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CDC Briefing on Public Health Investigation of Human Cases of H1N1 Flu (Swine Flu)

April 30, 2009, 11:30 a.m. EST

 

Glen Nowak: Thank you.  And welcome all to today’s briefing on the H1N1 outbreak in the United States.  You can imagine there's a lot of media interest and a lot of reporters calling in, so please, do try to limit yourself to one question.  We will turn it over to Dr. Richard Besser, acting director of the CDC, for an update. 

Richard Besser: Thank you very much, Glen.  Thanks to all of you for being here this morning.  As you know, this is a rapidly evolving situation, it’s a situation filled with uncertainty.  Our goal is to give you information as we have it.  As we get new information, we will be sharing that with you.  As more communities become affected by the H1N1 virus, the activities that public health and the community's undertaking to try and control this will become more visible.  And so there's going to be more concern, there's going to be more questions.  It's very important that people know where to get answers to their questions and where to find the best, most current guidance we have.  We're referring people to our website.  I'll give you more on that in a moment. 

I've been trying to make a point that there's shared responsibility when it comes to preventing infectious diseases, shared responsibility when it comes to fighting a new infection for which we have incomplete information.  There's things the government needs to do, and we're aggressively doing those things.  There's things communities need to do, businesses need to do and there’s a lot that individuals need to do.  I'll go through those again. 

Let me start with an update on our cases.  In the future we may move away from case updates because as we see more cases and more suspect cases, the numbers become a little murkier, and we'll focus more on where things are occuring and what that tells us about infections.  Today I'm reporting 149 confirmed cases in The United States.  We have 11 affected states with confirmed cases.  There are many more states that have suspect cases, and we'll be getting additional results over time.  In New York, there are 50 cases.  Texas, 26.  California, 14.  Again, I'd refer you to the CDC website where you'll be able to find all of this information.  The new state is South Carolina, which has 10 confirmed cases.  Two in Massachusetts, one in Michigan, two in Kansas (Editor’s Note: This is a correction), one in Arizona, one in Nevada, one in Ohio.  In the future, I think what I'll do is give you the overall number and refer you to the website for the states.  The age of cases is 16 years with a range of 22 months to 81 years.  The most recent case onset that we have confirmed is April 26th.  The majority of onset dates appear to be after April 18th.  Six of the confirmed cases have been hospitalized, including the unfortunate case we reported yesterday of the child in Texas who passed away. 

I want to put this in context again of the seasonal flu, so that people can understand, influenza is a virus we see every season -- every winter.  It can cause severe disease.  In The United States, there are 36,000 deaths from seasonal flu.  So I think as we see this virus in more communities, as we see more people who are infected by this virus, we will continue to see a broad spectrum of disease from milder infections to more severe infections.  Unfortunately, I do expect there to be more deaths. 

As we continue to look, we will see more cases in more states.  And we will see that there are differences in actions across the country.  But this is a good thing.  It's very important that we look to local and state public health, to look at their situation on the ground, their local contacts and take the recommendations we’re providing and apply them locally.  So you're seeing differences, and we hope to learn from these differences in terms of what are the most effective control strategies for this new infection.  There are reports that there's broader school closure in Texas, and we'll look to see what was the impact of that?  Is that an effective strategy? 

We're also going to hear that emergency declarations are made in different states.  As you know, we declared a public health emergency in The United States on Sunday.  That gives us additional authority to do things we otherwise would not have.  That holds true for states as well. You'll see states that are affected, many of them declaring an emergency to allow them to respond as effectively and quickly as possible. 

Let me go through some of the public health actions that are under way.  We continue to work with state and local health departments.  We continue to work with the World Health Organization, the Pan American Health Organization, and we're working in part with the tri-national team in Mexico.  Later this afternoon, we'll be publishing an article in the MMWR that is summarizing some of the data coming out of Mexico.  That's being reviewed still by the various groups that are authors to that.  Those bodies include the World Health Organization, Pan American Health Organization, Canada, Mexico and the United States.  So that will provide additional information on the situation in Canada. 

