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Oct. 30, 2009 -- Weekly 2009 H1N1 Flu Media Briefing

October 30, 2009

Audio recording (MP3)

ACIP H1N1 Vaccination Recommendations for Priority Groups (PDF)

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

Operator: Welcome and thank you all for standing by.'  At this time I would like to remind parties that your lines are in listen-only mode until the question and answer session.'  At which time you may press star one to ask a question.  Today's call is being recorded.  If you have any objections you may disconnect at this time.  I'll turn the meeting over to Dave Daigle. 

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Dave Daigle: I'm Dave Daigle, CDC media relations.  And today there's another media update with the CDC director on 2009 H1N1. 

Thomas Frieden: Good afternoon, everyone.  What we have today is essentially more virus, more vaccine and more treatment.  The disease continues to be widespread and is currently widespread in 48 states.  We're seeing some states decrease, particularly in the southeast of the U.S...  But we don't know whether that's a decrease before an additional wave.  It's only the end of October and flu season lasts until May.  In the past two months, we've seen more hospitalizations in people under the age of 65 than in most entire flu seasons.  So we know that there's been a lot of disease from influenza, from H1N1, in virtually all of the influenza we're seeing is still H1N1.  Genetically, the virus has not changed.  It's still closely matched with vaccine.  We have not seen mutations that would suggest that it would become more deadly.  And some of our recent survey data helps us understand what people are doing in response to the data.  I'm sorry, in response to the virus.  One of the things that we've been surprised to see is that even among people who have an underlying condition, such as asthma or heart disease or lung disease, only half sought care for influenza-like illness.  Only half went to their provider.  This emphasizes that whether or not vaccine is present and whether or not people recognize that they have an underlying condition, people with underlying conditions, who have fever and cough, should see their provider promptly.  Children are particularly high priority for prevention and for treatment.  This is a younger people's flu.  In a usual flu season, 90% of the deaths are among people over the age of 65.  In H1N1, 90% of the deaths are in people under the age of 65.  Up until now, there have been 114 laboratory confirmed deaths among children.  More than two-thirds of those have been children with underlying conditions.  In terms of the numbers of cases, hospitalizations and deaths, our focus is to prevent cases as effectively as possible.  And to encourage treatment.  Counting cases, particularly the numbers of people who had influenza-like illness, is not something that's likely to be productive or accurate.  We know that there have been many, many millions of cases.  In terms of hospitalizations and deaths, we can provide information and we do on our website, each year, of the number of confirmed laboratory confirm hospitalizations and deaths.  We know that that's an underestimate of the total.  Because there are people who don't get reported or laboratories that don't test.  Or laboratory tests that are falsely negative.  And over the coming weeks, we hope to be able to give you the best available estimate of the number of hospitalizations and deaths to date.  The number that you're familiar with, of 36,000 deaths per year from influenza in a normal flu year is based on estimates.  Based on the best available scientific data of the burden of influenza.  and we will having learned as much as we can from the pattern of H1N1, particularly in the communities where we have very intensive monitoring of hospitals and other sites of care, be able to estimate how many cases that are likely to have been or a range or an at-least number.  H1N1 vaccine supply is increasing steadily.  There's not enough for all providers or people who would want it.  And this understands to be frustrating.  But the gap between supply and demand is closing.  Last week, we had 16.1 million doses available.  As of Friday morning, 5:00 a.m., for shipment.  As of today, we have 26.6 million doses available for shipment.  That's an increase of 10.5 million doses in that seven-day period.  With that vaccination, with that increase in vaccine availability, we're seeing more schools doing vaccine clinics.  We're seeing more health care workers getting vaccinated.  More people at high-risk are being vaccinated.  More providers are getting the vaccine.  But it's not nearly as available as we'd like.  Also, we're seeing really, very strong demand for seasonal flu vaccination.  And I'm sure that all of the media attention to influenza is driving that.  But we are not seeing any spread of seasonal influenza yet.  But there's no reason to think that we won't have a flu season this year.  With other strains of flu.  Only time will tell.  