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CDC Briefing on Investigation of Human Cases of H1N1 Flu

May 6, 2009, 1 p.m. EST

 

Glen Nowak: Thank you and thank you all for your interest and attendance today, both on the phone and in the room.  Today’s media briefing on novel H1N1 virus will be conducted by Dr. Richard Besser.

Richard Besser: Thanks very much, Glen.  I want to thank you all for being here for today's briefing.  This remains a dynamic situation.  Each day, we learn a lot more about transmission here and around -- around the world.  And I want to say that we remain concerned. I will be giving the number shortly but we are seeing continued spread around the country. We are seeing increase in numbers of cases and I want to make sure that people understand that changes in guidance that take place are based on science, based on what we think are the appropriate measures to minimize impact on people's health.  We’re going to remain appropriately aggressive in terms of those measures. As we learn more, as the science develops and is refined, we are able to tailor those measures more appropriately. 

Yesterday, we heard in the news at CDC the death of a woman in Texas. I want to extend my sympathies to the woman's family.  Any death is bad. This reminds us that influenza can be a very serious infection and it's one that we need to continue to take very seriously. Yesterday, we refined our guidance, we issued new guidance on school closure and day care closure and I want to make sure people know that those guidances are up on the web.  This is a good example of how we use science to inform policy and so as we've learned more about the severity of the virus, as we learn more about the severity of infection, as we learn more about transmission, we are going to continue to refine our guidance and that's something that people should expect. We have had some questions from the media about the length of time for school closure and why we had 14 days before and why we are talking now about 7 for children.  This plays in, again, to the issue of uncertainty and severity.  At a time when we still knew very little about severity, when the reports out of Mexico were of a much higher severity disease than we are currently recognizing, the guidance was saying up to 14 days. The reason for that is one incubation period is about 7 days and so if you're dealing with something that's quite severe, you may see some variability on shedding. You go for safety zone.  And there we recommended two incubation periods. As we now see this infection, it is not as severe as we had initially feared, we can cut back on that.  And realize that, yes, after 7 days there may be some children who are still shedding but they will be shedding less virus and appropriate action after 7 days theymay return to school. 
Let me give the case number updates. As of 11 a.m. today, we are reporting 1487 probable and confirmed cases in 44 states. That's an increase of around 400 from yesterday there are around 850 probable cases and 642 confirmed cases. The confirmed cases are in 41 states, increase of three states with confirmed cases from yesterday. In terms of the age range the median age for cases is 16 years with a range of 3 months to 81 years. 58% of the cases in the U.S. are under 18 years of age.  We have reported a total of two deaths and we have 35 hospitalizations, which are confirmed. Plus 17 hospitalizations that are -- that are probable.  The median age of -- for hospitalized patients is 15 years. That's for confirmed hospital cases and that's about the same as for cases in general. The age range for hospitalization is 8 months to 53 years. We have reported hospitalization confirmed cases from 14 states. Looking at underlying disease for the 13 individuals for whom we have that detailed information, seven of them had known conditions that would put them at risk for more severe infection. 

