January 7, 2010
1957 Pandemic mortality graph
Image from Henderson ET AL,
Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science Volume 7, Number 3, 2009
In this figure, the upper solid line represents the number of pneumonia and influenza deaths reported from 108 cities weekly from September 1957 to April 1958; the lower solid line is the number of such deaths that would be expected based on previous years' experience with pneumonia and influenza deaths. The dashed line ("epidemic threshold") is almost never exceeded except during influenza epidemics.
Operator: Welcome and thank you all for standing by. At this time, I would like to remind parties that your lines are in a listen only mode until the question and answer session at which time you may press star 1 to ask a question. Today's call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the meeting over to Glen Nowak. Thank you, sir, you may begin.
Glen Nowak: Thank you and thank you for coming here today or calling in for this update on H1N1 influenza and H1N1 influenza vaccine. Today's briefing will be conducted by Dr. Anne Schuchat. Dr. Schuchat is the Director of CDC's National Center for Immunizations and Respiratory Diseases. I will now turn the podium over to Dr. Schuchat.
Anne Schuchat: Good afternoon, everyone, and happy New Year. It's great to see some of you back and have some of you on the phone. The H1N1 virus is still circulating and it is still causing disease, hospitalizations and deaths. Many people are still susceptible to this virus. And would benefit from vaccination. We want to avoid complacency. Today I'm happy to say that we have a very good supply of the H1N1 vaccine all around the country. Many people have gotten the vaccine already. Many more people want to get the vaccine and we want more people to get the vaccine. As of today, 136 million doses of H1N1 vaccine are available for ordering by the states. There are ample supplies of H1N1 vaccine in most of the country. The vaccine should be easily available pretty much anywhere you live, whether it's at your doctor's office, through the health department, through the clinics that are being arranged for the community, school clinics that are being held at pharmacies and retail centers. We believe there are vaccines all around the country right now. Most states have opened up vaccination to anyone who wants it. More places and more providers are offering vaccines, making it even easier for those of you who want to be vaccinated to protect yourself and your families to be able to do that.
I want to briefly mention flu activity. We don't have a new report today. Tomorrow, the FluView information will be coming out. But since we didn't hold one of these last week, I want to remind you where we are. The H1N1 virus is still circulating. We have an uncertain future. We want and need to avoid complacency. As of this past week, four states continue to report widespread activity. Those states are Delaware, Maine, New Jersey and Virginia. We're seeing drops in laboratory confirmed hospitalizations and deaths. But we actually did see activity increasing in a few other indicators. We still have more activity than we usually have this time of year, though it's certainly much below where it was several weeks ago. All the virus that we're seeing right now is the H1N1 virus. We haven't yet seen the emergence of seasonal flu strains in any numbers at all. We saw a slight uptick in the last week's reporting in the influenza-like illness visits to the doctors or emergency departments. That can sometimes happen right around Christmas, so we don't know if that will persist. We also saw an uptick in pneumonia or influenza deaths in this past week. And that isn't something that we necessarily see around the Christmas holiday. So that is something that we're really keeping our eye on. People are still becoming ill, though the numbers are down from the past, they are still happening and it's an important opportunity for us to do something about that.
