November 20, 2009
NOTE: This is a rough, unedited transcript and transcription errors may appear.
Operator: Welcome and thank you all for standing by. Your parties are on a listen only mode until the question and answer session at which time you may press star one to ask the question. This call is being recorded. If you have any objection, you may disconnect at this time. I will now turn the meeting over to Glen Nowak. Thank you.
Glen Nowak: Thank you for calling in and for being present today for our weekly update on H1N1 influenza. Today's briefing will be led by Dr. Anne Schuchat. She's the director of the national center for immunization and respiratory diseases and she'll be giving you an update on where we stand in terms of influenza disease as well as vaccine supply. I'll turn the podium over to Dr. Anne Schuchat. Thank you.
Anne Schuchat: Good afternoon, everyone. We are still seeing a lot of influenza around the country. But we are seeing increasing amounts of vaccine. Today I want to touch on three areas briefly. Flu activity and illness around the country, the vaccine supply and distribution, both for H1N1 and for seasonal influenza, and provide a few tips for holiday travel. And then of course take a lot of time to answer your questions. We are beginning to see some declines in influenza activity, but there is still a lot of influenza everywhere. 43 states are reporting activity, down from 46, but it's still much greater than we would ever see at this time of year. This past week, 21 influenza associated pediatric deaths were reported to us, 15 of those were confirmed to be due to H1N1. Six of them were influenza A, but the additional typing hasn't been done, but pretty likely to also have been from this new strain. That means we're up to 171 H1N1 influenza deaths in children that are laboratory confirmed. Of course as we've been saying, this is just a partial counting. We leave the estimates we provided last week give a better picture of the full toll that the virus has taken in the first six months of the pandemic and in a few weeks we'll be updating those estimates further. Overall, about 2/3 of children who have died from influenza this season have had an underlying conditions like asthma or neurologic problems like cerebral palsy and about 1/3 have not. The level of influenza activity we're seeing right now remains high. Even though we saw a little bit of a decrease this week, it is still higher than the peak activity in many years. We can't predict exactly what's going to happen over the weeks or months ahead. Influenza season typically goes from December to May. Nothing is typical about this year's influenza. We may have weeks and months of a lot of disease ahead of us. Our expectation is that the next several weeks will be busy ones as people increase traveling over the holidays, we may see a mixing of
strains people [Dr. Schuchat has amended her remark] around the country and of course I'll be reminding you some tips for travel later on. The H1N1 vaccine supply continues to increase. We're not where we want to be, but available vaccine is being quickly ordered and shipped and we are in better shape today than we were a couple weeks ago. Specifically today, 54.1 million doses of H1N1 vaccine have become available for the states to order. That's a cumulative total for the season so far. That number is 11 million doses more than we were at a week ago. As of Wednesday, 93% of the vaccine that was available to order had been ordered by the state. So we think states are very rapidly keeping up with the new doses and the doses are getting ordered and shipped out where they are promptly being used by providers and venues around the country. I also want to update the seasonal flu vaccine distribution and just remind folks this is managed by the private sector, but the manufacturers have let us know that as of last Friday, 94.5 million doses of seasonal influenza vaccine had been distributed around the country.
Let me turn to prevention during this holiday season. Flu is throughout the country, but it is not necessarily in every single community or family. And as families gather over the holiday, we might see an increase in influenza or other infectious disease activities, but there's a lot all of us can do to reduce the spread of flu. Because of the increase in travel that we're expecting over the next few weeks, CDC has just launched a new travel health campaign. Our campaign is designed to highlight four basic steps that everybody can take to be healthy this holiday season. The first step is to travel well. That means travel only when you are well. The second is to wash your hands often. That can be with soap and water or alcohol-based hand sanitizer. The third is to cover your cough and sneeze with tissues or with your sleeve. And the fourth is to get vaccinated against flu, particularly if you're in a targeted population. If you're if one of the groups recommended for flu vaccine, either the seasonal flu vaccine or the H1N1, we hope you'll be staying informed about where you could be vaccinated in your community over the weeks ahead. By practicing prevention, we hope everyone can enjoy the holidays and enjoy getting together and it's just a reinforcement of how these simple steps are.
