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Feb. 5, 2010 -- Weekly 2009 H1N1 Flu Media Briefing

February 5, 2010

Audio recording (MP3)

Operator: At this time, I would like to remind parties that your lines are in listen-only mode until 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 will now turn the call over to Glen Nowak. Thank you, sir. You may begin.

Glen Nowak: Thank you and thank you all for dialing in this afternoon for this update on H1N1 vaccination and disease activity. Today's briefing will be led by Dr. Anne Schuchat, the Director of the National Center for Immunization and Respiratory Diseases. And she will be providing an update on where we stand in terms of flu activity, as well as the H1N1 vaccination program. So I will turn the phone over to Dr. Schuchat.

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Anne Schuchat: Good afternoon, everybody. It's a pleasure to be able to update you today. The key points I'm going to talk about today are where we are with disease, and the program. This enormous program we've had together, the vaccination effort and some survey results. My key point is that H1N1 vaccination remains a good idea for this very preventable and sometimes serious disease. H1N1 flu activity seems to have leveled off, but the virus does continue to circulate, causing illness, hospitalizations and deaths.

Influenza-like activity is currently less than the national baseline level. And it's been below the national baseline for the past three consecutive weeks. That's fairly similar to what we would normally see at this time of year, with seasonal flu. Pneumonia and influenza deaths as a proportion of total deaths are actually above what we call the epidemic threshold level, and they have been over that epidemic threshold level for three consecutive weeks. Nearly all the flu viruses that we're seeing right now are the H1N1 pandemic strain. We're not seeing seasonal flu strains yet in any substantial numbers. This past week's virology results, there were only two seasonal strains -- influenza B, versus more than 100 influenzas As, mostly which were the H1N1.
We are remaining vigilant here and do not think people should become complacent. As I said, individual cases of the H1N1 influenza continue to occur, and people are being hospitalized, and they're dying. Vaccination is such an easy step to take and it's the best protection against this disease that can be serious. As opposed to last fall, today there is plenty of vaccine available. About 124 million doses of the H1N1 flu vaccine have been shipped to places around the country. Millions more are available, and there's extensive opportunities for people to be vaccinated, with vaccines in doctors' offices, health departments, offered in many school clinics and pharmacies throughout the country. It's really easy to be vaccinated now, and we hope people will take advantage of that. As I said, vaccination now is still beneficial, because this virus is still around. And none of us can say exactly what we'll see in the weeks and months ahead.

We have information to update you on today from our national H1N1 flu survey, which is being carried out regularly to understand vaccination use. The results I'm going to share are from interviews that were conducted between January 24th and the 30th. The survey involved 4,110 people. That survey lets us estimate that about 70 million people have been vaccinated against the H1N1 virus. That translates to about 23.4% of Americans having been vaccinated so far. We think that at least 76 million doses of the H1N1 vaccine have been given, because, of course, some people are getting two doses. We recommend two doses for all children under 10, and what we've seen is that among children in that age group who have already received one dose of vaccine, 37% have gotten their second dose. Overall, the coverage is the highest in children, with 37% of children having been vaccinated. That's based on children up to the age of 18.

We're continuing to do extensive monitoring of safety. As you know, we've reported detailed safety results on the first 61 million doses that have been distributed. Or administered. And the vaccine had a very good safety record at that point. The continuing safety monitoring continues to show excellent results. We think this is a very safe vaccine.

I want to provide a little bit of information about the vaccination program, the H1N1 vaccination program involved an incredible partnership between the public health and medical communities, between health, education, and the private sector. The state and local health departments tripled the number of providers that they work with in administering vaccines. We have a public health system, a Vaccines for Children program, where state health departments work with private providers to administer vaccines to children. That involves about 40,000 or 45,000 providers. But the state and local programs have enrolled more than 120,000 providers in the H1N1 program. With each of those providers needing to sign an individual agreement stating they would respect the rules of the program. So this is a tremendous effort that the public health and medical community committed to the past few months. I really want to thank them for their great work. There have been more than 70,000 distinct locations that have received vaccine. Some of those locations further distribute the vaccine to additional places. Our central distributor has shipped vaccines in amounts ranging from 100 to many, many thousands of doses, and they've shipped out more than 300,000 individual shipments. So this has been an extraordinary effort carried out on top of the usual childhood program, and really separate from the regional flu vaccine program.