I'm going to talk about a graph that those who are in the room will be able to see up here and those of you on the phone or looking at this online. If you go to CDC's website after the press conference, the media part of the website will show this graph. This was the mortality graph in 1957. This is really a reminder of why we are saying that we need to remain vigilant. This is why my colleagues and I in public health are encouraging people to be vaccinated, especially those who are at risk of complications. None of us can predict what's going to happen. But if you look at this graph, the bottom part of that curve, you know, the -- there's the camel hump and then it comes down to that valley. Well, that's where we are right now in that valley. We don't know what's going to happen over the next several weeks or months. But in 1957, this essentially gave the all clear whistle in that December/January time period. They had vaccine, but they didn't encourage its use and yet they did go on to see that increase in mortality. Experts disagree about the probability of that additional amount of illness and particularly severe illness occurring. But the best thing for us to do is not focus on the probability and really focus on the idea that vaccine is the best way for us to reduce the chances that we will have ongoing disease, hospitalizations and deaths. As long as this virus is circulating, it has the potential to cause illness. This next week, or beginning this weekend, we're going to kick off the National Influenza Vaccination Week. This is a converted effort that the CDC, Health and Human Services and all of our partners to encourage vaccination. It includes a focus on people at high risk for complications, adults with emphysema, pregnant women, seniors, children, really a focus on encouraging vaccination for anyone who hasn't yet been vaccinated and wants to be. Vaccination is especially helpful for adults with those chronic conditions. They have a higher risk of being hospitalized. And we know right now that they're less likely to have been vaccinated than our children. Vaccine is still important for pregnant women and postpartum women. They've had terrible complications from this flu virus. And although many have been vaccinated, we know others haven't. And we do encourage vaccination of pregnant and postpartum women. We think it's the time now for seniors who have wanted to be vaccinated but have stepped aside so younger, higher risk people could be vaccinated. This is your time, too, to come and get the vaccine. It should be available in much more places near you. There's lots of information at flu.gov about the National Influenza Vaccination Week and where to find vaccination near you. Going forward, the H1N1 virus is still circulating in the U.S. and we expect it to continue to circulate for some time. We need to stay vigilant. One piece of that vigilance is good surveillance. As such, we are urging doctors to continue to test patients with severe respiratory illness. People who are hospitalized with suspected flu really need to be tested. We'd like to know whether they definitely have flu and which type. So this is a call out for docs to keep testing your patients with severe flu-like illness. We need to continue our efforts to get vaccinations. More people are susceptible and need to be protected to reduce their risk of getting this virus. Having as many people vaccinated as possible is our best course of action, even if we can't read the tea leaves of the future. The illness is down. There's plenty of vaccine. It's a key window of opportunity. We don't want to repeat the story from 1957. I hope that -- That is the update for today and let's turn to the questions. We can start with a question from the room. Mike. Happy New Year.
Mike Stobbe: Happy New Year, doctor. Thanks for doing this. I want to follow up on something you said about an indicator being of flu activity, the pneumonia and influenza deaths. The last FluView I looked it, it seemed like it was going down. Do you mind offering some numbers?
Anne Schuchat: The week before it was down and then it went up again. So in the FluView that came out Friday. Oh, the actual numbers, I don't have them. We can get you the percentages. Its 7 point something, but I'm not sure. Essentially what we track is the -- we look at 122 cities that track pneumonia and influenza deaths among all deaths. They look at death certificates regularly and look at what proportion of those death certificates are because of -- are deaths caused by influenza or pneumonia conditions. And we track the percentage of that. There's an expected number and there's an amount above the epidemic threshold. For much of this fall continuing to now, we have been over the epidemic threshold. So that's what I was speaking about. But the percents we'll give you afterwards when we look them up. Let's go to a question from the phone.
Operator: If you have a question over the phone, you may press star 1 on your touch tone phone and record your name. Our first question is from Daniel DeNoon, WebMD. Your line is open.
Daniel DeNoon: Thanks for taking my question. And Happy New Year, Dr. Schuchat. Two questions, they're kind of related. One is would you see a little more about the uptick we saw this week on that ILI. It did look like things were trending down very precipitously and suddenly in many areas of the country sort of jagged back up and I wonder if you could comment further on that. Secondly, do you have a number on how many people you estimate have received the H1N1 vaccine?
