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UPDATE ON PANDEMIC FLU PREPAREDNESS

Thursday, February 1, 2007 2:00 p.m.

JULIE GERBERDING, DIRECTOR, CDC: Good afternoon and thank everyone for joining us for this important press briefing. This is another step toward pandemic preparedness and we are going to learn about two new initiatives that the Department of Health and Human Services and other parts of government have worked together to prepare for our public.

I would like to start by introducing Secretary Mike Leavitt, who is going to talk with you a little bit about one of the initiatives. As I think everyone knows, Secretary Leavitt has been an enormous champion of flu preparedness.

And it has really been under his leadership that we have been able to take giant strides towards really digging in, rolling our sleeves up and preparing not only the government but the entire network of communities across out country and across the world. Secretary Leavitt, we would love to hear from you.

MIKE LEAVITT, SECRETARY OF HEALTH AND HUMAN SERVICES: Thank you, Dr. Gerberding. A little over a year ago, the President mobilized the nation to prepare for a pandemic. I traveled to almost every state and territory to hold planning summits. At every level of government our plans are developing and resources have been allocated. Today we are better prepared than we were a year ago, but there is still much to do.

There is also a danger that as avian influenza slips from the headlines that people may begin to believe that the threat is no longer real. The media buzz may have died down, but the H5N1 virus hasn′t.

Over the past two weeks, seven cases of avian influenza in humans have been reported and five of those people have already died. To date, more than 265 people have contracted this disease. Dozens of countries across three continents have seen H5N1 claim poultry and kill wild birds. The disease is highly pathogenic. And it continues to spread.

Now we can′t be certain that the H5N1 virus will be the spark of the next pandemic. We can be sure that pandemics happen. It happened in the past and they will happen in the future. That is why we continue to take this threat so seriously. Preparedness has to involve planning at every level of government, every school, every business, every church, every civic organization, every family, every individual needs to have a plan.

To make sure that people have the information they need to have effective plans, we are releasing two initiatives today. The first, we are releasing a community mitigation guide. This document helps communities understand the appropriate steps that they need to follow depending on the severity of the pandemic. These steps can include things like closing schools, canceling public meetings, or the need to stay home for an extended period of time. By anticipating the need for these activities, we can execute them more effectively. These steps can help reduce the spread of the disease until a vaccine is available, and that means saving lives.

The second initiative I want to speak about today is a public service announcement or a PSA campaign. This will provide useful tips and it will help people know what to do about pandemic flu. It directs them to a government web site, pandemicflu.gov. There they can get more information.

We have an opportunity to become the first generation in human history to prepare for a pandemic. Let′s continue toward that goal.

Now before turning back to Dr. Gerberding, I would just like to show you two of our public service announcements and I want to thank you all for your attention to this very important public health issue.

(BEGIN VIDEO CLIP)

UNIDENTIFIED PARTICIPANT: Hey dad? Mom? Grandpa? I know bird flu is quite rare in humans, but could that change as the virus changes? Do the experts expect bird flu to have global ramifications? Should we be taking precautionary measures in case bird flu becomes a pandemic?

UNIDENTIFIED PARTICIPANT: Need some answers? Visit pandemicflu.gov or call 1-800-CDC-INFO today. A message from HHS.

UNIDENTIFIED PARTICIPANT: (SPEAKING IN SPANISH).

(END VIDEO CLIP)

DR. GERBERDING: Well, as you can see we are reaching out into the communities and doing everything we can to alert people across the whole network that we need to prepare. CDC is one part of the front line of pandemic preparedness, but we′re doing today by a number of the other partners who are working with us on these efforts.

And I would just like to acknowledge the tremendous contributions of not only my colleagues at CDC and in the Department of Health and Human Services, but some colleagues who have joined us from other very special components of the effort.

First of all, Dr. Paul Jarris, who is the CEO of the Association of State and Territorial Health Officers, is a true visionary in public health and he represents the whole governmental public health system, both local and state public health officials whose true role is on the front line.

I′d also like to introduce Dr. Carter Mecher who is a member of the Homeland Security Council, the Executive Office of the President and, Carter, you have really been behind the scenes doing the lion’s share of heavy lifting in terms of moving these guidelines through the government and we really appreciate and thank you for your leadership.

I′d also like to introduce Ms. Camille Wellborn, who is the special advisor to the Secretary of the Department of Education. I think one of the most rewarding parts of this effort has been the integration and the close working relationship with Education. And we couldn′t have done that without your contribution. So I thank you very much for that leadership.