In closing before we get to questions, I just want to say how sorry I am that people have been so frustrated, that people have had to wait in line, that people haven't always found vaccine at the end of the line. I wish that things had been and that they will go smoother. The public health system, the front line local and state health departments and the health care providers caring for patients and offering vaccine, are working really hard this fall and I thank all of them for the hard work they have been carrying out to make sure that vaccine as it does become available is quickly administered to the people in the priority groups. I'm glad to see the vaccine is becoming more available and that it's promptly being used when it is available. And I again just want to thank everyone at that front line for the incredible work they're doing and apologize for the frustration that the public has been experiencing. I hone we'll be able to build on the progress in the weeks ahead and now I want to turn to people's questions. I think we can start with one in the room. Mike?
Mike Stobbe: Thanks. Two questions: Do you know, do you have any data on how many swine flu vaccine doses have been administered so far? And, also, could you tell us a little more about the decline in infections? Is it true across the nation, are there any places in the country where there seems to be heightened activity lately?
Anne Schuchat: Thanks. We are carrying out coverage surveys where we'll be able to estimate how many doses have been administered and we're looking forward to shaving that in the weeks ahead. One thing I can say from our preliminary analysis is that about half of the doses that have been given have been given to children and the vast majority of the doses that have been given have been going to people who self-identify as in one of those priority groups. In terms of the disease activity, that's a great question. We've been trying to remind people that influenza is local. All ten regions of the country are starting to see a decrease in the average influenza-like activity, but there are several states where things are still increasing. States like Maine and Hawaii saw increases this past week over the week earlier. So just to say that the national average looks a little lower this week or that all ten regions now are seeing a decline doesn't mean that in every state or in every community it's a little better this week than the week before. If we look over seasonal -- or if we look over influenza seasons in the past, there can be multiple opens and downs over the season, so what I believe is the case is that we have many weeks ahead of us where disease is going be circulating. And, again, even if things do get better and better over the next several weeks, we look depend at that 19357 experience where after the first of the year, a second wave of mortality occurred. So a variable picture, but a little bit this week than the week before overall. In the room?
Michelle Marrill: Thank you. I'm with hospital employee health. I've heard concerns from a number of different hospitals about the safety devices, the needles that were provided with the vaccine. Specifically leaking at the hub and difficulty engaging the safety device and some of the other devices that require pushing a cap over the needle. I'm wondering if you have gotten any reports of malfunctions or concerns with the needle devices and, also, any information about how did you decide which needle devices would be provided.
Anne Schuchat: I'm going to have to briefly answer and then refer one of our staff to get back with you because I don't have a lot of the details on that. What I can say is I'm aware of some reports we had early on when providers received needles who were not familiar with the auto disable syringe, the safety device. They just thought wait a minute, I didn't get what I needed. So that was just familiarization and needed a little more education. I'm not familiar with reports of the leaking, but I think we could have a staff member follow-up with you. Let's take one from the phone.
Operator: If you'd like to ask a question over the phone, you may press star one. Our first question from Rob Stein, the Washington Post, your line is open.
Rob Stein: Hi, thanks very much for taking my questions. I have two questions really. First one was I know you don't though for sure, but I'm wondering do you think we might have hit the peak with it wave and it willing going down and then the second question was I was wondering if you could tell us it this report out of Norway about this mutation of the virus.