Anne Schuchat: Thanks for both of those questions and Happy New Year to you, as well. Influenza-like illness is measured through visits to doctors and visits to emergency departments. And we track the percentage of those visits to either the doctor or the emergency room that are caused by influenza-like illness with a case definition that involves temperature and respiratory symptoms. What we saw was things were trending downward and went down as low as 2.7% of visits. And then this past week they went up to 3.2% of visits. A little bit of an uptick and again, above that expected threshold. Now, that could be because flu is getting worse, but it could also be because people that people aren't making doctor's visits for other things. It was the holiday season during the period when that number came in and that may have been because the routine, preventive and nonemergency visits weren't happening. So that is why we're not really sure that that means a whole lot yet. You also asked about how many people do we think have been vaccinated. Our best guess right now is at least 60 million people have been vaccinated. We are getting more information and we're hoping in the next near future to be able to update you in more detail about the coverage and about the progress in vaccination. We know a large proportion of the vaccine given out has gone to children and that's one of the reasons we're focusing on the message for adults who really were waiting for their kids or kids in the neighborhood to get vaccinated. It's the time now for adults and seniors to be vaccinated. Do we have another question from the phone?
Operator: Heidi Splete, Internal Medicine News, your line is open.
Heidi Splete: Hi, Dr. Schuchat, thank you for taking my question. I was wondering, since this started last spring, usually flu season goes through the spring. Are you at all thinking in terms of an end to this flu season or are you thinking more in terms of this is just going to be sort of a chronic flu season? And are there any thoughts about that and how doctors should think about this flu season?
Anne Schuchat: We need to stay vigilant. The community and, doctors are used to the idea that flu season can last through April into the beginning of May. This past year, we had that surprise of a new flu season starting right on top of the -- when the last one was ending with the emergence of a new virus. We think 2 next few months will be very important ones to understand whether seasonal influence strains start to circulate and cause disease and to understand how much more of this H1N1 virus circulation occurs. So I can't -- I wish I could tell you exactly when this particular strain will stop circulating, but we don't know that. Next question from the phone.
Operator: The next is from Helen Branswell, the Canadian Press. Your line is open.
Helen Branswell: Hi. Thanks very much for taking my question. I'm at a disadvantage because I can't see the graph that you're pointing to or the slide that you have there, but I'm wondering, can you refresh my memory, in '57, that second dip that you're talking about, was that the second wave? And if so, is that situation actually analogous to the one that we're in now? Because most of North America has already been through two waves.
Anne Schuchat: Thanks, Helen. We'll make sure you get a look at the graphic. It's a graph looking at mortality and it's actually different than the one that looks at influenza like illness. In 1957, there were summer outbreaks of disease particularly in one Boy Scout jamboree and then there was a big fall wave of disease and there was an additional mortality wave in the spring or winter/spring in 1958 that was seen. No pandemic is identical to any other pandemic. So I think we try to learn from the past, but we have to be careful about being confident or overconfident about what to expect. So I do not know that the 1957 story is what we're looking at today. But I do know we have a lot of vaccine and we have a chance to not have to repeat history if that is the particular history that this strain has in store for us. Next question from the phone.
Operator: Again, if you have a question, press star 1 and record your name. Next, Hiran Ratnayake from Delaware News Journal. Your line is open.
Hiran Ratnayake: Hello. Thanks for taking my question. I have a question, it has to do with the flu activity levels, as you've mentioned earlier, Delaware is one of four states that's considered widespread. And I want to know if public health officials from each state are required by the CDC to take their baseline flu activity level in their region into consideration when they decide to classify their level each week as either widespread, sporadic, local or regional.
Anne Schuchat: I will answer as best I can. We may need someone closer to the surveillance to give you more details. The state level leaders have some flexibility in how they interpret the data for their state in order to classify disease as widespread, regional, sporadic or local, or local or sporadic, I guess, or no disease. That said, each of the states tends to use a similar system over time. So we have looked at the state public health official classifications to see how well they correlate with what we see from other surveillance systems in terms of influenza like illness activity against their baseline or the 122 cities or other systems that we have that can be linked to states and we see good correlation. So while we give flexibility to the state health authorities to give the best information they have available, we believe they're doing a pretty good job of designating the category for the state. Let's go a question in the room. Beth, Happy New Year to you.
Beth Galvin: Happy New Year, doctor. Do you have any new numbers, maybe an estimate of how many Americans have been sickened by this virus? And also, are you concerned that Americans are going to think that the threat is over because we're not seeing so much right now and so it's not necessary to get vaccinated?
