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Oct. 13, 2009 -- Weekly 2009 H1N1 Flu Media Briefing

October 13, 2009

Audio recording (MP3)

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

Operator: Good morning and thank you all for holding.  You've been placed on a listen only mode until the question and answer portion of today's conference.  If you would like to ask a question, please press star one.  I would like to remind all parties the call is being recorded.  If you have any objections, please disconnect at this time.  I would now like to turn the call over to Mr. Glen Nowak. 

Glen Nowak: Thank you for joining us this afternoon for a brief update on the H1N1 vaccine situation and influenza across the country.  Doing today's update will be Dr. Ann Schuchat, the director of national center for immunization and respiratory diseases.  Thank you. 

Anne Schuchat: Hello, everybody.  We'll try to keep this relatively short.  I want to let people know a little bit more about what we're learning about the H1N1 disease in people and a quick snapshot of where we are with the vaccination program.  As we noted on Friday, the H1N1 influenza is pretty much throughout the country with unusual levels of illness for this time of year.  We've had five more pediatric deaths reported to us since the last time I briefed.  So, again, tragic consequences for a lot of children.  We've been looking at more detail about the hospitalization data.  We have a network, ten states that do active surveillance for influenza-related hospitalizations.  And we've been trying to update information on patients that are requiring hospitalization from the H1N1 virus.  So the data that I'll summarize comes from reports of that emerging infection program network and will summarize information from cases that occurred from April all the way through the end of August.  Last week in the New England Journal of Medicine, there was a summary of the first 272 hospitalized H1N1 patients from around the country.  This is a bigger sample of what we're seeing.  The majority of people do have underlying conditions.  That's true of both children and adults.  We have information from about 1400 hospitalized adults and over 500 children who required hospitalization for the H1N1 virus.  We are still finding, as I said, most have underlying conditions.  In adults, the most common underlying conditions were asthma and chronic lung disease, chronic heart disease and immunosuppression.  And in children, the most common underlying conditions were asthma and chronic lung disease, neurologic or neuromuscular diseases, and sickle cell or other blood disorders.Again, we are seeing pregnancy as quite notable among hospitalized patients.  And in this among the 1400 hospitalized adults, 88 or 6% of them were pregnant.  So just a reminder of why those conditions, pregnancy and underlying conditions, are ones that we highlight as recommended to receive the vaccine when it becomes available in communities.  So let me turn to the immunization program.  As of yesterday, 9.8 million doses of the H1N1 vaccine were available to be ordered.  5.8 million doses have been ordered as of yet by the states to be shipped out.  And we're getting new orders every day and new allotments of vaccines.  So this will be a very dynamic circumstance.  I'm happy to say that about half of the vaccine that's available for order is now the injectable form.  Initially you know we only had been able to have the spray available, but now it's about half and half that are available and will be coming out toward the states relatively soon.  It does take time to process the orders, to package them for the right amounts that are heading out towards the many sites we'll be delivering vaccine, and this is going to be ongoing over the next days and weeks.  We're working closely both with the state and local health departments, with the professional societies, the physicians, nurses, nurse midwives, trying to make sure that we get good information out to the public as well as these special population groups and the providers who care for them.  We know that health care providers are really interested in what's going on with H1N1 as well as what's going on with the vaccination.  We've been doing a lot of outreach, calls and working through the professional societies to get good information out and these efforts will continue.  If there are providers who aren't sure how to be able to offer H1N1 vaccine, a reminder is you need to work with your state health department or, in some of the larger cities, the city health department.  You can enroll to become a provider who offers that vaccine and we're still taking enrollment through the different states.  So look to either give your health department a call or look on their website.  You really have one stop shopping at flu.gov.  There's a map that goes to each state and will have information on the way to contact the state health department about vaccination issues.  Going forward, we will -- are expecting that more vaccine will be getting shipped out regularly.  More places will begin vaccination efforts.  Now that there are both spray forms of the vaccine and the injectable, there will be an ability to offer vaccine to people who aren't eligible for the spray.  Only people between the ages of 2 and 49 who are not pregnant and don't have underlying conditions can receive the nasal spray.  So this injectable form of vaccine means that many more will be available -- many more people can take advantage of the vaccine.  This Friday, we hope to start providing state specific information so there will be a better sense of just how much vaccine is on its way to my own state.  We'll also be updating on the disease at that time.  We really know that the states and local health departments are working very hard right now to ramp up the vaccination activities.  Things will be changing every day and we just wanted to be available today to provide information for those of you with questions.  The state and local health departments will be the best source of information on what's happening where you are in terms of disease or vaccination, but we want to be available for the national picture.  So with that, I'd like to take the first question from the phone, please. 

Operator: Thank you.  Our first question is from Robert Bazell from NBC news. 