As you know, last night, the World Health Organization raised the pandemic threat (Editor’s Note: this is a correction) level to 5.  This is a good thing. It doesn't impact on what we're doing here in The United States, but it's really a wakeup call to the rest of the global community.  If you haven't been paying attention to what's going on here and in Mexico, it's time to pull out your pandemic plan and think about what you would do if this infection were occurring in your own borders.  It's time in the global community as well to think about what are the needs of other countries, what are the needs of other countries that don't have the resources, who haven't been planning intently as we have been here in The United States. 

I want to talk about some of the work we're doing in the field.  We are sending continuing deploying the Strategic National Stockpile.  This is the collection of anti-viral drugs and materials to be used in hospitals.  We have completed deployment to nine states, and material is moving to the rest of the states.  And so all that should be complete by May 3rd.  There are no reports, and we don't expect any reports, of shortages, of any anti-virals in any states.  Doing this movement of drugs is a forward leaning move in the event this would become much bigger than it currently is.  We have 34 CDC staff employed in the field in five locations, including 11 staff (Editor’s Note: This is a correction) in Mexico.  One thing about the work in Mexico, I wanted to let you know, that there's now a lab I've been running in Mexico that's able to do diagnosis and confirmation of the H1N1 virus.  This is a really big step.  It's going to help us with the studies there because we will really be able to confirm cases and look at the risk factors for those cases, how to treat it.  It's going to be very helpful in terms of speeding up the course of those studies. 

We've expanded greatly our information resources.  We've added 50 new staff for our information line, 1-800-CDC-INFO.  The other day with the influx, there was almost a 15-minute wait for some of those calls.  We're down to less than 90 seconds, which is good.  And that's dramatically reduced the drop rate on calls.  It's so important that when people want information, when they're concerned, they're able to get it.  That's going to help do that.  We're getting 4,000 calls, over 2,000 e-mails a day.  We've added new servers and technology.  We're getting 6 million to 8 million hits a day on our website.  We're doing webcasts.  We're doing one later today.  We're out there twitting as well.  And I've never twitted, but for those who twit, they find it's a good way to get information. 

We're issuing more recommendations and guidance.  We'll be putting out later today information for colleges and universities on what to do should they have cases on their campuses.  We've already put out -- we always have had guidance for flu outbreak control.  What this will do is provide some additional guidance for this new strain of what they should do on campuses.  Basically we want people to review their plans and be ready to implement them, track and report illnesses among students, and then promote the same activities we're asking everyone to do in terms of personal prevention. 

Yesterday we talked a lot about vaccines and the movement towards vaccines and had discussion around growing up the virus so that we're able to move towards production of a vaccine if we decide that is warranted.  And those efforts still continue to move forward quite successfully. 

Okay.  So in closing, I want to reiterate something that I said repeatedly.  What we call this matters much less than what we do.  We continue to be very aggressive in our approach, and we're going to continue to do that until the situation tells us we no longer need to do so.  There's no one action that's going to stop this.  There's no silver bullet.  But all the effort, the effort of governments, the efforts of communities, the efforts of individuals will help to reduce the impact on people's health, and that's very important.  The actions will vary by community, and that's a good thing.  We'll learn from that, what things are more effective and what things are not a good use of resources.  Those things that aren't a good use of resources we want to stop doing them so we can redirect our effort into things showing to work.  I know people are concerned and some people are afraid.  And it's important that we do what we can to take those concerns and fears, handle them into personal action and personal planning.  Because it can be very empowering.  There are things people can do.  If people start doing these things in terms of hand washing, covering coughs, staying home when they're sick, it will help not only for this, but when future respiratory illnesses come through, thereby a personal sense of responsibility that it is really not a good thing to try to do things that may spread that virus or infection in the community. 

Lastly, I just want to let you know how incredibly proud I am of the people here at CDC.  This goes for the hundreds of people who are working around the clock on this outbreak control but also the thousands of people at CDC who are doing our daily public health work.  While we are responding to this outbreak, we are also doing the work of promoting and protected health in other areas.  I just want to acknowledge that here because they're not here every day.  They're doing the work.  And it's really an incredible effort here at CDC.  And with that, I would like to take your questions. 

Operator: Thank you.  Our first question comes from Maggie Fox from Reuters.  Your light is open. 