The World Health Organization is reporting 1500 cases, roughly 1500 cases in 22 countries, with Canada, Spain and the United Kingdom having the highest counts outside of the U.S. and Mexico.  Mexico had been reporting 822 confirmed cases and 29 deaths. We have been talking about what does the epidemic look like in Mexico?  We have quite a number of people in Mexico, I will talk about that in a moment.  But I think that we need to put in context the idea of is it going away in Mexico?  What we hear about in Mexico is what we are seeing and will continue to see here is when you see a large outbreak or an epidemic, it's frequently made up of a series of smaller outbreaks and epidemics, so, what they are seeing in Mexico is parts of the country where they are seeing increases in disease and parts of the country where they are seeing decreases. When you add that all up together it may show some leveling off but it doesn't really give a sense of how dynamic the situation is.  Here in the United States, each day we are reporting new states that are seeing disease. And so, we will start to see in those states increases and at some point, we will be starting to see in states decreases. The rapid increases in confirmed cases that I had predicted for today that were reporting is largely due to the ability of more and more states to do testing and so some of the backlog on testing is going to lead to catch up and we are going to continue to see those numbers increase. In addition, we are going to continue to see additional people get sick.  I don't want to attribute it all to testing, but in terms of our ability to confirm cases, we are seeing more of that around the country.  We are continuing to see virus spread in the United States and around the globe. The majority of the confirmed cases in this country are in younger people.  And it's important that people have respect for this virus, because it does cause severe disease, hospitalization and death. We don't know yet about issues of population immunity. What we are seeing, as we talked about in previous days, we are not seeing as much disease in the elderly. This could be due to some underlying protection or it could be due to just the dynamic of it starting with the younger population before it traveled to the elderly. 
Everything we've seen to date leaves us with the understanding that we need to remain vigilant. We cannot let up on this. It's important that people understand that there's shared responsibility, that people need to continue to wash their hands, cover their coughs and most importantly, when they are sick, not send their children to school, not go to work when they are sick. Those measures can help reduce the spread in communities and keep people protected.

An update on some of the public health actions, the stockpile of -- all states have received their 25% allotment.  We are in the process of replenishing some of our stockpiles through purchases. CDC has been actively engaged, over 900 CDC employees are responding to this outbreak that does not include our individuals around the globe who work in laboratory, working with other countries on their surveillance. We have 93 people in the field, including 16 in Mexico, and we have 33 more who are pending deployment.  The PCR test kit has been deployed around the country, so all states and Puerto Rico, we have shipped it as well to 16 countries, so this will help with the diagnostic capabilities around the world.  And as I said this will also increase the number of cases through testing alone.  We continue to work to understand the virus and the illness that it is causing. It's very important that we understand transmission in various populations. We are working with Texas and California and we will be sending two epi investigation teams there to look in particular at the issue of health care worker transmission. We want to see what are the dynamics of transmission, are there certain practices putting people at risk and if so, what can be done to tailor the guidance that we currently are providing in that area? 

I want to put a little focus today on the issue of pregnancy and disease risk.  So far, we are aware of six confirmed and five probable cases of H1N1 infection involving pregnant women.  This is not a higher rate than would be expected in the general population. However, pregnancy is a risk factor, a known risk factor for more severe disease. We want to make sure that clinicians have information on how they should approach the issue of infection in pregnancy and that women who are pregnant have this information as well.  So, on our website, we have for pregnant women, fact sheets on what pregnant women should know.  We have guidance for clinicians, if they have a patient who is pregnant, they will understand how anti-virals should be used what, the treatment strategy should be in that circumstance. 

So, in closing, I want to remind you, we do expect to see more school outbreaks.  We do expect to see more clusters around the country. We do expect to see more transmission and we do expect to see disease in all states. We it continue -- continue to be working actively in the area of vaccine development and that is a critical part of strategies moving forward. Seasonal vaccine is in production. We are moving forward on the development process for novel H1N1 vaccine.  We are taking those initial steps that are very important and necessary should a vaccine need to be made. There are a lot of decisions that would need to be made between now and people receiving a vaccination and the decisions will be based on the best available science.  Lastly, I want to just address the issue of W.H.O. and levels and as we have discussed before, W.H.O. levels have to do with the number of factors. One is there sustained transmission of a novel virus?  We have met that.  For us to move or for W.H.O. to move from a level five to a level six, they will look to see is there sustained transmission of this virus in more than one W.H.O. region.  Right now, they have not confirmed that yet. They just have sustained transmission in this World Health Organization region.  With the number of cases in other countries, I would be surprised if we don't get to a level six.  But we are not there yet and W.H.O. has not made that move.  One of the hallmarks of flu virus is they undergo constant change, we are continuing to actively looking at the virus in the laboratory. As the flu season starts in the southern hemisphere, what takes place there is going to be incredibly important, how does the virus compete with other viruses that are circulating in the community, does it change, does it mutate?  If so, in what way?  Does it develop resistance? Those are factors, studies that will be ongoing as we move through that period. We will continue here at CDC to give you the information we know when know it.  We’re going to continue to let you know what we don't know and provide the daily updates as long as necessary. With that, let me turn to your questions. Starting here in the room. 