Anne Schuchat: We're hoping by next week we'll be able to update the numbers that have gotten ill, who have been hospitalized and who have died to add on to the estimates that we provided about a month or so ago. So we're working hard to get that estimate updated. I am concerned that people may be complacent, that people may think this is all over. I would hate for people to make decisions thinking there is no risk and then make get sick or severely ill. We have the chance for people to protect themselves and reduce the risk of serious complications. So I think complacency is probably our top enemy right now. Is there another question from the phone?
Operator: Bob Roos, CIDRAP news, your line is open.
Bob Roos: Thank you. Dr. Schuchat, I wonder if you have any idea of the -- or idea of the demand for vaccine at this point and is there concern that there will be vaccine left over, some vaccine doses that are available will expire before they can be used? I understand some of those have a shelf life of three months.
Anne Schuchat: We've been tracking demand both quantitatively and qualitatively. We continue to have demand, but we know people are changing their opinions week by week. There's been a pretty stable amount of demand among people who are definitely sure they want to be vaccinated. That's been a pretty stable pattern. But among people who think they probably want to get the vaccine, that's slipping down. And I think it gets to the last question about complacency. Am I out of the woods, or not? So we are seeing a drop in those that are certain they want to get the vaccine. Still, there are a lot of people who want to get the vaccine who haven't and there are a lot of vaccines. So there's plenty available for those who want to be vaccinated and there's a chance for everyone to talk to their loved ones about the chance to be protected. The question about expiration dates and throwing out vaccines, we're at a point where we're really focused on getting people vaccinated and making vaccine available. We believe right now we have ample supply that will be vaccine that is good through the next several months that will be active and effective in people. The vaccine that we have right now is a perfect match with the virus strains that are circulating. More than 60 million people have gotten this vaccine and we think it has a great safety experience. So everything we know says we have lots of vaccine now that's available for people to protect themselves and a lot more people can take advantage of that. We have time for two more questions. Let's go to the phone.
Operator: Tom Randall, Bloomberg News. Your line is open.
Tom Randall: Hi, Dr. Schuchat. I was wondering if you could talk more about the uptick in pneumonia and mortality. Specifically, I'm curious if historically there's been any correlation between weather and pneumonia and mortality. I know we've seen some unusually cold temperatures across a very wide swap of the U.S. in recent weeks.
Anne Schuchat: Yeah. There's a tremendous seasonality to pneumonia and influenza mortality and pneumonia in general as well as flu in general. The seasonality patterns have been ones that scientists have been fascinated by. Lots of speculation about humidity and crowding and the life cycle, maybe that short daylight has some effect. We don't know. We do know that sometimes after the holidays, we see an increase in respiratory illness including pneumonia and influenza, possibly related to everybody who got together over the holidays and possibly completely unrelated. So we don't know whether this incredible weather that some of the country is experiencing will lead to changes in the influenza transmission. But we know there's a lot of vaccine and a chance for us to interfere with those kinds of trends by reducing the risk that people will get sick. So let's go to the last question from the phone.
Operator: Joanne Allen from Reuters, your line is open.
Joanne Allen: In light of a decision by Germany and other countries in Europe sort of giving back supplies or canceling orders, wondering if the U.S. has any plans to do that or if there's been any discussion given that we do have a plentiful supply. Is it an oversupply?
Anne Schuchat: We are actively encouraging vaccination (Editor's Note: This is a correction) right now. As you've seen in the past few months, demand has been a challenging thing to predict and we've had supply and demand mismatches at various points in this virus's trajectory. Right now, we're at a point where we have ample supply and we're encouraging people to be vaccinated. So we haven't made decisions here in the U.S. like some of the ones people have mentioned in Europe about giving back vaccines, where we are right now focused is on vaccination and making opportunities available for people to be vaccinated. Thanks everybody for participating and we'll see you soon. Thank you.