Not here today is Dr. Richard – sorry - Hatchett who is part of the National Institutes of Health. But he is the person who really first conceived some of the premises that have led to the guidance that we′re bringing forward today and we want to acknowledge his intellectual property and his leadership as well.

And then finally Dr. Howard Markel is here from, where are you, thank you, from Michigan, who is one of the modelers and the scientists behind the scenes who have put together a lot of the data that have led to this effort.

On the telephone bridge we have from the Department of Homeland Security Mr. Alfonso Martinez-Fonts, who is the Assistant Secretary for the Private Sector, bringing the private sector into planning and infrastructure and protection of the things that keep society functioning is key to all of this.

And not least of all is Ms. Susan Howe, who is the Deputy Assistant Secretary for Policy in the Department of Labor, recognizing the important role that businesses and workers and employees play in all of this.

So let me start by giving just a little bit of context to how we went about trying to do the kinds of planning that communities need to protect people against flu. We have some premises. As Secretary Leavitt said, pandemic influenza is not necessarily imminent, but we believe it is inevitable. And it is not a question of if. It is a question of when. So we do have to prepare. It would be irresponsible if we didn′t continue our planning efforts.

And this isn′t just about H5N1 avian flu. This is about any novel influenza virus to which people have not been exposed and to which we might all be susceptible. Planning requires that a whole network is engaged. It means individuals and families. It means communities and it means the whole system of business, education, health care and government really work together so that we have a strong linkage throughout the entire network.

We are only as strong as our weakest link. When we think about preparedness, we have to think about at least four things, plans for sure. We have to think about products like anti-virals and vaccines. We have to think about people who are prepared and trained and know what their role and responsibility would be, whether it is in their family, their workplace or in their government role. But we also have to think about practice. As many of you know, CDC just finished its flu exercise as one component of practice. But what we are really thinking about today is how can we help people prepare and practice for what they would need to do in the context of a pandemic.

Our goal is all of this is to make sure that we do everything we can to save lives. Now we all know that if a pandemic virus emerged, the first thing we would try to do is completely extinguish it or quench it. But that might not be realistic given the speed with which virus can move around the world.

So, the next best thing we can do is to try and slow down the spread and buy some time. The best way to protect people is of course a vaccine. But we are not likely to have an effective vaccine in the first six months of a pandemic. So we have to put our heads together and figure out what can we do in the first six months before the pandemic virus vaccine is available.

We have looked at a lot of information to try to decide what things might make sense for the community for the few weeks that a pandemic is rolling through or threatens to affect them. We have looked primarily at the experience of the last three pandemics.

There has been extensive investigations on a city-by-city basis to look at what do the communities do to protect their citizens, which communities had the worst problem, which communities had the least problem, which communities had the slowest onset of flu cases, so that we could try to get a sense of what seemed to work in 1918 or in previous pandemics.

We have also modeled looking at what we know about seasonal flu transmissions, what we can assume about the transmission of a pandemic virus with various degrees of estimators. And we have been able to draw some important conclusions. One important conclusion is that the earlier you initiate an intervention, the more likely it is to make a big impact.

We have also looked at what we do know about seasonal flu and what we know about interventions that help slow down or prevent seasonal flu in ordinary years.

We have also used some common sense. We have pulled together some experts, really the best experts, not just in government, many of whom are here today, but experts in a multitude of fields and scientific endeavors and perspectives. And I think most importantly in this process, we have listened to people.

We have conducted focus groups and we have tried to understand what citizens are concerned about, what they might do, how long they might be willing to do it and what some of the barriers might be that would prohibit them from being able to do it effectively.

There will be more steps in the future. We are already investing about $5.2 million in research to help us characterize which interventions seem to be most effective, particularly during seasonal flu. We are doing more modeling of course, more sophisticated modeling with more perspectives. We are exercising and we will be seeing local and state governments and their community stakeholders doing a great deal of exercising throughout the next many months.

One of the important investments that we are making with the funding to the states is to provide a set of objectives and criteria for practicing preparedness efforts and response efforts, and we will be requiring that that focus specifically in part on these kinds of community interventions.

We are going to learn from that. One of the important things that we will learn is what looks feasible? Are the things that we are recommending things that communities really can do? What barriers would need to be overcome? What is the down side? What can we learn when people really set out to try to implement them?

And again, we will be asking for input from the public. As people understand what does this mean for my family or my house or my workplace, they are going to have a lot of questions and they are going to bring insights and perspectives that we just don′t have right now. We can′t anticipate everything. So we will be learning from them.