The vaccines have been administered in a number of sites. And what we know right now is that one of three doses that children received was administered in a school. So children might be vaccinated in doctors' offices or health departments, or at other clinics. But we know about a third of the children received their doses in schools, which is really an amazing success. Something we hope to build on in the future.

I want to briefly mention a survey that was carried out by Harvard to keep tabs on where we are with attitudes and behaviors around the country. I think they've issued a press release and I just want to make a couple of comments about their survey results. Their survey was also carried out recently between January 20th and the 24th, and I think they found very encouraging results that also do highlight and reaffirm some challenges that we have. They found that 21% of adult Americans had received the H1N1 vaccination, but another 16% indicated that they were planning to do so this month. So people weren't finished with their intents to be vaccinated. Of the people who had tried to get the vaccine earlier, but weren't able to, of those who were looking back in the fall when it was in limited supply, 71% said that they did intend to look again. And of course, now, the vaccine should be readily available. 40% of parents have reported that they'd ensured that their children received the H1N1 vaccine and another 13% indicated that they were planning to get their child vaccinated. So all in all, the Harvard survey results about immunization behavior and attitude were quite encouraging, especially when one looks back at the idea that we had so much demand for vaccine before we had a lot of vaccine in October. The behaviors and intents are still encouraging in the proportion that actually have been vaccinated.

They also did some evaluation of awareness. And I was really pleased to see that 76% of the surveyed people were aware of the public health messages and materials related to the H1N1 vaccination. It was very important to us in terms of the program that people be able to be informed, and take advantage of vaccination if they choose to. Fortunately most people did see one or more messages, whether through TV, radio, newspaper, or other venues. And I think it was somewhat heartening to see that about 3 in 5 Americans rated the public health response to the H1N1 as excellent or good.

Going forward, there are some challenges that they were able to highlight in their poll, and that I think our survey also showed. Many children still need a second dose. While we think that 37% of kids who have gotten one dose got a second dose, that means the majority haven't of those young children. So I urge parents to take your children back for that second dose. Maybe it will be at the school clinic, maybe through the doctor's office or some pharmacies. But please do that. It would just be tragic for you to have gone so far to do the right thing and have your child get sick because they weren't completely protected. Many people believe the outbreak is over, and I think it's too soon for us to have that type of complacency. None of us know whether we're going to have bursts of disease or clusters, or just ongoing transmission as we've seen in the past few weeks. But the virus does continue to spread. And those who haven't been vaccinated are still vulnerable to its harm.

About 15% of Americans in that Harvard poll have safety concerns about the vaccine. I take that seriously. I think it's very, very reassuring that extensive safety monitoring, really unprecedented amounts of safety monitoring of the vaccine is being used here in the U.S., have been extremely reassuring. Very good results. No major safety concerns at all. And so if safety was the reason you were waiting, I think you can be reassured on that front. The future is still hard to predict, but we know the virus is still around. The vaccine is very safety and effective. And the best way to protect yourself or your loved one is to take advantage of vaccine. I really want to close before the questions, thanking the tens of thousands of public health and medical providers, pharmacists, communicators who have worked incredibly hard and well together over the months past, and continue to work to the to protect the American public. So let's go to the questions, operator.

Operator: If you'd like to ask a question, press star 1 and record your name. The first one is from Maggie Fox from Reuters. Your line is open.

Maggie Fox: Hi, Dr. Schuchat. I know that H1N1 is still circulating, but there were some other viruses that some sentinel sites were finding. There seemed to be an unprecedented amount of other stuff circulating as well. I was wondering if you know anything about that that you could tell us.