Maggie Fox: Thanks a lot.  I would like to ask about the diagnostic tests.  What tests are available?  Can you tell us a little bit about this lab in Mexico, what its capacity is, how long it takes to test someone for H1N1, and where those tests are now so that we can judge a little bit more about the information that comes in, how long it will take to get a confirmation.  Thank you. 

Richard Besser: Thanks.  Testing is an important part of this.  We may change our strategy around testing if we start to see more cases in the community.  We may look at not doing testing with each case.  But right now what happens is you go to your doctor with flu-like symptoms.  And if the doctor is concerned you might have H1N1 virus, they'll take a swab in your nose.  That will be sent to a laboratory for culture.  And then from that there will be special testing done to see if this is one of the commonly circulating strains of flu.  If it's not, it will be sent on to the state lab for confirmation -- or for testing.  At this point, not every state is able to do the testing for the H1N1.  Up until I think yesterday CDC was the only place here that you could get that done.  We're in the process of rolling out across the country testing capabilities to every state.  The reason we're able to do that is that there's been a major investment over the past five years in our state lab capabilities.  And so these labs are ready to go, when they get their test kits to ramp up and do additional testing.  And so maybe by the end of this conference I can tell you how many states have that so far.  But our goal is to get it out to all the states in the very near future.

Maggie Fox: Can you tell us does Mexico have a test now?

Richard Besser: We have been working as part of the tri-national team and testing is now available in the laboratory in Mexico to confirm H1N1 disease. 

Operator: Thank you.  Craig Schneider from Atlanta Journal Constitution.  Your line is open. 

Craig Schneider: Can you tell me where Georgia stands in terms of having the rapid test and their ability to diagnose and so forth?  I understand Georgia, you know, does not have the vast reputation for the communication between doctors and state officials on reporting illnesses. 

Richard Besser: As a Georgia resident and as a volunteer Georgia physician, I've had great experience with the Georgia Health Department.  But we will get information in terms of whether Georgia has that kit now and, if not, when that might be available.  Let me take a question here in the room. 

Reporter: Thanks.  Mike Stobbe from the AP. – Doctor, Mexican health officials expressing optimism that they may have turned the tide there -- what is your assessment of the situation in Mexico?  Is it getting better?  And also what's your assessment of what's going on in The United States, if it's getting worse?

Richard Besser: I think it's premature for me to comment on the situation in Mexico.  I'm really looking forward to seeing more data coming out of Mexico to get a handle on that.  What we learn from Mexico will be very important for our situation here, in part to try and help us predict what we might see here in the future.  As I've been saying over the past few days, I'm trying to understand why they're seeing a different picture in Mexico from here is really the critical question, whether it has to do with the steps that were taken early on in Mexico, a difference in the virus, a difference in the individuals who were sick, a difference in how long it took to go for care or the type of treatment given.  We don't know the answers to that.  You know, I would love to hear and see confirmation that what you say is true, but I don't have information one way or the other on that.  Here in The United States we're seeing ongoing transmission, and that's what we expect to see with the new flu strain.  A new influenza travels very easily person to person.  So what I expect to see here is ongoing transmission in states.  What I expect to see here is a broader spectrum of severity.  I would love to see the same type of cases we're seeing which is primarily the less severe cases.  Again, people have growing medical conditions including viruses are not kind to people who have many underlying medical conditions.  Another question here in the room. 

Reporter: Hi, Dr. Besser Betsy McKay from "The Wall Street Journal."  A couple questions.  One is what is the latest you're discovering about the virus in terms of the virulence or to other flu strands?  We know it's a novel virus.  And I also wanted to ask how much better we are prepared with the pandemic -- particular things that have been done -- with this outbreak? 

