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CDC Telebriefing on Investigation of Human Cases of H1N1 Flu

June 4, 2009, 12 noon ET

 

Operator: Welcome and thank you all for standing by. At this time I would like to remind parties that your lines are in listen-only mode until the question and answer session at which time you may press star 1 to ask a question. Today’s call is being recorded, if you have any objections, you may discontinue at this time. I will turn the meeting over to Joe Quimby, thank you sir, you may begin.

Joe Quimby: Good afternoon to everybody.  I’m Joe Quimby from the Division of Media Relations here at the CDC.  Thank you all for joining us. With us today to provide opening remarks, take questions and answers, is Dr. Anne Schuchat, the director of National Center for Immunization and Respiratory Diseases.  Doctor?

Anne Schuchat: Good afternoon, everyone, and thanks for joining us.  Today I’ll give a brief update on the situation here in the U.S., but I want to, in addition, mention a couple other things –  an MMWR that's out just today on the Mexico situation, I’ll mention a report that was just issued by the Trust for America’s Health, a little bit on vaccine development, and then just some background about the WHO and its approaches to pandemic phases.  In terms of the case situation, we do continue to see more cases in places around the country.  Activity seems to be declining in the nation as a whole, but there are some areas where illness is ongoing.  We do have cases confirmed from all 50 states. The global situation is increasing with the WHO officially reporting 19,273 cases in 66 countries.  Of course, you know the southern hemisphere is going into its flu season and so cases are increasing in some countries there.  In the U.S., so as of our official counts for the day, are 11,468 probable and confirmed cases, with 770 hospitalizations or 2.5% of our cases. We have 19 known fatalities that have been reported to us.  As we've been mentioning, these case counts are really what we think of as a minimal estimate, a burden, really, we think that disease is much more common than that, but these are a way that we track some of the patterns.  When we look more closely at our cases and hospitalizations, we are continuing to see this focus on younger people.  60% of the cases and 42% of hospitalizations have occurred in people between the ages of 5 and 24 years.  Hospitalization rates, that is cases per population, are highest in people 5 to 24 and next highest in children under 5.  This is quite different than what we see with seasonal influenza where the highest hospitalization rates are in the elderly.  We have very low rates of hospitalization and cases in people 65 and over.  We tested isolates now from a wide geographic area, from the Americas, Europe, from Asia and New Zealand, and we're really not seeing variation in the isolates in the genetic testing that we do here. 

There's an MMWR report that was issued today.  This is a really nice summary by colleagues from Mexico, the Pan American Health Organization and then both Canadians and Americans that were part of this response team describing the outbreak in Mexico.  And there are a number of epidemiologic features summarized in the article that really turn out to be consistent with what we are seeing here in the United States and what’s been observed in other countries.  Key features that are similar are this off-season transmission of the influenza strain.  In cases predominating in children, young and middle aged adults with this sparing of the elderly that we've been noting here in the U.S. and certainly that was a feature of the Mexican report. The evidence from Mexico suggests that the outbreak there likely peaked nationally in late April.  There are decreases in case counts from the country as a whole, although some localizes transmission is continuing to occur.  So the Mexico report is a very helpful summary of the country that really first had the largest problem noted and, you know, with a helpful summary of the circumstances there to put this into context. 

I want to next mention that the Trust for America’s Health has issued a report describing lessons learned so far in responding to the H1N1 outbreak.  You know we are only several weeks into this response and I think it's very helpful that Trust for America’s Health has already done an extensive review and tried to identify what has worked and what -- where the gaps are.  This is the kind of review that we really encourage organizations and communities to do to think about where the gaps are and what we need to do to strengthen those gaps.  As we've been saying, this is not over.  The novel H1N1 virus is in many parts of the country and, of course, now increasing in some parts of the southern hemisphere and we are very busy in learning all we can about what has happened so far, reaching out to the southern hemisphere partners to work with them on understanding the course of illness there and then, of course, making extensive preparations for response in the fall, potential vaccination, laboratory and epidemiologic needs and really an extensive preparedness planning.  So Trust for America’s Health has a number of findings that they think people should think about in terms of lessons learned and gaps that might be built. 