So we do continue to recommend seasonal flu vaccine.  But we recognize that of the 89 million doses that have already been distributed, by the manufacturers, the overwhelming majority has already been given.  Manufacturers report that they'll be providing additional vaccines in November/December.  So additional vaccine should become available.  And the seasonal vaccine program is not run in the same way that the H1N1 vaccine program is run.  In the seasonal vaccine program, it's the manufacturers selling directly to providers.  And providers who order more, may be able to get more.  But there's right now, not enough seasonal flu vaccine for all who would want to receive it.  We continue to do everything that we can to reduce the impact of H1N1 influenza.  One of the issues that's arisen is a shortage or spot shortage in some areas of the liquid form of Tamiflu.  On October 1, we released 300,000 courses from the strategic national stockpile.  We are now releasing an additional 234,000 courses of liquid Tamiflu from the strategic national stockpile.  That is the entire supply from the SNS.  We held back some portion before, because in early October, it wasn't clear whether some parts of the country might need more than others.  And we kept it back for that purpose.  It's now clear that with disease throughout the country, it makes sense to release what we have.  And to get more from manufacturers as soon as they can provide it.  In addition to the liquid Tamiflu, we have worked with many of the national chains, which are willing to compound, to make the syrup from the adult Tamiflu.  something that is safe for a pharmacist to do.  Please don't try this at home.  This is something that should be done by a professional pharmacist.  And this is something that the pharmacy can do by taking adult Tamiflu capsules and carefully measuring it, putting it into a syrup that's palatable for children.  And with this, it should be possible sometimes with more effort than we would have liked, but should be possible for people who want to get Tamiflu, need to get Tamiflu, to get it.  And we're appreciative of the cooperation of the pharmacy chains in that effort.  When we released from the stockpile, it's done on a population basis to all parts of the United States and territories.  We're also working hard to improve vaccination efforts.  And I want to take a moment just to reiterate some of the basic information, nothing new.  But we continue to hear that there's confusion about who should get vaccine and when.  We have left for each state, jurisdiction, to have some flexibility within the priority groups, if they want to subprioritize.  But the overall priority groups remain as shown on this slide.  Five priority groups -- and the slide outlines which of them -- there we go, which of them can be used for, can receive which types of vaccines.  pregnant women, at this point are only recommended to receive the injectable vaccine.  Care-givers of infants under the age of six months can receive either the intranasal spray or the injection.  Unless of course, they have an underlying condition or are pregnant.  Children and young adults age six months to 24 years of age can receive either the intranasal spray or the injection.  Unless of course, they have an underlying condition or are pregnant.  People aged 25 to 64 with an underlying medical condition, should receive the injection.  And health care or emergency medical service workers can receive either the spray or the injection. Of course, again spray only if they don't have an underlying condition and are not pregnant.  These are the five priority groups.  There are some places that have subprioritized within that.  And that's up to jurisdictions, that may depend on local supply and availability.  the availability of large amounts relatively speaking of the intranasal spray, which is most easily used for health care workers, and for school children, is facilitating work in that area.  There is a little bit of an urban legend that health care workers shouldn't get intranasal spray.  It's an attenuated virus that is cold-adapted.  So it can't cause a continuous chain of infection.  It does not present a risk to patients.  In contrast, in unvaccinated health care worker does present a risk to patients.  So we encourage health care workers to get vaccinated.  In closing, I want it reiterate that we have more virus, we have more vaccine and we have more treatment.  We encourage the prompt treatment of people with underlying conditions and we recognize that states have real challenges to balance the increasing supply with the large demand.  And there will always be some mismatch between supply and demand.  But we're all working as hard as we can to get the vaccine out as rapidly as possible.  And as widely as possible, to those five high-priority groups.  And of course, it's always something that everyone of us can do, to stay home if we're sick.  Cover our cough and sneeze and wash our hands.  And for more information, always check flu.gov.  Thanks very much and we'll take questions starting in the room. 

