifically of how that might happen.  But we take every concern seriously and we will absolutely look at any data that is made available to us.  What we can say again is that we've looked carefully at our own data in this country.  I've looked at the data from New York City.  Australian data has been analyzed carefully and none of it suggests any problem from getting the seasonal flu in terms of h1n1.  That also tells us that there's no protection from getting the seasonal flu vaccine against h1n1 virus, to protect yourself from h1n1 with vaccination, you'll need the h1n1 vaccine and the good news is if you're 10 or over, you'll only need a single dose.  We're going to have both nasal spray and shots available.  They will be widely available in late October.  That means that the next two to three weeks will be challenging in terms of flu and flu vaccination.  But we're confident by mid to late October we'll have ample vaccination and lots of opportunities to get vaccinated in lots of different places in the different states around the country.  Thank you all very much.  Thank you.