We've been talking about vaccine development and planning for vaccinations.  Remember that we've taken the first steps of developing a candidate vaccine virus.  CDC has provided that virus to a number of laboratories and manufacturers in other countries that serve manufacturers there, really a virus that can then be used to produce pilot lots of vaccines that can then go into testing to see whether a vaccine would produce immune response, clinical protection and could be safe.  So those first steps that candidate virus vaccines -- or candidate vaccine virus strain sharing and go ahead for the clinical lot development is ongoing as well as the U.S. government committing to purchase a bulk ingredient that could be stockpiled for future vaccines.  That decision about whether or not to use a vaccine and how to use it if you're not going to use it has not been made and won't be made until more information is available about patterns of disease and about how a vaccine performs in this clinical testing.  So those are intensive efforts over the summer.  In the meantime, efforts have begun to plan for immunization, even if we don't have to go there, we really need to start the planning now.  That's how vaccinations might go forward. 

There's been some mention in the news and through the World Health Organization about the WHO phases and whether it might be appropriate at some point to go from phase 5, which is where we are currently, to phase 6.  And so I just want to provide a little bit of background about that type of decision making.  Designation of phase 6 would indicate that a global pandemic is under way.  It would suggest that the virus has spread widely.  It would not suggest that this virus is more severe than we've been describing. The phasing at WHO is an indicator of spread and not of severity.  So the WHO's decision, should they make a decision in the future to raise the pandemic alert level, would be a reflection of epidemiologic changes in other parts of the world, not here in the Americas where we also -- where we already have had extensive community spreads.  But it would be an indicator of the patterns of disease that are being observed or confirmed in other regions.  And it's really would have less implications here in the U.S. where we've already been having an active intensive response.  It still is uncertain at this time how serious or severe this novel H1N1 virus will be in terms of how many people infected will -- there will ultimately be, how severe complications or deaths would stack up.  So again, this phase 6 would be a transition to a more extensive spread, but not to a change in severity. 

As we've been saying all along, we're taking this very seriously here.  We know that the state and local health departments and the clinicians have been taking it seriously and we also really applaud the American public that has been taking this seriously and doing their part to keep their families and communities protected.  It's a good time for people to be thinking through plans going forward, how to cope with illness that might come back in your communities in the fall.  And so these planning efforts aren't just important at the government or institutional level, but also in the homes.  It's also a good reminder that we're officially entering hurricane season and that's another thing that is good to be prepared for. 

So I want to close at this point and just stress that this is a novel virus, this H1N1 virus.  The world has several weeks' experience now.  We really aren't even looking at a three-month experience yet with this particular virus and we need to remain humble and learn as we go.  Of course, here at CDC, we're committed to share what we learn as we learn it.  So let's now go to the phone for questions. 

Operator:  Thank you.  Our first question is from Fergus Walsh, BBC, your line is open. 

Fergus Walsh: Yes, Hi.  Thanks for taking my question.  Could you tell me where you stand at the moment with the level of hospitalizations?  Is that enough in itself if we get a pandemic and indeed an epidemic in the United States for you to think that it would be worth shifting from seasonal flu vaccine production to a pandemic H1N1 setup? 

Anne Schuchat: You know, the seasonal influenza viruses are estimated to cause 200,000 hospitalizations every year in the United States.  And we estimate about 36,000 deaths in the U.S. each year from seasonal flu.  Now, most of those deaths and most of those hospitalizations are in people over 65.  So the epidemiology of this particular virus does not seem to be causing a lot of problems in the elderly, who are more likely to die when they get infected with influenza.  2.5% of the cases we're counting have required hospitalizations and some of those hospitalizations have been severe.  So, you know, it would require intensive care unit and mechanical ventilation and such.  We're really at too soon of a stage to say how extensive a problem we might have with hospitalizations or severe illness in the fall should this virus continue to persist in our communities and go through a full season.  I can say that there is no intention here in the United States to pull back from seasonal influenza vaccination.  Manufacturers have been producing -- you know, going through the steps to produce vaccines and the timing of recognition of this virus here in the U.S. was such that the decision to take the early steps towards vaccine development did not really interfere with producing a vaccine for the northern hemisphere or for here in the U.S.  We are, of course, in this phase of considering whether we may need to vaccinate against this novel H1N1 virus.  As I’ve said, we want to learn from the experience of the southern hemisphere, learn all we can about how much disease and problem this caused here in the U.S.  and learn whether a vaccine even could be produced that would be safe and protective.  Next question, please. 