Robert Bazell: The interest in flu in general, these many programs that were set up to give seasonal flu that have been suddenly canceled.  Why do you think the people who were expecting to get their seasonal flu on a certain date and from their church or whatever, school or whatever facility, suddenly had to shut it down? 

Anne Schuchat: I wish it were easier for people who were looking for seasonal flu vaccine.  We are aware that there are difficulties in many communities.  The good news is 77 million doses have been distributed.  The other side of the story is that there's a delay in more of the seasonal flu vaccine getting out in a lot of areas.  We're expecting a lot more doses in November.  The main message I have is to be patient.  Right now we're seeing the H1N1 strains.  We aren't seeing much at all of the seasonal strains.  And we think there's time to be vaccinated against the seasonal flu.  Even if more vaccine isn't available until November or December, we think it will be just fine to be vaccinated then.  So really I'd like to apologize for how frustrating it is for you and ask for your patience in waiting for more of the seasonal vaccine.  Fortunately some of the H1N1 vaccine's coming out and we think it will be really important to get that out to people as quickly as we can.  Next question from the phone, please. 

Operator: Our next question is from Craig Schneider from Atlanta Journal Constitution

Craig Schneider: Thanks for taking my question.  I think a lot of people are expecting that the H1N1 vaccine shots are going to be available this week widespread in the United States.  But we're seeing that almost nobody has the shots yet.  Are you anticipating -- are you seeing any delays in the delivery of the shots and when would you expect that it will be out there for widespread use? 

Anne Schuchat: You know, I expect more and more doses to be available each day, but widespread use will probably be towards the end of the month.  Certainly this week the shots will be out in all the states or most of the states, I believe, but not in the large, large number that we'll be looking for later in the month.  And each of the states and cities is directing the vaccine to the places where it can be given quickly to high risk populations or to health care workers, to children and schoolchildren in some communities.  The states and locals are trying to take the doses available to them and find focused, practical ways to get them used promptly.  So week by week there will be lots more vaccine coming.  We were glad that it's almost 10 million doses that were available for order as of yesterday.  But I know that you won't see it everywhere until later in the month.  The next question from the phone, please. 

Operator: Thank you.  Our next question is from Miriam Falco from CNN medical news. 

Miriam Falco: Thank you for taking the questions.  Is there any way for folks who are curious about where their states are making these shots available, that they can go to a central place?  I mean, I know each state is running it differently, but are you providing any links on flu view?  Because we're getting the same questions, too, when are the shots coming here. 

Anne Schuchat: Yes, at flu.gov, there's a flu vaccine locator place that basically will say for each state what the latest information is.  Now, we are expecting states to be publicizing the vaccination that's going to be offered generally or for, you know, for anybody who is recommended to come and get, but the private offices that are providing vaccines probably won't be listing themselves on that site.  They'll be offering vaccines to their patients, but not to the general community.  So the school-located venues will likely be posted there, the retail pharmacies, the hospitals that are offering them.  But probably not those doctors' offices because we're grateful that so many providers are stepping up to do this, but we're asking them to vaccinate their patients, not shut down their practice and offer to everybody else in the community.  We are grateful for the many providers that are stepping up to this and we urge more to do so.  It's not too late to sign up with your state to become a provider whether you're a retail pharmacy or a doctor's office or a hospital.  So the short answer is, though, at flu.gov, you can find the central information that will tell you about any state and people then can be directed to their state.  Okay.  Next question from the phone. 

Operator: The next question is from Helen Branswell from the "Canadian Press." 

Helen Branswell: Thanks for taking my question.  You said earlier that you've looked at about 1400 -- data from about 1400 hospitalized adults and 500 hospitalized children.  I'm wondering, do you find that women are overrepresented in your figures?  There was a study published yesterday looking at critical care cases in Canada and even after you factor out pregnancy, women seemed to be overrepresented and I'm wondering if you're seeing it there, too. 

Anne Schuchat: A recent look at hospitalizations, I just have the underlying disease information.  I don't have the female/male proportion.  I believe we've been seeing -- we haven't been seeing a major difference, but we'll look into that and try to get you more information on that.  I don't have the latest on that.  Next question from the phone. 

Operator: Our next question is from David Brown from the "Washington Post." 

David Brown: Thanks again as always.  This is sort of following Helen's question.  Do you have or can you provide us today some demographic breakdown and some details of these -- from April series of hospitalized patients?  Because obviously there's lots of interest in what fraction was obese and what the age range and mortality was and all that stuff. 

Anne Schuchat: Today all I have is the underlying diseases, but this is just the kind of information we'll be able to get you.  I pushed to be able to get something new for you and what I got was underlying diseases.  As we've been seeing, the vast majority of hospitalizations and deaths are occurring in younger people, they're not occurring in people 65 and over.  That hasn't changed at all in what we've been looking at.  But the latest numbers on the breakdown of diseases, it doesn't separate, it's just 18 and over and under 18 that I have. 