Anne Schuchat: There are a variety of infectious agents that can cause respiratory illness. Influenza is a big one. But there are other viruses and there are other bacteria. We've been looking at the changes in disease activity. In particular, the pneumonia and influenza deaths that I mentioned that are over the epidemic threshold, trying to understand whether those deaths we're hearing about are caused by influenza or they're caused by other infectious agents. We are seeing in some parts of the country other viruses like rhinovirus and respiratory syncytial virus sometimes called RSV. That is sometimes accounting for increases in respiratory illness in young children or in elderly people. The public health workers around the country are looking into these matters, tracking the viruses and bacteria that can cause respiratory infections and trying to help us interpret the results we're seeing from the different syndromic systems. But our influenza virus monitoring right now shows virtually all of the viruses that are circulating, this past week, all but two have been the H1N1 virus, not the seasonal strain. So, let's go to the next question.

Operator: The next is from Mike Stobbe, Associated Press. Your line is open.

Mike Stobbe: Hi, doctor, thanks for taking the question. Two, actually. You said that it's possible the virus could continue to spread, but I was curious about, what do you think the likelihood is of a third wave, a full-blown wave considering how many people have been vaccinated, how many people have already been sick, that the virus is not mutating? And then the second question had to do with the pneumonia and influenza deaths. I just wanted to clarify your last response. Are you saying you think those are still mostly due to swine flu?

Anne Schuchat: Thanks, Mike, for those two good questions. I think the most likely problem right now is ongoing transmission of H1N1 virus, which week after week continues to circulate, continues to lead to hospitalizations and deaths and is very preventable right now. I think that is our most likely scenario. It's just impossible for me to say whether we'll have a very large peak in disease, but we don't seem to be seeing the disappearance of this virus. The past several weeks, there's really been steady transmission, rather than a disappearance. And we haven't seen the emergence of the seasonal strain. So I kind of think this virus is going to be finding susceptible people, particularly adults with chronic conditions, the elderly who are much less protected right now because of lower vaccination rates. And because there's been less disease in their communities. We know that school children and younger people have -- are at higher rates of immunization, and probably higher rates of natural protection because there was so much disease already in that group. So my sense is that, we are not at all out of the woods, because the virus continues to circulate, but the chances of a very large additional wave are very hard to predict. And maybe less likely than this ongoing transmission, which really can add up over time.

Your second question was about what I think the increase or excess of pneumonia and influenza mortality means. And I apologize if I was unclear. If I was unclear, it's probably because I don't know what the increase in pneumonia and influenza mortality means. It could be influenza, and if it is influenza, it is most likely the H1N1 virus. It may be other infectious agents like the pneumococcus and staphylococcus and viruses like rhinoviruses and RSV, or really a collection of all those things. Unfortunately when most people with pneumonia die, they haven't gotten all of the tests involved to confirm exactly what caused their death. Unfortunately, many of our diagnostic tests are not good enough to prove what the cause was. So we know that the excess deaths with that seasonal curve are usually attributable to influenza. But we're looking carefully right now, because we have the pneumonia and influenza deaths at that above-epidemic threshold level, but our other indicators are below the thresholds for baseline.

Glen Nowak: Next question, operator?

Operator: The next is from Stephen Smith, Boston globe. Your line is open.

Stephen Smith: Good afternoon. Thanks for having the call. I was going to ask, too, about this seeming disparity with influenza levels being below baseline, and influenza and pneumonia, hospitalizations and deaths above baseline. That leads me to ask this. Is there any indication that there has been a change in the virulence of the H1N1 virus? And I'm just wondering what the latest virology testing is showing in terms of genetic composition?

Anne Schuchat: Thanks. There's no indication of a change in the virulence of the virus. We continue to test isolates, as do our collaborators around the world and the genetics really look the same. The good news is that the antigenic characterization of the virus, what is done to understand the vaccine match, looks really, really good. The strains that are circulating right now are excellent matches with the vaccine strain of virus. The other thing I want to say, you know, we're looking at the different indicators, the influenza-like activity is below the baseline, but the pneumonia and influenza deaths are above. We do continue to see pediatric deaths. We had another nine influenza-associated pediatric deaths reported this past week. We were down below that in earlier weeks, and we were sorry to see that number go up. Some of them are recent, and some of them are older fatalities that are just now being reported. As we said all along, the reported episodes are probably the -- are not the full story. We think more than 1,000 children have died from the H1N1 virus based on the best evaluations we can do. So I do think that it can be puzzling when the systems show different things. But I think we continue to look in detail to understand these patterns. And right now, we aren't seeing signs of a major increase in this H1N1, but we are seeing persistent transmission, including hospitalizations and deaths. And as I said, vaccination is such an easy step to take to reduce a chance that will happen to you or someone you love. Next question?