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

Mike Stobbe: Hi.  Thanks for taking the question.  Hey, doctor, you mentioned before that you're going to be watching the southern hemisphere.  And you mentioned earlier in this call that as you've testified around the world there's not much variation.  But the flu is starting to occur in the southern hemisphere.  Could you tell us more about how it's unraveling there?  Is it -- what percentage of the cases are the swine flu, what percentage are seasonal and is it a bad flu season in the southern hemisphere so far or how is it going? 

Anne Schuchat: You know, we have information from a few places that have reported their experience.  And important to say is that it's early in the southern hemisphere.  It's the beginning of their flu season.  Australia actively tracks influenza.  They're one of the four WHO international collaborating centers for influenza.  And in Australia, they tell us that their season peaks in July and August.  They are seeing cases of this novel H1N1 virus. They're seeing cases of other viruses, as well.  But it's too soon to say whether this is dominating or not and it's very, very early before we would know whether -- with the extent of illness that they'll have.  But I would just give that as one example where there's been long-term influenza tracking and an active public health response and really good information sharing across countries.  Next question. 

Operator: Thank you, again, if you have a question, please press star 1 and record your name. The next is from Daniel DeNoon from WebMD.  Your line is open. 

Daniel DeNoon: Thank you, Dr. Schuchat.  During the TFAH report today raised specter that even if the flu this fall is very much the same as we've seen over the summer, the heightened flu activity we would expect may cause -- may overwhelm some hospitals in local communities.  Can you talk about preparedness of local communities and how CDC is going to be preparing possibly for the kind of surges, the kind of worried well that we saw in New York that overwhelmed infectious disease wards and made it kind of difficult to get people into ICU. 

Anne Schuchat: You know, partnership between the medical providers, the public health sector, business and the private sector and then, of course, the public is vital to preparedness for influenza surges or for other kinds of catastrophes.  And so I think there is a lot that we can do this summer to better prepare communities and the health system to be able to handle increases in influenza that might be greater than expected for the season.  So there is an active effort working between some of the public health organizations, the Association of State and Territorial Health Officers, the National Association of City and County Health Officials and CDC as well as with some of the medical provider groups to work together on this community preparedness to say what did work, what didn't work, where can we address some gaps.  I would say that we are working actively on strategies like what kinds of laboratory sampling should be done so that the laboratories can keep up with the information needs but also with the critical other things that they need to do.  We're also working on the clinical front in terms of what kinds of treatment would be needed, what kinds of testing is important for individuals versus for understanding the patterns.  Certainly the Department of Education and schools all over the country are looking at lessons learned from those kinds of school dismissals that we saw and really strengthening school preparedness.  Of course, schools need to be prepared for infectious disease problems but also for other problems that they see, whether they're natural disasters or some of the violence that we've seen in schools.  So really dusting off those plans, getting the pandemic plans that people have within their communities or organizations or also their emergency management plans.  For families of course, there's a lot you can do with having a communication plan.  Certainly as hurricane season goes forward, we urge people to remember the steps that they can have to be prepared should some of the services they rely on go out.  So this is a very good time for us to make sure that we're as ready as possible going forward.  I think that some of the steps that we've learned from our exercises in the past are how important it is for people to know where to get information and for the partners who respond to these kinds of emergencies to know each other and to know who is doing what and sort out the rules and responsibilities.  So those are the kinds of planning and coordination efforts that can happen within communities and a lot that we can do to make sure that the federal, state and local levels are well coordinated together that we can be working as one unified enterprise and really sharing the responsibilities of response together. 

Joe Quimby: Next question, please. 

Operator: The next is from Kate Traynor, AJHP.  Your line is open. 