Betsy McKay: Thanks, Dr. Besser.  I'm from the Wall Street Journal.  I have two questions, one about vaccine and one about hospitalization.  On the vaccine question is would -- if the virus changes, mutates and becomes more virulent, sort of a 1918 pattern, are we able to know right now that a vaccine that you're developing would be protected against the more virulent form?  The second about hospitalizations. I'm wondering how a normal a pattern the age group that is hospitalized, how normal that really is for, you know, compared with seasonal flu vaccine, the median age is 16 seems really young. 
Richard Besser: Right.  The first question, in terms of, you know -- if the virus changes over this period of time, will a vaccine work?  That's great question.  Each year with seasonal flu, the virus changes and at the time decisions are made as to what strain goes in the vaccine, you don't know what will be here the following season.  And so there's a process to pick that each year for seasonal flu.  And it involves experts from around the world making their best science-informed decision.  But at some point, there will need to be a decision if you're going to go forward, which strain you use. And you don't -- you won't know for sure until you know what's circulating in the following season.  But what we're seeing so far during the short period of time is a fair amount of stability in the virus, but what happens in the fall is not known.  In terms of the age distribution, you're right. We are seeing the same distribution in hospitalized patients as we are in milder cases in the community. And that's younger than what you would see in seasonal flu. In seasonal flu, you tend to see a predominance of burden of disease in the elderly and the very young.  And here, we are seeing it more in younger population. And so, that is something we are keeping our eye on, that is something that raises concerns and it plays into the question of why is that happening?  Is it because that's the population that got sick first?  The population that may have traveled to Mexico on spring break or is it something else regarding a protection, are the elderly potentially protected for some reason?  Those are things that we are continuing to look at, but that is a great question.  Another question here in the room? 

Ceci Connolly: Doctor, Ceci Connolly from the Washington Post. You mentioned Mexico. I'm wondering if you can elaborate a little bit more in terms of what exactly your teams are doing there, now that we are two weeks or so into this.  Are you starting to gather more useful information and you mentioned epi teams going to California and Texas to look at the question on health care workers.  Can you elaborate on that?  Do you have a particular concern at this point? 

Richard Besser: Let me start with Mexico.  I'm looking for the numbers, how many people I said down in Mexico.  Thank you. Yeah.  16 from Mexico and we are -- we are going to be sending additional people there. There are two -- a number of things we are doing.  One is just working on trying to describe the basic epidemiology.  That's been so incredibly useful over the past five days in helping us understand the issue of severity.  When initial reports out of Mexico were of very high rates of hospitalization and death, that was suggesting a very severe virus, a virus that could have devastating consequences. As we've learned more, we've seen that this is a virus that appears to be widespread in the community and that the issue of hospitalization and death was the tip of the iceberg phenomenon.  So, that has been very useful, getting laboratory set up is something that Canada, the U.S. and Mexico work on together and that has been very helpful in sorting -- sorting that out. Looking at spread around the country, Mexican government is putting teams in various states to be able to describe in more detail the epidemiology on the state basis. That is something that we do here and that is very useful, because your decisions on what you're going to implement are most appropriately taken at that state and local level. Different areas will be seeing different things and experiencing the outbreak in a different way.  So that's part of the assistance. But some of the new work that's going to be going on there is in the area of health care worker transmission and transmission to contact the cases. This will be very useful in understanding prevention strategies.  You know, when you're thinking about risk, who comes in contact with the most individuals who are sick and have flu?  Health care workers, people come in when they are sick. And we want to make sure that our guidance is as evidence-based as possible.  And if there are opportunities to prevent infections in that setting, we want to know what those are and what works. We have guidance up on the web now, but as I've said, as we gain more information, we will be able to tailor those interim guidance so that they are most effective.  So, that's the kind of work that's going to go on in Texas and California and that's what the teams are assisting the Mexican government with as well.  Take a question from the phone, please? 