Operator: The next is from Betsy McKay, "Wall Street Journal." Your line is open.

Betsy McKay: Thanks, Dr. Schuchat. I had two questions. One question is about the pneumonia deaths. I just wondered what age group most of these deaths are in? And if that's giving you any clues about the causes? And my second question is about H1N1 vaccine. I just wondered if you could tell us at this point, given vaccination levels, how much vaccine the government does plan to take delivery of? Are you still planning -- is HHS still going ahead and taking delivery of the total of 195 million, or 250 million doses? Or are you scaling back?

Anne Schuchat: Right. Thank you. There have been -- let me give the vaccine doses first and then come back to the other one. The government has ordered 229 million doses of bulk antigen of H1N1 vaccine. So not all of that is going to be filled and finished, or decisions may still be under way as to how much of that would be filled and finished. 155 million doses of H1N1 vaccine have been filled, and finished by the manufacturers, and released to the U.S. population. So that's the story on the vaccine doses of H1N1. Your other question was about the ages of the pneumonia and influenza excess deaths. And most of the pneumonia and influenza deaths are in the elderly. And so that we are looking at patterns by age. And we're not seeing anything particularly unusual in terms of the age. We're looking geographically at places that are seeming to have more hospitalizations and deaths from pneumonia and influenza, and that's what I was mentioning before, where some of those investigations were showing up a bit of rhinovirus or a bit of RSV. These are active investigations. And it really highlights for people that sort of muddy -- how muddy it can sometimes be to understand these. I think you know that the government invests a lot in improving diagnostics for influenza, as part of our pandemic preparedness. And as we're all a little bit frustrated not knowing what's going on with the pneumonia deaths, it speaks to the need for better diagnostics to other respiratory infections as well. Next question, please?

Operator: The next is from Elizabeth Weise at "USA Today." Your line is open.

Elizabeth Weise: Thanks so much for taking my call. I wanted to get a sense of when you're talking to providers who are -- I presume you've got a fair amount of interaction with people out in the field -- what are you all hearing from parents about the concerns about getting their children vaccinated?

Anne Schuchat: You know, the CDC's tracking has also been looking at that, among parents who haven't vaccinated their children, what are the principle reasons. Our results are a little bit different from the Harvard poll's results. We find that the most common reason parents cite is actually that they just don't think their children need the vaccine, for whatever reason. And in general, we find that in immunization surveys in general, it's usually how bad is this condition, or how common is it, or is it going to happen to me or my child. That's the driver for those who plan to be vaccinated versus not.

Concern about side effects is often present. And that is the number two reason that we see parents express in terms of reasons why they may not have gotten their child vaccinated. But of course, the -- these data have been gathered -- the ones I'm citing were gathered back in November, earlier in December, before we had such a wealth of safety data. So I would say that at this point, it's always understandable for people to wonder about the safety of vaccines. And it's something we take very seriously at CDC. But we have an awful lot of data, unprecedented amount of data about the safety right now. And I think that parents really should be reassured about that. Next question from the phone?

Operator: The next question is from Donald McNeil from "The New York times."

Donald McNeil: The Harvard study found that 40% of parents got the vaccine to their children by the time the survey was taken. And 13% more plan to get kids vaccinated. Your response to that earlier, you found overall that quite encouraging. I would think that would be just the opposite. The message the CDC has been putting out for months is everyone should get their children vaccinated. Now it's only 40% of parents have done it. And maybe it will creep over 13% if everybody does it this month. Are you really that encouraged? I would think you would be discouraged.