All this learning means that we have to be prepared, that whatever we are using as a planning tool today is very likely to have to be updated. So you will notice that the guidance that we are talking about starts with a very important word. That word is interim. And we mean something very specific when we say interim.

We mean that this was our best effort right now, pulling everything together what we have looked at. But we fully expect that as we learn more we are going to need to update this planning tool and we will do our best as important updates become relevant to provide refreshed guidance and make that available with information about why the updates were necessary.

I am not going to spend a lot of time going into detail about all the aspects of what is in the document, but I do want to hit a few highlights. One very important, and I think, new concept that we introduced in this planning is the concept that not all pandemics are equally severe and that we can use what we know about epidemiology to create a severity index.

So by that we mean, a pandemic that does not move very fast from person to person, or does not have a very high fatality rate would likely be a fairly mild pandemic. One of our recent pandemics was very mild. And the kinds of interventions that we might recommend in that setting wouldn′t be the full court press that we would use if we were dealing with something more serious.

On the other hand, we know in 1918 for example, we had a pandemic that not only moved with extraordinary speed from person to person and around the world, but it also had an unusually high mortality rate. We would categorize that as a category 5 pandemic.

And we use the word category because there is an analogy here to the hurricane analogy. Everyone knows what a category one hurricane is. Everyone understands what a category four or five hurricane is. And we have embedded in our minds some understanding of the difference in severity, of a different level of planning that might be required and the different harm that could come from these kinds of different scenarios.

So as we try to develop protection measures for the community that match up well with the severity, we had to make some assumptions, but we also relied on the models to really help us determine what would likely slow down the spread of a pandemic and save lives.

I have a graphic that I think illustrates what our goal is with all of these interventions. What we are trying to do is take a situation, particularly in a severe pandemic that looks like this, with a very high peak and a very early peak of cases in any given community and spread that curve out over time so there is a lower peak as well as perhaps a total reduction in the number of cases, certainly in the number of cases at any given time.

This is an important goal because it will help save lives. But it will also help decompress our health system and the tremendous burden that a pandemic would place on hospitals and outpatient clinics and intensive care units.

But it may also result in an overall ability of us to sustain society, to continue to have our economies moving, our businesses operating and the critical infrastructure in our communities able to protect citizens and provide for their security and their essential functions.

So this slowing down and buying time is a key principle. We don′t expect that we would be able to protect everyone. We don′t expect that there would be no mortality or no deaths or no impact from any pandemic. But we do believe we can make a difference and these planning measures are designed to do that.

So, category one planning measures are really those that we would think of using with any infectious disease. Category one would include keeping your hands clean, because we know that viruses can be spread from person to person by touching someone or something that is infected and touching your mucous membrane or your eye or your nose or your mouth.

Also the old fashioned advice we learned in kindergarten, cover your mouth and nose when you sneeze or cough. So cover your cough. You have seen those signs around the airports these days. And also, common sense advice about simply staying home when you are sick. You know it is not a good idea to go to work when you are sick with a respiratory illness, no matter what you think might be causing it, and we would certainly want that advice to be followed in a pandemic.

But specifically in a category one pandemic, where we are dealing with a novel virus, we would want to isolate people that had that infection so that it did show a reduction in the risk based spread in group settings or out in the public settings. I will just go to the opposite extreme and talk a little bit about a category four or five pandemic, where we have high transmission and high mortality.

In these cases, we would recommend a whole list of interventions including the same ones that we would use for category one, respiratory hygiene measures as well as isolation of cases. But we would also recommend isolating contacts who have been exposed to known cases, or people who are living in a home with a person who has the pandemic virus.

We would recommend early closure of schools, really dismissal of students from those schools. Schools wouldn′t necessarily be closed because they may be functioning for other purposes like distance learning or providing food supplies for students, et cetera. And I will let the Department of Education representative say a little bit more about that if you have questions.

But in addition, we would expect under these circumstances that we might need to have schools closed or students dismissed for long period of time, for example, up to 12 weeks as the wave of the pandemic went through the community. This we recognize has a lot of down sides and is very difficult to do, because you don′t necessarily dismiss students from school and let them congregate in the shopping malls.

You have to introduce additional measures to keep them separated from each other when they are not in the classroom. And so that means a lot of change in families and a lot of change in communities. But we do think that this is an important component under a circumstance where children are dying, to really help protect their lives and add to the ability to slow down the spread of the pandemic.

Finally, we would be expecting communities to implement measures to increase the distance between people. In other words, not come to large meetings or group settings like this and to try to work from home or stay away from crowded areas so that you have less chance of coming in contact with any given person who is infected with the pandemic virus.