Operator: The first from Ann Pistone at ABC. Your line is open. 

Ann Pistone: Thank you very much.  Doctor, from the experience of the CDC and the public health community has garnered the last few weeks dealing with H1N1, what is the most important changes or enhancements that need to be made to BioSense, to better prepare for more severe or intentional outbreak? 

Richard Besser: Thanks.  BioSense is an electronic surveillance system that took place in many places to look at various syndromes, so we can look and see how many people are coming in with flu-like symptoms, see how many people are coming in with a number of different conditions and it's one of the systems that we are currently using to look at visits to hospitals.  It's a useful piece of surveillance information.  And so, you know, we will -- we will, as we go forward, look to see what pieces of surveillance information were most useful and provided good insight in terms of what was taking place on the ground and what wasn't.  I think it is premature for me to comment on any of the particulars, because we haven't done -- we haven't done the look become to say, okay, which pieces of information were critical, critically important to decision making at what point?  How can we make sure that we've got a detailed understanding of what's going on in various places?  Next question from the phone? 

Operator: The next is from Robert Lowes, Medscape Medical News. Your line is open. 

Robert Lowes: Dr. Besser, the people at W.H.O. have announced they will be looking at a possibility of one starting wholesale or mass production of the H1N1 vaccine as well as possibly halting production of seasonal flu vaccine.  That is predicated on how much has been produced of the seasonal flu vaccine.  What is your reaction to that?  Is it a prudent step?  Consider halting seasonal flu vaccine production? 

Richard Besser: I missed the first part. Where did you say that was taking place? 

Robert Lowes: The officials at W.H.O. announced today they would be convening experts to consider wholesale production of a new influenza virus,  as well as halting production of seasonal flu vaccine. 

Richard Besser: Thanks.  The World Health Organization has an expert committee they convene to address global issues around pandemic flu.  That's the body that helps inform them whether it's time to move phases of a pandemic.  And that's body that will help inform them as well in terms of the global position on vaccination. And the U.S. government has participation on that committee.  I think we have three members on that committee.  And so I will be very interested to see what their discussions say and where they come down on vaccine production. Here in the United States, we are pushing forward with production of seasonal flu vaccine and that's moving forward very aggressively.  We are also undertaking those steps in the development of an H1N1 vaccine that are necessary to do now, so that's providing the virus strain, growing that up as a seed stock and once that's grown up, providing that to manufacturers so they could do initial study if they were to move forward with the vaccine.  And so you know, World Health Organization has a responsibility for developing recommendations for the world and we would definitely welcome and we will be participating in those discussions. Let me take the next question here in the room. 

Mike Stobbe: Thanks, Mike Stobbe from the AP.  Two questions, first, following Betsy’s, about hospitalizations and the age, is age appearing to be as great or greater a risk for hospitalization than underlying conditions?  And second on underlying --

Richard Besser: I wouldn't put too much on the data that I gave on hospitalization. In terms of the chronic condition, that was based on 13 people, there is -- that kind of information, dealing with very small numbers is subject to great change.  And given the number of people hospitalized is very small, you run the risk of overinterpretation, the range there was three months from 81 -- eight months to 53 years, so it is a very wide range.  You talk about it as a median, middle number of 15 it may signal a little more than you want to interpret there.  But looking at hospitalizations and risk by age is really, really important.  I mean, as this progresses, I fully expect we are going to see more hospitalized individuals and we are going to continue to look at that factor. 

Mike Stobbe: Second question, on underlying conditions, understanding the point you just made about the small number of cases, can you tell us what underlying conditions are recurring in those, I guess, 13, and there's a lot of attention on the death yesterday. Was pregnancy in that case the underlying condition or did she have something else that you believe exacerbated the death? 