Anne Schuchat: Thank you. I think that we've gone through an extraordinary effort together with the American public to recognize a new threat, this new influenza strain that was causing a pandemic. The companies and NIH developed a vaccine and tested it clinically last summer. And the public health and medical community offered vaccine to millions of Americans. I think that we saw higher coverage with H1N1 influenza vaccine in children than we usually see with seasonal influenza vaccines. It's only in 2009 that influenza -- the seasonal influenza vaccine became a routinely recommended vaccine for children 5 to 18. And so I'm encouraged on many fronts that two-thirds of states carried out school vaccinations, that the coverage rates for this H1N1 vaccine effort appeared to exceed past years' seasonal flu vaccine rates. And that probably what I mentioned the encouraging comment about the poll, I think it was that many people who hadn't yet gotten their children vaccinated were intending to do so. So I think that -- I, of course, hope we can do better in future years. But I think we have a strong baseline to work from. And as you know, we're not done. The vaccination effort does continue. The states are working hard to get the second dose clinics done with schools. And doctors continue to offer the vaccine every day. So I think that we're in a dynamic stage right now, and we're hoping to do a good job with the rest of this year. And of course, build off this, for the future years. Because seasonal influenza is a serious disease that kills thousands, and disrupts families. And we do have an opportunity in future years to have to only worry about one vaccination program instead of two. So I think that we have a lot to build on for the future. Next question?

Operator: The next is from Joanne Silberner, NPR. Your line is open.

Joanne Silberner: First, I want to make sure I've got my definitions right. When you talk about activity currently being less than the national baseline level, is that for this time of year? And can you give us a more quantified idea of how much less?

Anne Schuchat: Right. The influenza-like illness activity refers to the percent of doctors' visits that are caused by flu-like symptoms. You know, of all those reasons that doctors are seeing -- that people are coming to the doctors, how many of those visits are due to a flu-like illness. What we saw this past week was 1.9% of all the doctors' visits in our sentinel system were caused by influenza-like illness visits. The national baseline is 2.3%. That national baseline is a three-year average basically. It's based on, you know, technically it's two standard deviations above the three-year rolling average for what's called the inter-epidemic period. So during the off-season, what are the numbers? And on two standard deviations above that turns out to be 2.3%. Though more detail than you wanted, I think. Did you have a follow-up or was that the question that you had?

Joanne Silberner: On the deaths, how much are the deaths, and how new is that? Has that been all along, or just in the last three weeks? How much is the separation?

Anne Schuchat: Sure. During the fall, when we had a lot of influenza-like activity, we also had a lot of -- quite a -- an increase in the pneumonia and influenza deaths. There was an 11-week consecutive period where the pneumonia and influenza deaths exceeded what we call the epidemic threshold. Then they came down. But, you know, this can go sort of up and down a bit. And now we have had a -- three more consecutive weeks where we're exceeding the epidemic threshold. During some of the fall when we had a lot of influenza, and actually during the spring when we had that early wave, we didn't see the excess pneumonia and influenza mortality. That excess pneumonia and influenza mortality is often highly influenced by what's going on in the elderly, because the elderly are typically those who die from pneumonia and influenza. Whatever's happening in the elderly can drive those. So we have had divergence. But during the peak of disease in the fall, there was convergence. Both the influenza-like activity was high and so were the excess deaths. Next question, please?

Operator: The next question is from Kip Grosenick from Fox News Channel. Your line is open.

Kip Grosenick: Thank you. I appreciate you taking the question. Doctor. Since the number of cases of H1N1 are lower than some had originally feared, will the initial response to future pandemics be scaled back, or will what we saw this year as a CDC and national response serve as sort of a blueprint moving forward?