As I said, these represent a complete list of interventions that we would recommend. What an individual community or state would do depends very much on the local circumstance.

And one of the aspects of this that we′re going to get a lot of feedback from and we really worked with our state partners on is, when do you start these measures? Do you start them after the pandemic has taken off in your community, do we start them when there′s a virus anywhere in our nation?

These are really tough questions and we′ve had a lot of dilemmas about this. Right now we think that the sensible place to start is whenever the pandemic, the first case of the virus has appeared in a state or in some situations, the metropolitan statistical area where we′ve got cities that are in two states simultaneously that that would be the point where we would implement these measures.

And they would continue for the expected period of time that the pandemic wave moved through the community based on prior pandemics that would be somewhere around 10 to 12 weeks or less. But of course, there′s uncertainty in that as well.

So the earlier the better because that would give you the best chance to target effectively and reduce spread, but also continuing in the category five until the cases had diminished and the pandemic threat appears to have moved on and out of a given area.

We′ve got real tough decisions here. There are a lot of dilemmas. One dilemma is how do you talk to people about this kind of intervention without panicking them. It′s very tricky to help people understand that preparing and knowing what actions that need to be taken is really very empowering.

People will do something, but if you give them solid advice about what they can do and they have a chance to practice or think about it ahead of time, they′re much less likely to panic and they′re much more likely to be able to handle the situation and do the appropriate things.

We also think it′s very important to get the right balance between understanding that we′re not in the pandemic now and we′re not on the brink of one, as far as we can tell, but that we still need people to engage.

Secretary Leavitt talked about complacency. We know that the avian virus, H5N1, has not been so much in the news, but that doesn′t mean we′re not concerned about it. Certainly at CDC we′re concerned about it. And I think all of the folks here agree with that assessment. But we also don′t want to artificially “cry wolf” or raise alarm ahead of the time when people really need to take effective action.

So these are dilemmas and it′s going to be difficult to keep the balance right at all times, but we′re working on it.

And probably the best solution is to simply keep you informed, let you know what we know, let you know what we′re recommending, let you know what we′re learning as we go forward and keep people updated if any changes or improvements in the recommendations are necessary.

Our next steps really are to initiate more of this exercising. I′m sure we′ll learn a lot about feasibility and particularly maybe the unintended consequences of some of these interventions, their costs, whatever unexpected disruptions they might cause.

We′re going to be developing some very specific tools. For example, it′s one thing to say if you′re sick with the pandemic virus, you should be cared for at home unless you′re too sick to survive that, but it′s another thing for family members to know how to take care of you and to have the tools and the equipment and the knowledge base or the access to information resources through the telephone or the computer that would really help you feel confident that that was the right thing for you and your family.

And we will be making more investments in science. We know that if we invest more, we′ll learn more. And I think we all agree that we have a lot more to learn about influenza, influenza transmission and the ways we can truly protect our communities and our families in that setting.

So let me stop here and introduce to you one of the CDC leaders who′s played a large role in helping to formulate this guidance. I must say that it takes a network to do that too and Dr. Cetron is not alone in his contribution. He has a whole army of people here and has been working with a lot of people for many months on this guidance. But he is the expert. And I’d really love Marty to have a chance to give you some of the very specific detailed aspects of this – Dr. Cetron.

DR. MARTIN CETRON, DIRECTOR OF CDC’s DIVISION OF GLOBAL MIGRATION AND QUARANTINE: Thanks, Dr. Gerberding, and you’re right, this is a, this was an effort that reflects a huge army of people behind it. Someone said the amount of time, the nine months or more that we spent working on this and the number of people involved was akin to a sort of birthing a new child. And we’re anxious to see this come into the world.

In fact, it will take a lot of guidance and a lot of input and a lot of mentoring to watch this process mature. It’s interim. It’s planning guidance. It is not meant to be the final word. We’ve learned over and over again how we need to maintain our flexibility.

I think it’s going to be very helpful, the feedback that we’ve gotten to date about the idea, the concept of a U.S. Pandemic Severity Index has been uniformly positive. This is a tool which we believe is a missing access to pandemic planning and preparedness.

Most of the planning to date has gone along the idea of how close is the threat in time and space to me? What is the proximity of the risk? But it really hasn’t addressed the idea of how bad, how severe is the risk.

We know quite well when you need to use measures of this sort that can be socially disruptive, attuning and balancing the severity of the threat with the types of interventions and tools in your toolbox are very important.