Richard Besser: I don't have any additional information on the woman from Texas. The other patients, it was a wide range.  There wasn't something that was popping up as predominant, but there were only seven people with a chronic condition. As we gather more information on that what we will be looking to see is there a risk factor that is putting people at greater risk?  Is it something that we can alert people to that would have protective value?  But right now we don't have that information. Thankfully, the number of hospitalized individuals is small.  In the room? 

Michelle Marsh: Michelle Marsh from CBS Atlanta News. I have two questions. One is how soon do you project a vaccine will be available?  And second, various health officials are discussing the possibility of asking people to get three vaccinations by this fall, one for the regular flu and two installments for the H1N1 virus. I just want to get your response to that and whether that’s a possibility. 

Richard Besser: Well, when  vaccine would be available, you know, it’s really early to say because of all the steps that need to take place.  What I can say is that we’re doing all the steps necessary now should a decision be made to ramp up for vaccine production. That is, growing up the seed stock, making sure that that's going to be available for manufacturers, engaging in discussions with the industry so they understand the virus and understand what studies they are going to need to be undertaking.  In terms of a number of doses to put it in perspective, before a vaccine is administered to anybody there is a series of studies that need to be taken under the direction of the NIH and approved by the Food and Drug Administration. And what they are looking at is they need to do studies to determine how much stuff needs to be in the vaccine, how much of an antigen needs to be in the vaccine to stimulate protection and immunity. Then they also need to see, do you get sufficient immunity from one dose?  Do you need more than one dose?  And with each vaccine, it's different.  With different age groups, it's different.  And so, it is really early to say how many vaccines someone's going to need till those studies are done.  But that's going to be very important information because it will -- the number of doses you need will impact on how many people you will be able to vaccinate.  And, you know, hopefully, we will be able to find a vaccine that worked very readily with one dose. Back to the phone? 

Operator: Elizabeth Weise with USA Today, your line is open. 

Elizabeth Weise: Hi, thanks for taking my call. I actually had a question about the number of cases in Illinois, which has jumped and is now the highest in the nation. I know part of that's testing artifact, because they just got their kits over the weekend, but do your folks there have any sense of why Illinois has even more cases than New York at this point? 

Richard Besser: No I would have to refer you to the folks in Illinois to understand the testing dynamic.  Mayor Bloomberg was here visiting CDC a little while ago and his comment when he was meeting with the media was you want 200 more cases?  We will test 200 more people.  And so, you may see in different places different approaches and strategies to testing. And so I don't know the specifics on Illinois, but I'd refer to you them on that.  But some of the differences you will see by state are have to do with viruses and transmission. Some are going to do have to be much more where they are in ramping up their laboratory testing capability and what they report out.  Another question from the phone? 

Operator: The next question is from Suzanna Hoholik with the Columbus Dispatch, your line is open.

Suzanne Hoholik: I know you keep talking about these test kits and the Ohio authority said they have not received theirs even though a couple of days ago, it was supposed to be on their way.  How many are coming and when will they be here? 

Richard Besser: Well, I will follow up after this press conference and see what the situation is there. The test kits have come out. Some of the states have not been able to fully use them yet because the first five runs need to be validated with our laboratory. And so, we will follow up and see what's going on with Ohio, but I appreciate that information.  Next question from the phone? 

Operator: The next is from Delthia Ricks,  Newsday.  Your line is open. 

Delthia Ricks: Thank you, Dr. Besser. I would like to know rather than a potential pandemic strain, could this possibly be a newly emergent H1N1 that may compete with or replace the current H1N1 in circulation? 

Richard Besser: I think I missed the beginning, you were asking whether the strain we’re seeing here culd replace the other H1N1 that’s in circulation? 

Delthia Ricks: No, a potential pandemic strain – could this be one that is newly emergent but will ultimately replace the H1N1 that is circulation?  In other words, we may not really be looking at a pandemic strain? 