Kate Traynor: Hi.  Thank you for taking my question.  I saw an estimate of the World Health Organization recently that the bulk of the seasonal influenza vaccine for the northern hemisphere will be finished up at the end of July.  So I’m wondering if you can comment on that particular estimate.  And also, if that's the case, is CDC going to take some kind of official push for organizations to start their seasonal influenza vaccine campaigns early to sort of clear the decks in case you need to start vaccinating against the new virus? 

Anne Schuchat: You know, the estimates for manufacturing are always challenging.  We always want vaccines to come out on schedule and it’s just very difficult season to season, manufacturer to manufacturer, to predict precisely when we'll have product and exactly how much we'll have.  When you look over the past five- to ten-year seasons of influenza, we've had very different timing of availability.  Of course, these investments and expanding manufacturing are giving us a much more robust manufacturing base.  I think it's really too soon for me to be certain whether vaccine supplies will be available during the summer months or not.  That said, I would say that we are working with our local and state immunization partners and the preparedness community as well as across the federal government to talk about immunization planning, both for seasonal influenza and potentially for a vaccine that would be developed against this novel H1N1 virus.  And so the concept of how would vaccination against two different kinds of influenza vaccines work in terms of where would it be given, the timing, the logistics and so forth.  So I do think that these are important discussions to have, understanding that we can only -- we cannot predict perfectly the timing of when seasonal flu vaccine would be available.  We also cannot -- we also cannot -- have not yet made a decision to immunize against the seasonal flu [Editor’s Note: This point is clarified in the last question].  Next question, please. 

Operator: Next is from Madison Park CNN.com, your line is open. 

Madison Park: Thank you.  I wanted to go back to the issue of preparedness and the Trust for America’s Health Report.  And see, outbreak of the avian flu a few years ago helped the CDC in terms of preparing for an outbreak of the H1N1 virus?

Anne Schuchat: I’m sorry, I missed the last part of your question.  Something got blurred there.  Could you say that again? 

Madison Park: Did the outbreak of the avian flu help the CDC in terms of preparing for an outbreak of the H1N1 virus? 

Anne Schuchat: Yes, absolutely.  The H5N1 virus that was circulating, that continues to circulate in parts of the world and that had been a particular problem in bird populations and then in people particularly in a few Asian countries, really was a wake-up call for the world that serious infection threats like influenza are out there and we have a lot of work to do.  So there have been a lot of investments that have greatly helped strengthen our preparedness.  Some of those investments were to carry out exercises to practice how we would behave during a pandemic, exercises at the federal level here in the U.S., exercises at state and local levels and then there have been exercises in many countries around the world.  I would say those exercises helped immensely in going through steps that would be important, whether they were scientific steps like how to track disease or communication steps like figuring out how to explain what's going on to people, also practicing how we would ship antivirus medicines out to the states.  These things were worked out well in advance.  The other investments related to the H5N1 virus that were particularly helpful were investments related to diagnostic tests.  It's actually through supporting new diagnostic tests that we first recognized this novel virus here in the U.S. with a test kit that was being tested to see whether we get better at recognizing this virus, new, unusual viruses.  And then, of course, another test approached and the CDC had worked on and gotten FDA approval was really ready right in time and is was -- we were able to ship test kits to all of the public health laboratories in the U.S. and then to labs around the world within a record time so that they would be able to specifically diagnose this problem.  So there's been a lot of chaos from worrying about the bird flu and I think we're grateful that people around government and in the private sector have been taking this so seriously.  A lot of research, a lot of modeling, a lot of lessons learned looking back to the 1918 virus as well as the bird flu virus that put us in a better depth -- put us in better shape to be prepared right now.  That said, we have a lot more work to do and as that Trust for America’s Health Report suggested, gaps remain.  So this is an area that we're working very hard at right now to make sure we're as well prepared as we can be here in the U.S. for the fall. 

Joe Quimby: Thank you. Next question. 

Operator: Thank you again.  If you'd like to ask a question, press star 1.  The next is from Jon Cohen, Science Magazine.  Your line is open. 

Jon Cohen: Thanks for taking my question.  I want to return to something that I asked you earlier and I don't think I was clear in what I asked.  I’m curious about the vaccine for the other 280 million Americans and when the decision will be made whether to make it or not.  Not whether to use it, but whether to make it and how could it possibly be ready in the fall, given the timeline? 