And it’s important for us to understand that we do not intend all these tools to be used in just any, in any sort of a pandemic, but reserving most of these aggressive tools and measures for the most severe in which the number of lives saved can be potentially significant and worth some of the cost.

We also realize as we look back through history is what cities did – 44 cities did, is that many of these measures ultimately every city adopted at some point or another, and the difference may be in the timing of using these measures and whether they’re coordinated in an effective way for us to really gain the benefits of them.

But likely we will all be paying the disruptive or the social costs of these measures at some point if it’s a very severe pandemic, and we would like to not reproduce some of the lessons of 1918, which is waiting until the bodies and the mortality is so high that it’s insufferable to really begin to implement our measures then.

So early, targeted, layered measures as were outlined in this plan are the key and I think, you know, with that, besides recognizing that this is interim and we will continue to learn, we’re looking forward to a continued partnership in the process that we began with these guidance documents that would be an ongoing effort with the Departments of Education, Labor, Commerce, Homeland Security, Treasury – every major Federal department has been involved and their seals and logos appear on the cover of this document.

Many of our extensive network of public health partners at the state, local, county and community level as well, and we will need that continued collaboration and cross linking.

This is going to be really hard work, and there’s no doubt about it, and what we’re talking about here is not easy to conceive or to implement. But I can imagine one thing that will be much harder than going under, undergoing this preparedness effort right now, much, much more difficult to try to come up with a solution on the fly in the midst of a crisis like a severe pandemic in which the case fatality ratios are very high.

That will be extremely hard and almost intolerable, insufferable. We know that there’s going to be adverse consequences from these measures, but if we plan and prepare now, and practice, we’ll make progress in being able to anticipate these measures and find creative workarounds.

And with that I would like to just end my comments and perhaps give an opportunity for our key state health partner, Dr. Paul Jarris from ASTHO, to make a few remarks about how this guidance impacts both at the state level.

DR. PAUL JARRIS, ASTHO: Thank you Marty and thank you Dr. Gerberding. I would like to join my colleagues across the states, territories, local health agencies in applauding Secretary Leavitt and Dr. Gerberbing for their untiring leadership in preparing our nation. We truly do appreciate it.

I also want to thank them and applaud them for issuing this report. It is an excellent report, long awaited and we welcome it. The strategic and coordinated implementation of early targeted and layered interventions will be essential in protecting our public during a pandemic. It is important to know the process used in developing these interim guidelines, really a model for government openness and involvement.

The best scientists were brought to bear to apply the best science we have today. In addition, stakeholders from multiple sectors were brought to the table. And the practioners in the counties, the territories, the fields and the tribes were brought to the table with their experience in the local communities and with the given populations they serve.

But importantly, the general public′s input was sought. It was a survey done by Harvard University of the public and ASTHO partnered with the CDC and others in public engagement meetings around the nation, bringing together people in different cities and communities to ask them what they thought about these measures and when they would be applied.

The best policy will not succeed, no matter how good the science if it is not acceptable given the values and the beliefs of the population who you are asking to implement them. That process was extremely important and made for a much richer and more successful program here. A couple of things I think are worth noting.

We cannot pause our preparation while we wait for perfect science to be developed. This is developed on the best available science. For those of us in the field, I was a State Health Commissioner. My colleagues in the cities, the counties, the territories, we need to act. When something hits, we need to act.

So we were really depending on the CDC and our federal partners to apply the best that is known to us today. And as they work to develop new information, we will update and go forward from there. But this plan gives a very good starting point. A few things to highlight, the pandemic severity index is a very important new tool for us to calibrate our response.

As Dr. Cetron said, it is important that we implement these things is an appropriate and timely way. We learned that not all pandemics are the same, as we saw in 1918, 1957 and 1968. And so our responses cannot be all the same. Development of preplanned scenarios, which can be custom applied to the situation is key. As was mentioned, these measures do have down sides to them.

Dismissing children from school has implications for the work force, for the children, for their learning, for their nutrition in some cases. We don′t want to use these lightly. We want to maximize the benefit and minimize the adverse effects.

Having preplanned scenarios to apply in this manner will allow us to apply them in a rational thoughtful way because, as we know, otherwise they will be applied in a haphazard way and we will get the down sides without the optimum potential benefits.

Another important point was establishing triggers, the notion that there will be trigger events, such as the first case in a locality or municipality that is confirmed. If we have the same trigger across the country, we will have a coordinated response, minimize the confusion for all of us and most importantly for the public and the population as they wonder when they should or should not go to school or go to work.