Richard Besser: What we need to look at is what happens in the southern hemisphere, and that is going to be very important.  How does this H1N1 compete with other H1N1s and other strains in circulation. The difference between this strain and other H1N1 is that this is a novel strain.  That originally -- that has many components, has a swine component, it has an avian component, it has a human component and it is a strain to which we feel the population does not have immunity.  The other H1N1 that's been circulating is one to which many people probably have some baseline immunity, given that if they were vaccinated last year or they have been exposed to this before.  So it's kind of a confusing point. There are different H1N1s. This one here -- this novel strain is one we feel more people would be at risk for and that's why it's different than the one in circulation. Whether it replaces it or not, it will be hard to say but that is what we want to look at coming up.  Back to the room. 

Michelle Marsh: Just a follow-up to the question that I had before.  There's been a lot of concern that by the fall season, this may look like the calm before the storm.  Can you speak to that as to what is being done to make sure that when the fall season comes around, things are not -- we are not overwhelmed with even more cases than we are seeing now? 

Richard Besser: Thanks.  You know, I wish I could predict what we are going to see in the fall because that would make it very easy to make the kinds of decisions we are going to need to make as a nation over the next few months. And we could see a number of things happen.  We could see the current strain fizzle out and never come back again.  We could see the current strain come back as it currently is or we could see it mutate and change and come back in a more severe form.  What we need to do during this period is really a shared responsibility and that is make sure that we are prepared and that is making sure that we are prepared as a government and as a public health agency and that our laboratories are ready and our epidemiologists are ready and we are ready, should this come back much more -- as a much more severe infection. We need our communities to be ready so that they would know, what would they do if this came back and was really severe and we needed to take measures like closing schools?  How would they ensure that children who got school lunch got that at home?  We are not going to see problems in terms of nutrition. How do we ensure that parents who want to do the right thing and stay home with their child when they are sick can do that and not lose their jobs?  Those kinds of preparedness efforts over this period of time will really help minimize or reduce the impact, should this come back more severe and will also leave us prepared for any other type of emergency that could come to our community. Okay, last question from the phone and then we will take the last one in the room. 

Operator: The next is from David Brown, Washington Post. Your line is open. 

David Brown: Yes, thank you.  Dr. Besser, does CDC or HHS have any preproduction contracts, standing orders, so to speak, with vaccine manufacturers to buy a pandemic strain vaccine?  And I'm not talking about H5N1 which is already bought, but standing orders now?  And if it does, how many doses do you have on a standing order and with what companies? 

Richard Besser: David, I'm going to have to refer you on that question.  Bruce Gellin in the department is the head of the National Vaccine Program Office. And that's the -- that's the office that really coordinates a lot of these efforts and I don't know the answer to that question, but he would be able to address that.  Last question in the room? 

Mike Stobbe: Thanks.  Doctor, just following up on your comment about preparation for the fall.  When Mayor Bloomberg was here this morning, we asked if he was -- had any special preparations under way for the fall. He said no.  What should local communities be doing?  Should they be – should the health departments be hiring or certain staff be trained in giving vaccinations?  What do you think communities should be doing specifically? 

Richard Besser: I think just to clarify the mayor's comments, New York has done intensive pandemic plans and so, in terms of doing something special based on this, I think they are doing what everyone's doing, and that is looking at their plans, making sure that they are making the changes to those plans based on this strain and what's circulating and what needs to take place. At the federal government, we are doing that.  We are constantly looking to see what have we learned so far what changes do we need to make?  As we go forward to the fall, what pieces of information are going to be critical to some of the decisions that need to be made?  What do we need to be sure that we are ready?  I mean, one of the things that we have done that I already mentioned is already worked to replace some of the stocks of anti-viral and Tamiflu that have been distributed so we’re gonna be building those stockpiles back up, so should they be needed, we have them ready. Thank y'all very much.  Appreciate it. 

End

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