Betsy McKay: Thank you.  It's premature to say anything about virulence compared to other strains, but that’s an important question.  The virus is being shared and has been shared broadly.  And we look to the research community to be working on addressing those.  Dr. Fauci has been talking a lot about the contributions of NIH and the biomedical community and research community.  They're revved up to be addressing those questions.  In terms of preparedness, it's really hard to point to one thing.  When you talk about preparedness, you're talking about systems, integrated systems and systems that are practical.  And pandemic flu, if you look at what we have been practicing for the past five years and what we've been planning for, pandemic flu was number one on what we were looking at.  And while micros don't read the plan and you need to move away from the plan pretty soon after day one, the fact that we've been exercising several times a year for a pandemic and the state and local health departments have been getting tremendous resources for this, it has meant that when it arrives we didn't have to sit down first and say, let's talk about flu, here's the things you need to look up for with flu.  And with a lot of emerging infections that's where the conversation is starting.  What we find is that we can talk about concepts like community mitigation, which is a term for how do you control something in the community?  And the public health community knows what we're talking about. They've been doing planning around that.  And that is -- that's a big piece.  The second piece is laboratory capability, that we have that around the country.  And it's a precious resource and one that we need to maintain.  Next call from the phone. 

Operator: Thank you. Maryn McKenna, CIDRAP News, your line is open.

Maryn McKenna: Thanks so much for doing this.  I would like if possible to get a little more granularity on the planning for potential vaccine.  You talked yesterday about a seed strain being developed and distributed.  Can you let me know if it's been distributed to all the flu vaccine manufacturers and, if not, could you let us know which ones are participating?  Can you talk at all about how working on a seed strain will impact their production of seasonal flu vaccine for the coming year and whether that will work for their timeline?  Pretty much any other detail you might have. 

Richard Besser: Sure.  I will tell you what I know on that and then I think we should share some additional information around that.  We are growing up the virus that would be used for manufacture.  So we've isolated the standard strain.  That being grown up for manufacturers.  It hasn't been distributed to manufacturers yet.  You grow up the seed stock to a certain level, do pilot testing, look to make sure that what you have hasn't changed at all, and then that's able to move forward to the production stage.  In terms of production, what we are talking about, and these are still discussions, is that we would complete the production of next year's seasonal flu vaccine so we would have next year's seasonal flu vaccine.  And then manufacturers switch over to manufacturing a vaccine for this H1N1 disease.  That's what we're planning for.  We don't need to make that decision right now.  What we need to be doing right now is growing up enough virus and doing the initial pilot test.  That's about as far as I can go on that.  And tomorrow let's have someone here to take some more details on the vaccine manufacturing.  We want to make sure in the vaccine manufacturing we are still able to protect the country from seasonal flu and be able to protect from this virus if we decided to do so.  Here in the room. 

Reporter: I’m the medical correspondent CBS Evening News with Katie Couric.  Have you done any computer modeling about how many people you think may be affected in the first strain and in 1918 people who were affected by the relatively milder first wave were actually protected when the more serious second wave came?  In that modeling if you've done it, have you ever thought about whether infection now might be protecting people from a potentially second deadly wave?

Richard Besser: We have done a lot of modeling around pandemic preparedness.  We have modelers involved now who are giving us their advice and input.  And I think that modeling can take you so far.  It's very helpful, too, as we consider various potential interventions.  So, for example, the issue of border closure and should you close a border or implement very stringent entry or exit screening.  Modeling has been helpful in showing what's the added value of that.  And what it told us going into this was if you had a pandemic or potential pandemic strain starting at distant shores, and you implemented very quickly stringent entry screening, you might be able to delay the widespread dissemination in your country by a few weeks.  Now, a few weeks, that doesn't sound like much.  But if you don't have it in your border, that few weeks may allow you to do the kinds of things we've been doing now, implementing surveillance, distributing countermeasures, doing those kinds of things.  Once it's already inside, as the president said last night, the horse is out of the barn.  So those measures don't have any added value.  That's helpful information as you're trying to target your resources most appropriately.  The second question about what we know from history about early infections, and the really good one and a challenging one, is if you have a mild infection now it could protect you when the strain comes back at a later time, if it came back at a later time as a more serious strain.  And we don't know the answer to that.  But it's something that we'll be thinking about and looking at.  We'll be looking to see did those people who had mild infection amount a significant immune response.  It's hard to predict that if this goes away whether it will come back more severe or like the virus in 1976 would it go away and not come back at all.  So those are some of the discussions that we'll be able to have once we're able to knock this one out when we're moving on to discussing vaccine policy.  Now, I think that as many modelers as you'll have you'll have that number of estimates.  It's useful information, but there's no number that we have that we're using.  Yeah? 