This guidance is an excellent step forward. We are looking forward to working hard now in revising our plans in the state, local, territorial and tribal communities. We will learn a lot from that. It will be a very intensive process, not only updating our plans but as Dr. Gerberding says, the important thing here is exercising it. You play what you practice and we have got the practice. That′s going to require intense, devoted attention and work across all sectors, government and private, and it will require continued ongoing resources so that our nation is prepared. Thank you very much.

DR. GERBERDING: We′d be happy to take questions. While the room is warming up, we′ll take the first question from the telephone.

OPERATOR: Thank you. And again, if you would like to ask a question on the phone lines, please press star one. Our first question comes from Maggie Fox with Reuters, please go ahead.

MAGGIE FOX, REUTERS: Hi. Thanks very much. I′ve got one question about the plan and then one somewhat related question. About the plan, does – are there any details or is there any guidance for what officials can do when they close schools like feeding the kids who aren′t in the school, you know, who are in the school lunch program? Do you offer any guidance on that at all?

The second question is about this season′s flu, this flu season now. Since this is kind of a preset scenario for a pandemic, Dr. Whitley from the University of Alabama says he′s got nine pediatric deaths so far in this flu season. Can you guys comment on that, how unusual that is and I understand CDC is looking at samples of those viruses taken from those kids right now?

CAMILLE WELLBORN, DEPARTMETN OF EDUCATION: Thank you. The food service program is looking into what the alternative ways to continue to feed children. I will say that they′re working with CBOs, SEOs to link those partners together. But this is something – this program is not out of the Department of Education it′s out of the Department of Agriculture.

But I think Marty might be able to address that even more.

DR. CETRON: Sure. One of the good things about putting a stake in the sand for planning guides is that you have marks that you can then begin to prepare around. In our outreach across the country, we′ve heard some very creative potential solutions for this.

For example, some said that well, if we -- if the issue is really just the crowding of the classroom, maybe we just dismiss the students, but we keep the school open, we keep the school cafeteria open, we produce those meals, maybe it′s just a distribution issue instead of bringing all the kids to the meals, maybe we bring the meals to the kids.

Those are some of the creative solutions that are coming from the public and the stakeholders and people who say I can cope with this, I can figure this out. They will undoubtedly be more. And as these get exercised, we hope we′ll be able to capture best practices and solutions and work around to these things all along.

Continuity of education is, as Camille′s department has been working on all sorts of creative ways. Maybe teachers come to the school and that′s the central nexus or learning point for virtual education.

So I think once we understand what the challenges that are posed by the interventions and the mitigations, we could find workarounds and solutions. I can assure you we probably wouldn′t be as creative in coming up with those solutions if we had to think of them on the fly in the crisis of the very severe pandemic.

DR. GERBERDING: Thank you. With respect to your other question about seasonal flu, unfortunately, it′s not unusual for there to be pediatric deaths in any flu season. We do have monitoring programs in place to try to understand early if we′re seeing an unexpected number of pediatric deaths.

We don′t have signals indicating that at this point in time. We do know that the majority of the virus circulating in the flu season so far has been a strain that the vaccine is an excellent match for. There are some B virus strains that are less well matched to the vaccine, but they′ve been a very small minority population and we′re not seeing any attributable excess mortality from that situation.

Let′s take a question from here in the room.

DAVID BROWN, WASHINGTON POST: Yes, this is David Brown from the Washington Post.

The – in your survey you found that the majority, 57 percent of people said they would have serious financial problems if they had to miss work for one month and one in seven families said that they would be unable to have an adult in the household go to work during a prolonged time when kids were at home.

So, I′m wondering since financial security is a key variable I infer for people enthusiastically participating in following this guidance, I′m wondering why you didn′t, or if you considered addressing the question of strongly advising that employers continue to pay people, you know, out of the kindness of their heart and social responsibility during a prolonged, you know, pandemic.

And also whether the federal government, whether there′s any financial support, you know, in terms of unemployment compensation. That whole – those issues I couldn′t see being addressed in here.

DR. CETRON: That′s a great question, David, and in fact, part of the reason we engaged the entire family of federal partners on this is that we realized that everybody has a part to play in coming up with these solutions.

I believe that Sue Howe might be on the line from the Department of Labor and she could address some of the specifics in the way that the Department of Labor is addressing these. But, very much the issues you raise are actively being worked on in terms of unemployment types of leave, special leave programs, how those can be -- what we want to do is we want to align the proper incentives so that the guidance can be adhered to and that people don′t have to run into conflicts of interest between, you know, getting a paycheck or doing the right thing from a public health perspective.