Anne Schuchat: We have a tremendous experience to learn from. This pandemic isn't over yet. And of course, we're still responding. But we're also trying to harvest the lessons learned, so that we can do better in the future. How bad a pandemic is, or how severe it is will be a function of many things. But a critical factor is the influenza virus itself. If we have the next pandemic, with an influenza virus, like the H5N1 bird flu strain, we need to do a lot more than what we've done this year. Because our health care system has not been stressed with overflowing intensive care units, and not enough ventilators and so forth. So we aren't done with our pandemic preparedness, just based on the response we've had here. So I don't think that scaling back is really what we're talking about. But more moving forward, learning from this, and getting much of the system to work better. We've talked extensively about the need to produce large amounts of vaccine more quickly. Many of us think that if we had an earlier lead on this, we could have had vaccine available in large amounts before that big surge in the fall. So that speaks to better, more timely detection everywhere in the world, where the next pandemic virus might be emerging. Lots of opportunities to improve our diagnostics. And, you know, if we'd had much more vaccine available early, would we have been able to deliver it promptly. We didn't actually have to test some aspects of the system. So I don't think anybody is thinking about scaling back. We're thinking about planning based on this experience, and based on the scenarios that could come. The next pandemic could be much, much worse and we don't want to be any less prepared, we want to be much more prepared. Next question?

Operator: The next is from Michelle Merrill from Hospital Employee Health Newsletter.

Michelle Merrill: Thank you very much for taking my question. I was interested in finding out if you know anything about vaccination rates of health care workers, specifically whether they were higher with H1N1, and also, illnesses of exposures of health care workers, and any hospital-based transmissions? Do you have any handle on what occurred?

Operator: Yeah. The health care worker vaccination has been a strong interest of ours. The final data aren't in on that. We've been collecting information on H1N1 vaccination, as well as seasonal flu vaccination. There are a couple different types of surveys. The latest data I saw, things were not all that consistent. We were waiting until the studies were a little bit more complete. So I think that it's a critical issue going forward, that we really urge health care workers to protect themselves, and protect their patients. And vaccination is the best way to do that. So we're not where we need to be, but we don't have final numbers for either the H1N1 or the seasonal story right now. In terms of the transmission in health care workers, I don't have information on that today. So we have time for two more questions.

Operator: It's from Miriam Falco from CNN medical news. Your line is open.

Miriam Falco: Thanks, Dr. Schuchat. Good afternoon. You mentioned that the response in this whole process has been encouraging. Have you heard from the pediatricians, and the doctors and the people who were actually the ones giving the vaccines, and gotten any feedback from them on how this has been working?

Anne Schuchat: In an ongoing fashion, we've been reaching out to the professional organizations, the public health community, many constituents. We've had begun to have some formal meetings with the education sector. And I think we formally want to get good input. We know that the pediatric community is absolutely vital. They were critical in providing antiviral medicines, caring for kids, providing vaccination. There was a lot of vaccination in the doctor's office. And of course, they're the bedrock of our routine program. So I think that what we expect in this kind of response is a lot of variability, that doctors' offices in one community saw one pandemic and doctors' offices in another community saw another pandemic. Sometimes in the same community doctors across town had different experiences, just as parents did. Some parents whose school their kids went to had the vaccine. We're trying to do formal evaluations to identify the best practices and know what is the best way we can serve the public, medical community, the nation at large. Time for the last question?

Operator: The next is from Tom Randall from Bloomberg news. Your line is open.

Tom Randall: Thanks, Dr. Schuchat, thank you for taking my call. I was wondering about the announcement that they're reducing the expiration date by more than a year. Could you comment on how many doses are affected by that expiration change and if other companies are doing the change? And your thoughts about it if the hypothesis that it is somehow related to the syringes and if there are any plans to make changes in the future?

Anne Schuchat: Right. This latest correction, I think they're calling it a field correction, includes 12 million doses. But that's a deceiving number. The vaccine lots that will be affected in terms of a shorter shelf life amount to 12 million doses. But the actual number of unused doses is likely much, much lower, because most of those doses were shipped early in the season, when things were being used immediately. So, you know, that was one more complexity for the pediatricians and the public to handle, that we wish had not had to occur. On the other hand, I know that the FDA and the manufacturers are really looking into this. Of course, the potency issues with the prefilled syringes are a special focus of attention, to understand mechanically what may have been going on, and to learn from that for the future. So thanks, everybody. And we appreciate your continued interest in the story.

Glen Nowak: Thank you, operator. That concludes this press briefing.



  
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