Reporter: Dr. Frieden, the figure that you gave on pediatric deaths, 114, how much of an increase does that signify over the previously-reported figure? 

Thomas Frieden: For laboratory confirmed?  It's an increase of 19.  Laboratory confirmed, pediatric deaths one week to the next. 

Reporter: When was the prior figure reported, last week? 

Thomas Frieden: It's a weekly report.  Mike? 

Mike Stobbe: Mike Stobbe from the AP, thanks, doctor.  of the first with the pediatric deaths, that's the largest or one of the largest single-week jumps.  can you explain what happened?  is it the volume of disease in general?  And then I wanted to ask about the swine flu vaccine doses.  Do you know who is getting them?  Has there been a breakdown?  Is it mostly children? 

Thomas Frieden: There's a certain rhythm of flu spread in a community where we see first an increase on the number of cases generally first in children.  Then in older people.  Then an increase in hospitalizations, as people develops complications.  And then tragically, deaths following that.  And the hospitalizations may follow by about a week.  The number of the peak in cases, peak in hospitalizations can happen about a week later.  And the peak in deaths, two to three weeks after the peak in cases.  So we are expecting to see, sadly, increasing numbers.  And one of the reasons we've emphasized that only half of the people who have underlying conditions have even sought care.  Let alone gotten treatment.  but sought care for their influenza-like illness.  If you have asthma or heart disease or lung disease, if you're pregnant and you get the flu, see your provider right away, it's important.  In terms of who is getting the vaccine, about half has gone to children and half to older people, only about 1% to 2% to people over the age of 65 at most.  That, however, is very preliminary and partial information.  We hope to have more in the coming week about who's been receiving the vaccine.  Our focus has been to get it out and getting reports in on who has been vaccinated has taken more time.  We know that in some states and jurisdictions they've done a terrific job of getting kids vaccinated in school-located clinics and have also welcomed others in the community to get vaccinated in those same clinics.  Clinics during the school day, for example.  Where people can just, school kids can get vaccinated without disrupting their learning, to be brought out of class for one period of time, one part of class at a time.  That's been a very successful model and an important one.  because in future years as we try to increase seasonal flu vaccination, that's the kind of infrastructure and experience that's being established, that is an investment and will help us to address seasonal flu in the years to come.  Betsy? 

Betsy McKay: Just a couple of questions.  About the virus itself, do you think it's still mostly children who are getting this?  We hear so much about schools.  You don't hear a lot about workplaces, adults.  I know there are adult deaths and deaths of pregnant women, so there have to be adult illnesses.  Is it still mostly limited to the younger people?  And the second question is, maybe it's early to ask this, but do you have any information on adverse events from vaccination? 

Thomas Frieden: We're seeing increases first in kids.  But also in young adults and adults up to the age of 50, we've seen pretty substantial increases in many areas.  So it's not just kids who are getting the disease, we're seeing a fair amount in younger adults.  For adverse reactions, it is early.  But we have systems in place to see are there more adverse effects, adverse events than we would anticipate.  As we know, every time there's a vaccine given, there's a risk of something bad happening.  Something bad could happen whether or not the vaccine is given.  And for more information, we'll be coming out shortly, about what are the expected background rates of serious bad things happening, like Gullian-Barre syndrome, sudden death, heart attack, miscarriage.  Those are some of the things we look at.  Just because something happens after vaccination, doesn't mean it happened because of the vaccination.  We've seen a small number of deaths following the vaccination for all of those things that we have investigated.  There's been a clear explanation that it's not vaccine or infection or condition.  So it does not appear that the vaccine was related in any way.  We'll see a small number of people with allergic reactions that are concerning, but not higher than anticipated.  So it's still early.  If there were a problem, to have seen it.  But nothing we've seen so far is concerning.  On the phone? 

Operator: Thank you, at this time if you'd like to ask a question, press star 1 on your touch-tone phone.  Our first question is from Jeffrey white, "Dallas morning news." 

Jeffery Weiss:  I've been watching the per capita delivery of the vaccine as your shipment numbers have come out week to week.  And taking a look at today's most recently-released numbers, there's still a petty broad difference.  8.4 doses per 100 in Alaska and Vermont.  Down to Florida, at 4.1 doses per 100.  And there's a pretty good range.  And I know that the allocations are being done on based on population.  Do you have any explanation for why the shipments don't seem to be matching that? 

Thomas Frieden: We're working very closely with the states.  Some of them are leaving vaccine in their allocation because they want to have it shipped directly to schools.  Where they're doing a school-located clinics.  Others have had some challenges in getting the system up and running.  We've worked very closely with each of the states.  It's quite a challenge.  We've report a global number.  But there are actually multiple different products.  There's not just the intranasal versus the injection.  But for the injection, there are different formulations of it.  And that has to be broken down by 100s or in some states, thousands of providers and sent out to the providers.  so it's not such an easy job to get the vaccine out in the first days of vaccine being available, there was a lot more variability than there is now, in the proportion that's being drawn down.  We're at over 80% of everything that's being indicated rapidly, and we want to increase the number sometimes the number that we provide you the snapshot and so the vaccine reporting is available.  So there's a little bit of a lag that can make it look like it's not being drawn down as rapidly as it is.  In some situations where there's been slower-than-anticipated ordering, we've worked directly with the states to see what we could do to report it.  And whether there are any issues that need to be addressed.  On the phone? 

Operator: Rob Stein, "Washington Post," your line is open. 

Rob Stein: Hi, Dr. Frieden thanks very much for taking the questions.  I was curious about your thoughts for recommendations that came out this morning for the W.H.O.'s stage committee on vaccinations sort of suggesting that kids may only need one shot, not a booster shot as well.  I was curious what you thought about that. 