And so there are some efforts and initiatives underway and perhaps Sue if you can have your mic opened, you may want to give us some insights into some of the work at the Department of Labor on this.

SUSAN HOWE, DEPARTMENT OF LABOR: Thank you Dr. Cetron. This is Sue E. Howe at the Department of Labor. David, you raised a very good point and as you look at the guidance that CDC is releasing today, it does address those issues as foreseeable consequences.

The participants in the Harvard study acknowledged their concerns. This is certainly something the Department of Labor and other departments in the federal government will be looking at. But also, the guidance encourages employers to revisit their practices, look at teleworking, look at job sharing, flexible shifts, the provision of leave during a pandemic.

Again, we′re focused on a severe pandemic, which is certainly different than leave policies that may be in place currently. Also at a time when you want to encourage people not to come to work when they′re sick whereas there may be a lot more tolerance for people coming to work when they′re sick during seasonal flu or with other illnesses.

So the Department of Labor is looking at this in collaboration with CDC and other federal agencies. And we’ll be engaging stakeholders. And part of the feedback that we hope to receive from the guidance is a better understanding of what more information is needed. And how we can help remove those barriers. And as Marty mentioned, ensure the appropriate incentives are there for people to be able to comply.

DR. GERBERDING: Thank you. For those who didn′t catch who that was, that was Ms. Susan Howe, H-O-W-E, the Deputy Assistant Secretary for Policy in the Department of Labor. Let′s take a question from here in the room.

MIKE STOBBE, ASSOCIATED PRESS: Mike Stobbe from the AP. So we′re seeing these PSAs come out – PSAs are coming out and you all are reminding the public to think about pandemic flu and perhaps prepare.

Based on this guidance, could you just remind us what should people buy and not buy right now? Should they try to buy masks? Should they try to buy Tamiflu? Should they know to stick to canned goods? What should they get right now?

DR. GERBERDING: You′re bringing up one – a very important point that while we′re talking about the non-pharmacologic interventions, in other words, things other than drugs and vaccines, this is one piece of a comprehensive pandemic preparedness strategy and we do have a separate lane working on how we will use anti-virals.

We are not recommending that the public procure anti-viral therapy right now because we have other methods for developing access to those drugs. But as the supply of anti-virals improves and expands, we may, we will be revisiting our policies and our approaches to that in making sure that we have done everything that we can to ensure access in communities particularly in vulnerable populations or people in hard to reach areas.

So there are a lot of creative and innovative ideas about that as well that aren′t the focus of this intervention but are relevant.

One of the areas that people have the most questions about relates to masks. We have a very good understanding about the role of masks in health care settings and other similar environments, but the use of masks in the community is still somewhat controversial.

Masks can do one of two things. They can either prevent you from coughing out virus or they can prevent you from breathing in fine particles floating in the air that might contain virus in them.

The best use of masks for flu is to use a mask to prevent your coughing from going out and infecting someone else. And those kinds of masks can be purchased anywhere. And we never have a problem with putting on one of those masks any time they are suspected of having a respiratory infection.

But the masks that prevent you from breathing in the fine aerosols that can be important in flu transmission don′t work if they don′t fit perfectly. So our dilemma is how to do we allow for people′s interest in these masks but the requirement that they sit ideally to the face and also for some people they create a resistance to breathing that can compromise their respiratory function.

So it is not a simple matter to use one of these special masks. They are called N95 respirators. And you can look forward to receiving some updated recommendations from experts similar to the process we used for this guidance that will be addressing the use of masks in community settings for citizens.

Those are not going to have a long time frame from here out. But, I can′t give you the exact day yet when they will be finalized and cleared and we will announce them as soon as we can.

I think I will take a question from the telephone please.

OPERATOR: Thank you. Jennifer Couzin with Science Magazine, your line is now open.

JENNIFER COUZIN, SCIENCE MAGAZINE: Thanks for taking my question. I was wondering if one of you could comment a bit on the models that were used for the recommend responses to each level, number level of pandemic and how you handled cases in which there were models that conflicted with each other about which responses would make the most sense.

DR. CETRON: That is a great question and thanks for asking that. There was a network of modelers called the "Midas Network," that was supported by funds from the National Institute of Health. And it was a series of academic modelers from different universities in the United States as well as some colleagues in the U.K. What was really reassuring about the work of the modelers is although some of the numbers differ in each of the different group′s work, there was a remarkable confluence of results around common themes.