Reporter:  Hi.  Is it safe to fly? I ask that because today on the "Today" show, Vice President Joe Biden said if it were his family members he would tell them not to fly at all, that it's not safe.  And what can you tell us about the reported case in west Georgia? 

Richard Besser: All right.  I think this is what we call in public health a teachable moment.  In terms of what things are indicated and what things aren't.  There's a lot of things that we can do to try and reduce our risks.  A lot of things people are doing on their own.  For us in public health it's important to say what things are evidence-based, what things can you do that could put yourself at risk and what things can you do to reduce your risk.  In terms of flights, if you have a fever, flu-like symptoms, you should not be getting on an airplane.  That is part of being a responsible part of our community.  You don't want to put people at risk.  I think flying is safe.  Going on the subway is safe.  People should go out and live their lives.  There are some people who may not be comfortable doing that.  As a public health community, we can put in context what the risk is, so that people are doing things to reduce their risk, hand washing, covering of the cough, avoiding ill people.  And if we look to each other to be responsible and not get on airplanes and places when we're sick, that makes everyone else safer.  In terms of a case here in Georgia, I'd refer you for details on that to the Georgia health department.  They did recently confirm that they have a case of H1N1 in Georgia, but I can't say anything more about that case except they have announced that they have a confirmed case here in Georgia.  Take a question from the phone, please.

Operator: Thank you.  Steven Smith from the Boston Globe. Your line is open. 

Steve Smith: Hi.  Good afternoon, Dr. Besser, and thanks for taking the question.  I'm wondering if you can discuss in the week or so that agencies have really been looking into this what the most important telling scientific discoveries are regarding the virus.  In other words, what have you learned further about its transmissibility, what have you learned about it being capable of in any way of changing its genetic machinery, what are you seeing about its continued susceptibility to anti-virals?

Richard Besser: I can share a little of that, and then I think tomorrow we'll have one of the experts from the laboratory come and give you more details on that.  We are sequencing strains of the virus.  What we're looking for is there change as it moves through communities.  And we are seeing slight changes.  But at this point we're not able to take those changes and say anything about whether it impacts on how severe the infection is.  But that's going to be very important.  What we want to look at as the virus goes person to person, does it change in any way the impacts on how serious an infection could be.  What you would like to see is it's decreasing as it goes person to person.  We don't have information yet to link the particular strains that someone has to the seriousness of the infection.  We only have 109 confirmed infections.  We'll be looking at that.  But we haven't seen any change in our ability to use the current anti-virals, oseltamavir and zanamavir for treatment.  We haven't seen any changes.  That's something that we'll continue to look for.  Tomorrow let's have one of those laboratory experts here to provide more on that.  One of the answers to the question about testing kits, we have a preliminary kit in New York and California.  These are at the research levels to make sure the kit is operating properly.  And then we'll be sending out reagent kits starting tomorrow to all states, assuming that the research kits that we sent out are working properly.  We want to make sure, whenever you're developing a new diagnostic test, you want to make sure it's working and can work as well as what we have here at CDC.  So that's what's going on currently.  All right.  Here in the room. 

Cece Connolly: Cece Conley from the "Washington Post."  I'm wondering if there's any value in a situation like this in doing any autopsies and if anybody has given thought to that, with the Mexico cases or the one in The United States were related.  Do we know what the actual cause of death has been in most of these, and does that help you in any way by knowing that? 

Richard Besser: The first question regarding autopsies, there is a lot that can be learned when you're looking at a new infectious disease of doing autopsies.  They can tell you something about how the infection is causing disease and how it's causing its symptoms.  I don't have information to share in terms of cause of death.  And I think behind your question is some of the thoughts that in 1918 the pandemic that some of the issue in terms of the high rate of death in the young healthy was their own immune system revved up and was part of the problem.  That's a really good question.  That's something people are thinking about and we'll be looking for, to see whether the it's the infection itself, whether it’s the immune reaction to that or whether it's moving on later.  In earlier pandemics there were bacterial infections afterwards that were a problem.  Those are things we’re looking for.  We have no information on those right now. 