Thomas Frieden: We've looked at that.  The NIH has done clinical trials and they're anticipating perhaps as early as next week, additional data on that.  The preliminary data did not show the kind of response in younger children that we would have hoped for in order to say -- a single dose would be sufficient.  But only the data will show.  Throughout this entire response, our approach is, look at the data and follow the data.  Follow the best science that's available.  We hope to have that within the next week or two.  And working with NIH, if the data show the difference, we will reconsider our recommendations for the time being.  We're sticking with what the ACIP has recommended. 

Operator: Steven Smith, the "Boston globe," your line is open. 

Steven Smith: Good afternoon Dr. Frieden, thank you for taking the call.  Clearly in regions such as New England and elsewhere in the nation, we have seen sharp rises in reports of influenza-like illness, visits to medical offices.  The ILI data in Massachusetts released today showed visits happening at a rate above the peaks of the past two flu seasons.  I'm hoping you can assess, based on the constellation of surveillance data at your disposal, whether this truly means more people are stricken with flu than previous years, or conversely, to what extent this is actually reflect patients seeking care more aggressively than in previous years.  Which would potentially skew the sense of the rapidity of spread. 

Thomas Frieden: That's a great question.  What we're seeing is quite characteristic in many places.  A steady increase in the proportion of people in emergency department who are there for influenza-like illness.  And an exact mirror image of that, of people who are, who have influenza-like illness and get admitted to the hospital.  That suggests that people are going to emergency department who don't need to be there.  If you're sick with flu and you wouldn't have gone to the hospital emergency department before you ever heard of H1N1, you probably shouldn't go now.  on the other hand, if you have an underlying condition, if you have asthma, heart disease, lung disease, trouble breathing, or you got better and then get worse again.  Or you've gotten very sick with flu, by all means, seek care promptly.  But yes, we do think that a significant proportion of the demand, particularly for emergency department care, is related to the lack of, to the concern and the media attention to influenza at this time.  However, where we have intensive monitoring of about 25 million people in various states in the country were able to seek a hospitalization rate for flu.  That hospitalization rate, which wouldn't, we think really be much affected by people who are coming in to just because they're concerned, that hospitalization rate is higher than an average flu season already.  And we're still early days, nationally, in the spread of H1N1.  So we do think that there is truly, more disease this flu season.  Joanne? 

Joanne Silberner: Thanks, Joanne Silberner from NPR.  I'm a little confused about the Tamiflu issue.  Yesterday I heard something about you could break up the capsule and mix it with chocolate chirp.  And you're saying not to kpaund, what's the difference? 

Thomas Frieden: There are adult capsules and pediatric capsules.  The pediatric capsules can be mixed with syrup or chocolate, something sweet to make the medicine go down.  For the compounding that pharmacists do, taking the adult capsules.  So if the pediatric dose, you can mix the pediatric dose you can mix it with something sweet to give it to the kids.  If the pharmacist, him or herself wants to make you a liquid and give you a liquid from an adult capsule, then only the pharmacist should do that. 

Tom Regan: Dr. Frieden, two questions, please, Tom Regan with channel 2 news.  You mentioned the pediatric deaths earlier.  Do you have any update on adult deaths since last week?  I had one other question, I forgot it.  But if you could respond to that one, first. 

Thomas Frieden:  I forgot the second question you asked, anyway.  Adult deaths, we have to estimate.  We can't know exactly how many adult deaths there are for many reasons.  Some people die outside the hospital.  Some people die without being diagnosed in the hospital.  Some people who are tested have the test be falsely negative, or inconclusive, or aren't tested at all in the hospital.  Or aren't recognized as having flu.  That's why the most accurate, it's a little counter intuitive.  The most accurate accounting of deaths is an estimate, rather than an actual enumeration.  And within the next couple of weeks, we hope to give you the number on more of a real-time basis.  We've presented at a scientific meeting yesterday, some information about what the ranges may have been through the summer.  In terms of the number of deaths and we want to move that forward, that we can get real-time within a couple of weeks.  On the phone? 

Operator: Marilyn Serafini, "National Journal," your line is open. 

Marilyn Serafini: Thanks for taking my question.  I wanted to ask you, you said that in some areas, that the trend is going down a little bit.  That perhaps, it sounds like what she's saying we may have reached the peak at least of this particular wave?  Is that what you're saying? 

Thomas Frieden: No, nationally we're still seeing influenza-like illness increase.  So although there are some areas that have shown decreases, including here in Georgia, overall there are many that are still seeing increases.  And as a country overall, the overall number is still increasing.  Mike? 