Anne Schuchat: I wish I knew if we had hit the peak. What I can say is that even when a peak has occurred, half of the people who are going to become ill haven't gotten ill yet. And that a peak of influenza-like activity in the outpatient setting doesn't mean the same thing as a peak in hospitalizations and deaths. We often see a lag in the latter two indicators. The key thing that I immediate to say is influenza is in-predictable and it is so early in the year to have this much disease. We don't know if it these declines will persist, what the slope will be, whether we'll have a long decline or it will start to go up again. So I think this is why it's so important that we at that time basic steps of prevention, washing our hands, covering our cough and sneeze, staying home when we're ill and taking advantage of the vaccine. The second question was about Norway and we are aware of reports from more way of an unusual virus that was identified, a mutation in a couple -- in a few virus isolates. I don't want to underplay that because it's so important for to us track influenza viruses carefully, to look at them genetically for changes in virulent or immune properties. What I can say is the mutation that was identified has no implications for how could the match of the vaccine is and it has no implication for treatment with antiviral medicines, but it's important to track and look for changes. So we would look for things like spread of that particular mutation and whether in large numbers it was associated with more virulent disease. So we appreciate Norway reporting what they found. Another question from the room?
Beth Galvin: Hi, thank you for taking our questions. I'm curious about what you usually see during the holidays with people coming together and what you really think -- is washing your hands really the best technique? What do you do if you have sick relatives, a sick cougher sitting next to you on the plane?
Anne Schuchat: I think usually we don't have this much influenza by thanksgiving. So we have seen with a lot of respiratory infections that there's increases in January right after the Christmas holidays, some people say, well, all the kids get together with their grand parents and that's a lot of exchange of warmth and love, but a little exchange of viruses, too. So we don't really know what's going to happen with thanksgiving. But we think it's critical, if you're sick, to stay home. And if your child is sick, to keep them away from others. Washing your hands, covering your cough or sneeze, are really important. If someone on the plane is coughing, you can ask the flight attendant could they move them to a less crowded part of the plane, you can try to keep them away from others. That's not always possible during thanksgiving travel. We did issue our travel tips for traveling well and there's lots of information on them at CDC's website and also at flu.gov. So I think the key messages are enjoy the holidays, enjoy being with family, and if you are sick or your child is stick, try to keep them away from other people. Another from the phone?
Operator: The next question is from Craig Schneider of the Atlanta Journal Constitution, your line is open.
Craig Schneider: Hi, thanks for taking my question. I came in a little late. With you saying that you're expecting an uptick in disease through the holidays because of people watching over one another, so to speak?
Anne Schuchat: A couple key points. We don't know whether disease will increase or not. The influenza-like activity is a little bit hoer that week than last week, but we feel that everyone needs to being vigilant. There's a long flu season ahead with frequent travel, lots of people coming together, we might seat an increase in disease and we want everybody to take steps they can to try to prevent that. We're expecting a lot of vaccination activity this weekend and early next week before the holidays and so for those who are checking flu.gov to see about vaccine near you, keep an eye out because there might be some opportunities to get vaccinated before the holidays. Next question from the phone?
Operator: Betsy McKay, the Wall Street Journal, your live is open.
Betsy McKay: I just wanted to follow-up on the question about the mutation in norway. I wondered if you could talk a little bit more about is it possible that this mutation has produced a more virulent form and what has CDC uncovered through its own work?
Anne Schuchat: this mutation has been seen sporadically here and there around the world. Sometimes it's been seen in patients who had very mild disease and sometimes it's been seen in people who had more severe or fatal disease. And, of course, lots of virus without this mutation has been seen in the fatal as well as the milder forms of H1N1 influenza. There's some theoretical reasons why this particular mutation might lead an influenza virus to live easier in the deep part of the lungs and cause lower respiratory infections, but we've actually seen lower respiratory infections in a severe viral pneumonia without this mutation. So I think it's too soon to say what this will mean long term. It's an important finding and they're looking into it, but I don't think it has the public health implications that we would wonder about. Did you have a second question? Oh, what have we seen so far? I believe it's been seen in the U.S. But associated with mild disease. I believe. I might need to verify that. Do we have another from the room? Okay. We'll go back to the phone.
Operator: Miriam Falco, CNN Medical News, your line is open.
Miriam Falco: Thanks. Two questions. Number one, are all the manufacturers that have been licensed in the U.S. Now supplying vaccine? I know that it took a while to ship.