David Brown: Can I just ask an unrelated follow-up question?  When will the injectable vaccine, when will the first supplies of that be shipped to states and cities? 

Anne Stobbe: I believe it's happening right now.  I believe there will be sites giving the injectable vaccine this week.  We know people were ordering injectable I think and that there's been shipments both yesterday and -- actually I think Sunday and Monday, shipments were going out.  So I'm pretty sure that they'll be injectable doses given probably tomorrow and definitely the next day.  Next question from the phone, please. 

Operator: Our next question is from Mike Stobbe from the Associated Press. 

Mike Stobbe: Thanks for taking questions.  Can you give detail on the underlying conditions?  Can you give us a percentage?  And also could you put this new information in context?  Is this the largest data pool we've had on U.S. hospitalizations and is there any difference in your finding about what percent as compared to previous looks? 

Anne Schuchat: What we're seeing is consistent with early looks that we did, the 272 patients hospitalized.  We do see some people without underlying conditions and we're still analyzing these data, but our findings are very consistent with the early look.  In terms of adults, asthma made up 26 -- or 26% of the adults who were hospitalized had asthma.  About 10% had diabetes.  8% had other chronic lung disease besides asthma, 7.6% had immunosuppressive conditions and 6.1% were pregnant.  If this would be the largest for the U.S. experience of adults hospitalized, we wanted to make sure that we weren't missing some important underlying conditions that we hadn't talked about earlier.  In terms of children, one thing to make mention of because I'm not sure we've mentioned it before is the sickle cell or other disorders of blood.  Conditions for which we do recommend influenza vaccine, but we found that of the children in our hospitalization series, 5.8% had a hemoglobinopathy, the most common of which is sickle cell.  So these data aren't very different from the earlier ones, because we have larger numbers, we're feeling more confident about that the vast majority of underlying conditions that are risk factors for this severe consequences like hospitalizations are included in the list of groups that we've recommended to be vaccinated.  Next question from the phone, please. 

Operator: Our next question is from Brian Hartman from ABC News. 

Brian Hartman: We're hearing reports that some hospitals are beginning to advise against children visiting patients and just wondering what you think about that and does the CDC have any guidance on limiting pediatric visitors to hospitals.And then a quick follow-up, if you've learned anything at all about obesity as an underlying condition from the surveillance that you just talked about. 

Anne Schuchat: I don't have the obesity data for this hospital series, but it is one of the things we're looking at in more detail.  In terms of hospital practices, hospitals are really looking carefully at ways that they can reduce transmission of influenza in the hospital environment and among those are administrative controls, the ways that we can keep people ill separate from other people, whether those are people ill in the hospital, people who are in the emergency department and coughing, or perhaps visitors.  So I don't believe CDC has any recommendations about changing the practice of children visiting hospitals, but certainly hospitals are taking a careful look at their own facilities.  There's a lot about the structure of a facility that -- how crowded it is and how many places people can be that might lead them to take that kind of step.  We know that hospitals are really -- some of the hospitals have had quite a challenge  handling quite a lot of ill people over a long period of time.

Operator: Our next question is from "USA today." 

Elizabeth Weise: Thanks for taking my call.  A question about the pregnancy as an underlying condition.  Do you have any sense for what the mechanism is for why pregnant women are at greater risk? 

Anne Schuchat: There are probably two factors that influence the risk that pregnant women have for influenza complication.  And this applies to both seasonal flu and the H1N1 flu.  In pregnancy, there's a change in the immune system which makes it easier for the woman to hold the fetus and not have immune reaction to the baby.  And so risk of infections can be greater.  The second issue is probably more mechanical, that as the woman gets larger with the baby growing, there can be pressing on the airways and really a restrictive lung disease.  So it's harder to take a deep breath and it's harder to fight off a lung infection especially in the later stages of pregnancy.  So both of those are part of the story here and of course the really difficult complications in pregnancy have been one of the features of that pandemic, that of course make us remind women that if you have respiratory symptoms, fever and cough, please take them seriously during your pregnancy and let your health care provider know about them.  Prompt use of antiviral medicines may be very important in that circumstance.  And if you're pregnant, it's a really good time to find out about the vaccine and get your questions answered.  Because vaccination is the best way to protect yourself and the baby from the complications of flu and there are many, many people get influenza vaccine every year, seasonal flu vaccine, about 100 million people.  The H1N1 vaccine is made exactly the same way as the seasonal flu vaccines and we think the safety including the safety in pregnancy should be excellent.  So I strongly encourage pregnant women to talk to their providers about this and get your questions answered in the next several days and weeks while you're waiting for the vaccine to be available near you. 

Operator: Our next question is from Betsy McKay from the "Wall Street Journal." 