Mike Stobbe: Mike from the AP.  Doctor, could you repeat how many courses of pediatric Tamiflu have been released?  What day were they released.  And also I wanted to ask you, you talked to the president recently.  Is he conveyed to you, his concerns about how the response is going or the has he asked for any changes or new initiatives? 

Thomas Frieden: We released on October 1, 300,000 courses of pediatric liquid Tamiflu.  And we are releasing in the coming days, the remainder of the strategic national stockpile which is 234,000 additional doses.  We're talking with the states and localities today, they're available for calling.  It's possible that not all states will call them down.  But that's the number that can be released, that's the number that exists in the stockpile.  The president is deeply concerned about strain strain.  He's directly involved.  He's briefed regularly.  He asks a series of important and relative questions and wants to make sure that we're doing everything that we absolutely can to respond as effectively as we can, and learn the lessons for the future, so we can get our technology in better shape through a real focus on influenza and other emerging diseases in the future.  On the phone? 

Operator: Robert Bazell, NBC news, your line is open. 

Robert Bazell: Thank you.  Do you recommend, Dr. Frieden, any special precautions for Halloween?  We've had enormous amounts of email and questions from over the telephone about people wondering, should they send their children out?  Should they take any care with the candy they select?  Should they be aware of what homes they're going into, and gatherings and I just -- you want sick kids it stay home.  But is there any advice beyond that? 

Thomas Frieden: Have fun, stay safe and yes, if your kid is sick, please keep them home.  From all activity, school, for Halloween.  We have time for two more questions.  On the phone? 

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

Miriam Falco: I've got two questions.  The first question is, do you have any data on how the school vaccinations clinics are going?  How many children are taking advantage of these flu vaccine locations.  and also, can you clarify, especially in the confusion from the W.H.O. briefing this morning, how many vaccines, a 6-month-old, for instance, would need, of H1N1.  And also how much of the seasonal flu. 

Thomas Frieden: We're just beginning to get information in on school-located vaccine clinics.  We have distributed a best-practice document describing some of the experience from Maine.  Which has been very effective at getting large-scale involvement in getting vaccinations done in schools with the minimum of disruption.  We are encouraged, if we see half or more of the kids get vaccinated in the schools, we don't expect to see anything like 80% or 90% of kids getting vaccinated.  Though if it happened, that would be great.  But even to get significant proportion vaccinated is a real accomplishment.  It's hard to get the consent forms back.  It's hard to arrange the logistics; kids are out sick sometimes, so they can't be vaccinated if they're not there.  In terms of number of doses under age ten.  Two doses of H1N1.  And for seasonal flu, it's a little more complicated.  The first year you have seasonal flu vaccine, two doses.  In subsequent years, if you got your two doses, then one dose.  Last question on the phone?  We'll take one more from the phone. 

Operator: Donald McNeal, "New York Times," your line is open. 

Donald McNeil: You've given away the last of the pediatric Tamiflu pediatric stockpile now.  What are the chances of replenishing that stockpile?  And are you willing to start importing generic Tamiflu, if necessary if there's a shortage from the brand manufacturer? 

Thomas Frieden: We have ordered additional Tamiflu from the manufacturer.  And we are looking forward to delivery early next year, if that stays on schedule.  In any case, because of the availability to make liquid Tamiflu from adult capsules, we think that the pharmacies will be able to provide that as a service, going forward.  We didn't see a reason to keep it in reserve when we have so much illness in children out now.  And since it is widespread throughout the country, there was a reason to I think, provide it everywhere now.  In terms of generic, we're certainly open to all possible considerations.  Everything would have to be FDA-approved.  We would not want to have non FDA-approved medications here and we'd have to look at what the legal and other issues are, if there is a lack of availability.  Tom, last question. 

Tom Regan: Yeah, Tom Regan, WSB TV.  We've heard stories of schools closing as a result of mass illnesses related to flu.  Are you aware or is the CDC aware of any public facilities building throughout the country that have taken that kind of action as a result of mass illness or sickness? 

Thomas Frieden: We haven't heard of other facilities closing.  We have seen some schools closures, generally because they've had such a high degree of absenteeism.  We reiterate for schools you really can stay open, even with high degrees of absenteeism, if you have the administrative wherewithal to continue operating and if you don't have kids, a large proportion of kids who have serious health problems like muscular dystrophy or schools for kids that are medically quite frail.  We've heard about schools that have had to close for very understandable reasons if they don't have the staff to open or operative effectually.  But the key, I think with school closures and general community approach is we want to minimize the disruption.  We want to protect the public's health while minimizing disruption.  So people can go about their lives, go about their work, and go about their schools without undue difficulty.  Thank you all very much. 



  
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