Anne Schuchat: Four of the five manufacturers that are licensed in the U.S. Have been shipping. All four have been providing vaccines to our central distribute tore and going out to the rest of the country through the sites that the states designate. GSK was the fifth manufacturer to receive a license for the U.S. And based on what eve seen, I don't believe they've started shipping yet to us. I think that was expected much later. Another question from the phone?
Operator: David Templeton, the Pittsburgh Post Gazette, your line is open.
David Templeton: Yes, thank you. I'm wondering when will people who don't have underlying risk factors or are in one of the risk pack tore groups can expect to get the vaccine. Or when vaccine will be available for people that otherwise are healthy.
Anne Schuchat: I can't unfortunately give and you precise date across the country when that will happen. What has been recommended according to our advisory committee for immunization practices is that the states or the health care providers who are administering vaccine really focus on the target populations first and that we all to efforts to promote awareness among the arrest get populations about the need to be vaccinated and where to get it. And once demand in knows target groups has been reached or pretty much satisfied, that it makes sense to move on to the additional population of healthy adults 25 to 64 and then once that group is satisfied, to move on to seniors who just fortunately haven't been hard head by this virus. They recommend that had instead of us having a national today's the day, that there be a threshold at the local or provider level to move on. When your patients that you're seeing who really are in these priority groups have gotten vaccinated, keep going. This real goal of having vaccine in people and not sitting in storage, about it's a challenging sweet spot to find and I think as we go through the weeks ahead, we could see very dramatic changes in demand, even greater increases or decreases. And we could see, of course, hopefully an increase in supply. So it could be relatively soon that in some communities that demand in the earlier groups has been satisfied. But evening the next several weeks, we have a lot of priority groups still to cover on average. Is there another question from the phone?
Operator: Richard Knox, National Public Radio. Your line is open.
Richard Knox: Thanks, Dr. Schuchat. The other day, the WHO released data on the first results looking at adverse effects. I wonder if you could give us some surveillance from the United States.
Anne Schuchat: Thank you. We have a number of surveillance systems that are tracking adverse events and we're hoping to report fully on that. I hope next week actually. What I can state so far is that we haven't seen any signal of unusual occurrences with the H1N1 vaccine or the seasonal flu vaccine for that matter that would prompt us to feel urgent interventions are needed. We're looking carefully. Of course each event that is reported is evaluated by our clinical system and we look for patterns. And then we also have active systems that are tracking severe conditions like Guillain-Barre Syndrome with or without any kind of vaccine exposure. So I think the full details of what's been found, we hope to be sharing next week and I don't actually have details today unfortunately. Is there another question on the phone?
Operator: Maggie Fox from Reuters, your line is open.
Maggie Fox: Thanks, I'm wondering in all the polling that you're doing, have you seen any signal that there's been a shift in attitudes towards vaccinations, anything that can make you feel confident that people will start accepting influenza vaccines better than they have in the past?
Anne Schuchat: from the survey results that I recall seeing a couple days ago, I think the last several weeks have been pretty consistent that people who -- that we have much greater interest in being vaccinated among people in the target population, that parents are more interested in having their children vaccinated than low risk adults, for instances, are in being vaccinated. Among those who are not interested in being vaccinated, they don't think the disease is serious. And some people have concerns about the safety of the vaccine. So what we've tried 0 do with that survey data is made sure people know what we know about the disease and its risk and the threat that it plays for you or your family and about the vaccine and the good safety profile it has so far and the systems we have for tracking it. But we haven't seen dramatic changes in the last few week. We look for those, but it looks pretty stable at this point. But with everything with influenza, I can't predict what it will look like over the next few weeks. Another question from the phone?
Operator: Steve Sternberg, USA Today, your line is open.
Steve Sternberg: Thank you. I'm wondering about the healthy children who have gotten H1N1 and who have died. You said about 1/3 of pediatric deaths are in healthy kids and I'm wondering what your research shows about that population. Are there any common factors, anything having to do with the location in the lungs or the pathogenesis?