Betsy McKay: Thanks.  I also have a question from your surveillance data, the hospitalizations, which we're so glad you're sharing with us.  I wondered if you know how many of these hospitalized adults and children have no underlying conditions at all, I.E. perfectly healthy.  And, separately, do you have insights yet into what is making some of these people with no underlying conditions so sick?  A lot of people out there are wondering could this happen to me and when should they call the doctor. 

Anne Schuchat: Thank you.  These data are preliminary and I have to say I rushed to get them for you, so what I can say is that the pediatric data needs to be looked at a little bit in more detail because we haven't pulled out those children under two who, of course -- just being under two is like an underlying condition in having a complication from influenza, but in the adult group, it was more than 45% actually didn't have an underlying condition that's listed on the ACIP list of underlying conditions.  We're still looking into what proportion of them may have had severe -- morbid obesity or extreme obesity, but it was the majority that had at least one underlying condition.  And then the second question you had -- oh, about what's the mechanism.  I think a key point is that this virus can be serious even in healthy people with no underlying conditions.  We have seen and reported results from the autopsies that have been looked at.  That was a reported case a couple weeks ago.  And there were two persons in these terrible fatalities.  One was a viral pneumonia, a very severe -- the virus really overwhelming the lungs on its own.  That is not the most common manifestation of the H1N1 influenza in people, but it can happen.  And when it can happen, even a healthy young person can really succumb to it.  It's a very severe presentation.  In about 20% of the fatalities, what we saw was the influenza leading to a bacterial pneumonia.  Sometimes it was the staph aureus including the MRSA, sometimes it was the pneumococcus and that's where we're telling people remember that pneumococcal vaccine which is so important in protecting people from pneumococcal pneumonia.  So what I would say is that most people who develop H1N1 influenza will have an illness that can be cared for at home without needing treatment, but some people will have a very severe course.  And so if you have warning signs, difficulty breathing, if your child -- if the parent notices that your skin is turning gray or blue, that it's difficult to wake you up, that you're just so irritable that you can't stop crying, those are warning signs in children.  Warning signs and respiratory symptoms and fever are reasons to seek care or talk to your health care provider.  So I think it is sobering that some totally healthy people suffer this very rapid deterioration from the H1N1.  That is not the usual presentation, but it can happen.  And as this strain spreads around the country, the numbers of people suffering from that have been increasing.  We have time for two more questions. 

Operator: Our next question is from Tom Maugh from "L.A. Times." 

Tom Maugh: To clarify on this 1400 adults and 500 children, that is just from the ten surveillance states and the percentages you gave, those are from this study or the previous study? 

Anne Schuchat: The data that I described today is just from the emerging infection program network states.  They're either whole states or counties within a state.  So this is not the national picture because we basically aren't recording data on every hospitalization in this level of detail.  What we're doing now is intensifying the surveillance in the emerging infection program network site so that we have better clinical data to share.  The percentages were just from this series, not from the national picture or what we had talked about earlier.  So all of these hospitalizations occurred in one of the emerging infection program network sites and the underlying diseases were gathered through these partnerships that we have with the state health departments and some universities in those emerging infection program network sites.  So this is one of our special surveillance systems that we've been -- put in place a few years as going as part of strengthening our preparedness for influenza.  These same EIP network sites will be looking at vaccine effective also and also some of the adverse events that might follow vaccines.  So you'll be hearing more from us about what we learn from the emerging infection program network sites and we're grateful for the collaboration out there from the state and local health departments and clinicians in those communities.  I think we have time for one more question. 

Operator: Thank you.  And our final question is from Daniel DeNoon from Web MD. 

Daniel DeNoon: I've heard from some providers, particularly of our pediatric practice, that they actually canceled their order for the H1N1 shots because the huge volume of paperwork that's larger than other vaccinations and particularly because of the requirements that nurses are under, LPNs or even MDs must give shots and not nurse assistants.  Is this a problem that you're starting to see across the country? 

Anne Schuchat: Thanks for mentioning that.  I hadn't heard about that problem.  We really tried hard to provide -- to limit the barriers to providers.  We modelled it after the vaccine for children program which has about 45,000 enrolled in the country to provide vaccines given through the government entitlement program.  Certainly some providers will be really busy caring for ill patients and taking on vaccination can be difficult.  We really urge people to reconsider.  I hope that some of that -- that that's just a rare event the one that you're hearing about.  I haven't heard it commonly, but perhaps after this, we'll hear more about that.  And so I really -- i do want to thank all the providers and other sites that have enrolled to offer vaccine.  We are hearing that a lot of people want to be vaccinated and of course as a government, we're really committed to get enough vaccine out there and have a system where anyone who wants to be vaccinated is able to be over the months ahead.  So I want to just end maybe by thanking all those who are stepping up to be providers and if they're not providing, to carefully refer people to places who will be vaccinating.  Thanks, and we will probably have another one of these on Friday. 




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