And those themes were that, earlier better than later and clearly early had a big factor in the predicted effectiveness of the intervention. And secondly, although a series of partially effective measures may not be sufficient in and of themselves, when these are layered one on top of another and used concurrently as we have proposed for a severe pandemic, they have a real additive effect.

And because epidemics grow rapidly and very quickly, if you target transmission blocking interventions at multiple key stages and key foci where transmission is very high, adding these measures as layers on top of each other can have a tremendous impact. And so the numbers differ from one model to another in terms of the absolute predicted magnitude of response, but there is a tremendous harmony in those two principles, early and layering a partially effective measure can have a real impact in reducing the amount of transmission.

It is reassuring to me that 21st century models that use 21st century movement patterns and 21st century city dynamics actually are very consistent with the work that Howard Markel has been doing with us at the University of Michigan, looking back over a hundred years into the past, and the same kind of themes come out of those lessons there.

Earlier cities that employed measures early tended to fare better, and when cities applied multiple layers they had a generally more favorable mortality curve than those who did not, and I find it heartening and reason for optimism that although separated by a hundred years in time, these two ideas are converging.

I think it’s reason for optimism and is part of the basis of the decision as Dr. Gerberding highlighted that went into the issuance of this guidance.

DR. GERBERDING: I would just add to that, the Institute of Medicine has taken a look at these models and these issues and they’ve made some very specific recommendations.

I also mentioned earlier the importance of additional investment and research, and so we are investing in more modeling, paying attention to the advice from the Institute of Medicine to try and improve the robustness of these models in an effort to try to reconcile some of the differences in interpretations and limitations of what we have so far.

Let me take another question from the room. Who has the microphone? Then I’ll take a question from the telephone. My queue line is showing that there are many people in the queue.

OPERATOR: Thank you, Jai-Rui Chong with the Los Angeles Times, your line is now open.

JAI-RUI CHONG, MEDICINE COLUMNIST, LOS ANGELES TIMES: Hi. I was wondering if you could provide some more detail on this, you know, the category rating system, like you were saying that, you know, 1918 would be category five and it seems like for a seasonal flu would be category one, but you know, where does Hong Kong flu fall?

Do you have certain examples of what four and three and two would be?

DR. CETRON: The 1957 and 1968 pandemic fall into the category two, and somewhat for different reasons. What you might find, although the illness rates for ’57 and ’68 varied along that spectrum of what is anticipated for a pandemic between 20 and 40 percent of the population getting sick, and there were wide ranges for ’68, almost 39 percent illness rates were observed.

The case fatality ratio which becomes the real major driver in distinguishing the categories was quite low, and because the case fatality ratio was where it was, the overall projected number of deaths for an unmitigated pandemic were to recur like ’57 or ’68 would place it into a category two like event.

Now we know one thing that we’ve had few pandemics fortunately to draw experience on, but each of them threw us curve balls, whether it was high attack rates and low case fatality ratios or very rapid spread and high case fatality ratios like 1918, we can almost be certain that the next pandemic will throw us yet another curve ball.

The tool that’s used to construct the severity index allows us to mark the major parameters, illness rates and case fatality ratio and factor them in to how we might forecast or categorize a pandemic threat as it begins to emerge on the horizon and allow us to tailor our response accordingly.

DR. GERBERDING: And one of the aspects of this that we need to acknowledge is that it puts a big burden on our local, state, and international health investigators, because getting information about what the transmission risk is and what the case fatality ratio is as the pandemic is emerging takes a very effective response investigation in order to get those parameters, and what you would probably see is some tendency to plan to err on the side of caution early on before we have the specific information to help us back off the aggressive interventions that would be required in category five.

Fortunately, we only really need to do that investigation a few times, or one time mainly at the beginning because we can make some assumptions that once the pandemic is established, the transmission patters will probably be somewhat same, the same when it′s reached equilibrium.

So, we′re not required to do those measurements over and over again exactly the same way in every community. But nevertheless, we′re not used to having to make those estimates in real time and that′s one of the things that we′re working on in exercising at CDC.

If we′re going to use the system, then we have to be able to make these measurements quickly enough to give people information about whether or not school closure is going to be a part of the expected community intervention.

I′d like to end now and just again, thank you all for your interest and for your participation in this press briefing. As we learn more we′ll update you and these interim guidance really are a planning tool.

We look forward to the next phase of practicing, refining them and moving this into an environment where we′re providing more specificity and more tools that people can really use in their homes, their schools and their work places.

Thank you very much.

OPERATOR: Thank you. This does conclude today′s conference call. We thank you for your participation.

END

####

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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