Anne Schuchat: the common factor that we found so far is the bacteria co-infection, the used that the children have an influenza virus causing disease and then they get one of these common bacterial infections and it's very severe pneumonia on top. We've seen them on autopsy series that the staph aureus that was causing in school kids a couple years ago and actually continues to. We've also seen the pneumococcus and it's a bacteria that we have a good vaccine for, a vaccine that's good in children and high risk adults. When we see these reports causing fatal disease, it's reminder that they need to think with antibiotics, also, and if we're recommended to southwest pneumococcal vaccine because we're a child under five or have a chronic condition that we get that vaccine. We really underuse that vaccine given how common the pneumococcal infections are particularly following flu. Another question from the phone?
Operator: Bob Roos, CIDRAP News, your line is open.
Bob Roos: We've heard a rumor that there is a cluster of antibiotic resistance in Wales. I just wondered if could you comment on that? And also one other question, there's a recent report in the journal PLOS current about accept different viruses having been identified. I wonder if you could comment.
Anne Schuchat: Thank you. I haven't heard the report of the cluster of resistant cases in whales. That's the kind of thing that we all take seriously. Fortunately so far the Tamiflu resistant influenza viruses have been quite rare with the H1N12009 strain. We've seen a dozen or so at this point, but the cluster issue will be an important thing to track and understand because that would be a sign of transmission. So the whales report I'm not familiar with. The issue about the PLOS reports, I think the finding that -- first I should say I have not read the report, but I think the fact that there are multiple claves of influenza would not be surprising. We know viruses are constantly changing. What we do know is that as our laboratory scientists look at hundreds of thousands of strains, we are not seeing changes that alter the vaccine protection. Still even with these variations that have been designed, the vaccines that have been developed are very good matches. If there are genetic changes, it would still be a good match. Some genetic changes matter for immune response and some don't. And so the good news is even with varieties that are being seen as the genetics of the viruses are tested, the vaccine still works really well. We have time for one more question from the phone. Or the room? The room doesn't look like they want to ask another question, so let go to the phone.
Operator: Charles Davis with WedMD, your line is open.
Charles Davis: Yes, there's been reports that have suggested that older folks are not quite as susceptible to H1N1 and that may be due to cross reactivity. In addition, there's been some reports most recently by a Dr. Sanchez from the armed forces health sciences center that suggests that vaccination with either the flu mist or vaccine provides some protection. The question is if these are actual proven, planning for the future, will the future seasonal flus perhaps contain something that will give us more herd immunity like perhaps a version of the H1N1 as part of the vaccine?
Anne Schuchat: Let me take a couple parts to your question. The elderly have relatively spared the virus. There are some cases, but much fewer than we'd expect. And this is likely to be because of pre-existing immunity likely from exposure to similar strains long ago. The question about the protective effect of the seasonal flu vaccine against H1N1 veins, I should clarify, there have been a few different studies. In Australia, they reported results and did not find any increased risk or any decreased risk of H1N1 disease following exposure to the seasonal flu vaccine. Last week in the MMWR, we reported on information from the U.S. Where we didn't find protected or increased risk of disease. There have been some reports out of Canada about increased risk and then report from Mexico and now the armed forces about a decreased risk. What I can say is that we believe the seasonal flu vaccine is a good idea to protect against seasonal flu strains in general and the H1N1 vaccine is needed to protect against H1N1 disease. But going forward, the world health organization already looked in to the question of vaccines against seasonal disease in the southern hemisphere and each year they pick a strain for H1N1 and a strain for h3n2 and a strain for b. And this year as they looked towards vaccine formulation for the southern hemisphere, next summer, which would be their winter, they recommended that this 2009 H1N1 strain be incorporated in to vaccines that are targeted against their seasonal disease. So it's quite likely that this strain might make its way in it to the northern hemisphere this year if it didn't change a lot. We are usually after a pandemic the next couple year, the strain is still pretty common among seasonal strains. So I think that's it. Thanks, everybody. Happy holidays if you're not back next week. We probably will be back, but I won't promise.