Anne Schuchat: Oh, thank you.  I’m sorry.  I didn't understand that part of your question.  So far, the decision that has been made is to produce vaccines for clinical lots that will go into these clinical studies of safety and effectiveness, safety and immune response.  And then a second decision was made to procure bulk ingredients for potential production that could be used for stockpiled vaccines.  Additional decisions would be made later in the summer, so the decisions that have been made were appropriate given what we know about a novel virus.  Those are the kind of things that we did for the H5N1 virus and they were also steps that needed to be taken because of some outside deadlines that were out there.  We have time before additional steps on production would need to be made and so I think we will be sharing information about future decisions when those -- you know, when things are a little more timely.  I also want to mention that, you know, CDC's role in this is really developing that candidate vaccine virus strain that's handed off for manufacturing.  The decisions about procurement are ones made at Health and Human Services under really the leadership of BARDA within the Assistant Secretary for Preparedness and Response.  We have a coordinated federal government approach to these discussions, but they would be in the lead of that type of decision making. 

Joe Quimby: Thank you.  We have time, operator, for two more questions. 

Operator: The next is from Erin Sykes, NBC News, you line is open.

Erin Sykes: Hi good afternoon.  I’m wondering, schools are closing for the summer, so are you anticipating a drop in cases or possibly a new emergence as children go off to camp or on vacation? 

Anne Schuchat: You know, there have been outbreaks of influenza at summer camps and there have been times when influenza viruses persist in the summer here in the U.S.  So we'll be monitoring for clusters and for unusual influenza occurrence in the summer and using the surveillance systems that we traditionally use to track what’s going on with influenza like illness or viral circulation.  So we are wondering whether there will be a change or not.  Usually when schools dismiss, summer has arrived and whether it's the school system or the seasonal changes, influenza usually goes into a low point during the summer here in the U.S.  So we're keeping an open mind about what will happen and we are alert to the idea that there have been outbreaks in camps as such.  We've provided some information, communication and guidance to summer camps so that they'll know, you know, the basics of looking for the virus and how to handle children that are ill.  But we really -- we have -- and so I would say that we are going to be actively looking this summer. 

Joe Quimby: Our final question, please. 

Operator: That is from Mike Stobbe from Associated Press.  Your line is open. 

Mike Stobbe: Hi.  Thanks for letting me go again.  Doctor, I think there's kind of an assumption that we likely have a round of seasonal flu vaccinations maybe in the early fall and what remains to be seen is whether there would be a decision about a second round of vaccinations against the novel virus.  But did you say a minute ago that we have not yet made a decision to immunize against the seasonal flu? 

Anne Schuchat: No, no, if I said that I didn’t mean to, thank you for getting me to clarify.  We recommend seasonal influenza vaccines for many people, you know, most of -- we have new recommendations for all children between the ages of 6 months and 18 years.  Certainly seniors, adults with medical conditions and people who were household contacts of those at high risk are all recommended to receive influenza vaccine.  We recommend it for pregnant women and we really recommend seasonal influenza vaccine for anyone who wants to reduce their risk of getting influenza.  So we definitely -- I did not mean to say we have changed that recommendation at all.  The decision that we haven't made is about whether an immunization program against novel H1N1 virus ought to be taken. That's a decision that we will make, depending on the epidemiologic and virologic characteristics that we see with this new virus and based on the performance of the test vaccines that are studied in people over the summer months. So that decision would be something made early in the fall once information from the clinical trials is available, together, of course, with the information on the epidemiology of disease.  So we continue to recommend seasonal flu vaccines for many people and we think that's a good idea.  We haven't yet made a decision about whether an immunization program against this new strain will be needed.  On the other hand, we're actively planning, how would we do an immunization program for this novel strain if that decision is made.  We can't wait until that decision is made to start our planning, just like we couldn't wait to plan for a pandemic until there was a pandemic.  We actually have been exercising for a pandemic response for many years now. 

Joe Quimby: Mike, thank you very much.  Ladies and gentlemen across the country and the world, thank you all very much for joining us.  Dr. Schuchat, thank you very much.  This now concludes our press briefing. 

END

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