Cece Connolly: I'm assuming it gets a little trickier with other countries.  [inaudible]

Richard Besser: I'd rather not comment about that particular child or case.  From the phone? 

Operator: Richard Knox from NPR.  Your line is open.

Richard Knox: Thank you very much, Dr. Besser.  I wonder if we can find out anything about whether the emerging evidence that the WHO seemed to indicate today of community transmission being seen in New York in particular, or elsewhere beyond schools and families of returning travelers from Mexico, any evidence of transmission like casual contact in the community?  And secondly, I wonder -- you mentioned there were six hospitalized people now and are confirmed cases.  Can you tell us any more about if any of those are critically ill or on ventilators? 

Richard Knox: I don't have additional information to share on the hospitalized cases.  I refer you to the states for more information.  And I don't know if we have it on our website which states have hospitalized information.  Okay.  I don't have additional information to share on that.  The studies that are going on in the particular states are looking at the issue of transmission to try to understand that dynamic.  We definitely have cases occurring in many states that aren't related to other clusters.  And how casual the contact was, I don't think we have information on that.  But our experience from influenza virus in particular is that it's a virus that spreads pretty easily person to person.  So it doesn't require as a virus that you have to have close personal contact to acquire it.  It tends to spread fairly easily.  And so we'll be looking to see whether that's the case.  But we would expect that it would transmit easier in crowded settings.  Less so in areas that are less densely occupied.  But we don't know yet how easily.  And the big question is how easily does it transmit.  And those infections that are transmitted, are they more serious, less serious and so on.  And we don't have information to share on that yet.  Two more questions from the phone and then we'll come back here to the floor.

Operator: Thank you.  Alice Park from "Time" magazine.  Your line is open.

Alice Park: Yes.  I'd like to go back to the vaccine question.  Dr. Besser, is it your opinion that were a vaccine to be created from that seed stock that you're working on now, that it would be applicable to cases that are occurring now or as a result of the transmission that's occurring now or because it takes so many months that we would be looking forward to create a vaccine, would this really be looking forward try to prevent any additional spread of this virus and strain of flu during next flu season.

Richard Besser: We're hoping to see the transmission now go away with the efforts that are under way.  And with what we know about flu virus transmission, be ready in the fall to vaccinate people if we decide that that is warranted.  And so that would be the plan to work towards developing a vaccine.  It can be administered in the fall if we felt a vaccine administration was the way to go.  Next question from the phone.

Operator:  Thank you.  Steven Reinhard (ph) from Health Day.  Your line is open.

Steven Reinhard (ph): Yes.  I wanted to ask you many outbreaks -- there are many more people who are sick but don't seek medical help.  Sometimes I think that averages 30 to 1.  Do you have any idea what that could be in this case?

Richard Besser: They aren’t sick? 

Steven Reinhard (ph): They are sick but don't seek medical attention. 

Richard Besser: Yeah.  I don't know.  That's a tough question.  When there's an outbreak going on, you can either see people sick who won't take medical care but often will see individuals who are sick or are a little sick and they're concerned because of what they're hearing and they want to be evaluated to make sure that's not going on.  So we don't have information on that phenomenon.  We are doing monitoring of E.R. visits in many places across the country as part of different surveillance systems that are in place.  But I don't have data that I can pull up of emergency room visits.  And last question here from the floor. 

Reporter: I was wondering if we go ahead, if we make the decision to go ahead with the vaccine, what is involved?  How much time will it take and how quickly can we get something on the market where Americans might be able to get access to it? 

Richard Besser: We would be targeting the fall.  And then the question is who gets vaccines?  Who do you vaccinate for flu?  And there would be looking to see what we learned now in terms of who are the risk groups that are at greatest risk from having bad outcome from the flu.  But then we would also want to engage in public discussion around that and to the engagement and input.  It's less of a science decision than it is societal decision.  Because clearly we would not be looking or able to have vaccine for 300 million people.  And let me put that in context as well.  We're a resource-rich nation.  And when you're seeing a new infectious agent, it doesn't respect borders.  And so part of the discussion is around what is our commitment here, what is our commitment as members of the global community.  And this is something that will undoubtedly require a lot of discussion and public input to see where we want to go.  Thank you very much for your time. 

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