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Media Briefing: Update on 2009 H1N1 Flu

September 3, 2009, 12:00 p.m.

Operator: Welcome, and thank you for standing by. At this time, your lines have been placed on listen-only until we open up for questions and answers. To ask a question, please press star 1 on your touch-tone phone. Today's conference is being recorded. If you have any objections, you may disconnect at this time. I would now like to turn the conference over to Mr. Glen Nowak. Please go ahead, sir.

Glen Nowak: Thank you, and thank you all for being here or for calling in today. This is our weekly H1N1 update. And today we are joined by Dr. Thomas Frieden, the Director of the Centers for Disease Control and Prevention. Dr. Frieden will open this with some introductory remarks, and then we will take questions from both the phone and the floor. So, I will turn this over to Dr. Thomas Frieden of the CDC.

Thomas Frieden: Thank you, Glen. What I'd like to do this afternoon is give you an update on some of the recent developments with H1N1 influenza. And just one second. The first point to make is that H1N1 influenza is here, it is spreading in parts of the U.S., particularly in the southeast, and in fact, it never went away. We had H1N1 influenza throughout the summer in summer camps, and now with colleges and schools coming back into session, we're seeing more cases. The good news is that so far, everything that we've seen, both in this country and abroad, shows that the virus has not changed to become more deadly. That means that although it may affect lots of people, most people will not be severely ill. However, the H1N1 influenza and influenza generally is unpredictable, and that means two things. First, we have to vigorously monitor to see whether it's changing, who it's affecting and what's happening with it. And second, we have to be ready and prepared to change our approach depending on what the virus does.

Today, CDC is releasing additional data on some tragic pediatric fatalities that occurred in the spring, and I'll provide you with more information on that, in addition, on flu.gov, you can see a report that outlines the experience with H1N1 influenza in five countries in the southern hemisphere. And the experience in those five countries is very similar to what happened in this country in the spring. Large numbers of people, particularly school kids, became ill. In some locations, hospitals had challenges to keep up with the number of people coming in, but overall, no increase in the level of severity, no increase in the death rate. In these countries, some possibility that indigenous populations were more severely affected by H1N1 influenza, that you had a greater likelihood of having severe illness from H1N1 if you were a member of a tribal or indigenous population. That's not proven, but it's a possibility. This information, as well as the child information that I'll be presenting shortly, emphasizes what we should do to prepare and what are the groups that are at highest risk, and therefore, we need to reach out to the most.

The MMWR study being released today outlines 36 deaths that were among the first deaths among children in this country. In two-thirds of those, the child had at least one severe underlying illness or underlying disability, actually, rather than illness, in most of the cases-- cerebral palsy, muscular dystrophy, long-standing respiratory or cardiac problems. So, most of the children who had fatal H1N1 infection this past spring had an underlying condition. There were some children who didn't have an underlying condition and who did become severely ill, and they were generally infected also by bacteria. When you get the flu, your immune system can be a little weakened, you can be more susceptible to other infections. That's an important message for doctors to know that if someone has the flu, they get better, then they get worse again with high fever, that's a clue that maybe they should be treated with antibiotics, things that will help them. Most people with flu don't need treatment, and I'll discuss that more in a bit.

The review of the several dozen children who died this past spring emphasizes that flu can be very severe, and it's important that we do everything we can to protect people from the flu, and I'm going to outline some of those things that we're doing. It also identifies groups that are particularly important to address. We have been working closely with pediatric societies, with parent groups and others to ensure that, for example, children with special needs, children with cerebral palsy, muscular dystrophy, other developmental disabilities, are promptly treated if they develop fever in flu season and are at the front of the line for flu vaccination when it becomes available.

Also, earlier today, about an hour ago, the Institute of Medicine released a report on protection of health care workers from influenza. Protecting health care workers is critically important. We want to ensure that health care workers are and feel safe when they come to work. They are the first line of defense, and we need to ensure that we do everything we can to reduce to the greatest extent possible their risk of becoming ill on the job. Protecting health care workers involves many different factors, including how the hospital or health care setting is organized, whether people who are not severely ill come in for care and overwhelm the system and how many different health care workers have contact with people who may be infectious. What's particularly important are circumstances where we think the risk is highest, but in all cases, we want to ensure that health care workers are safe. The Institute of Medicine was charged by the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration with looking at what kind of mask or respirator health care workers should use. Their charge, consistent with the OSHA mandate, required them not to look at the economic or logistic situations, but just look at their view of the most recent science on protecting health care workers. We have just received their report. We are studying it and we will review it in the coming days and weeks.

The next issue that I'd like to discuss has to do with vaccination. There's a lot going on with vaccination. We continue to anticipate that vaccine will be available by the middle of October. The vaccine itself will be free. The administration may be charged by individual providers, although in the public health system, all vaccination will be free, we anticipate. It will not be easy to get vaccine uptick. We have the possibility or even likelihood that it will be a two-dose series for children, at least, and perhaps for others. We are going to be trying to reach out to children in large number and parents to get kids' vaccines, because we know that so many kids can get the flu, and the vaccine is likely to be quite effective. My kids will get the flu vaccine when it becomes available, and I would recommend that all school children get vaccinated. We also are recommending that all people with underlying conditions get vaccinated, people who have asthma, diabetes, lung disease, heart disease, neuromuscular conditions, neurological conditions that increase their risk factors and women who are pregnant.

Vaccination programs will be run by the states and localities throughout the United States. We are working closely with all jurisdictions to help them identify the challenges that they'll face in vaccinating the people in their area and in addressing those challenges. We are in the process of releasing about $1.5 billion in vaccine planning, preparedness and administration funding. That will allow each jurisdiction to identify what are the strengths there. And some jurisdictions will work largely with the public sector. Other jurisdictions will work largely with the private sector. Each place will know what the strengths are in their area best and will be able to reach out to the speciality clinics. For example, children with special needs or people with asthma or diabetes, to have the detailed planning available.

We also are looking very closely at the possibility of reports of adverse events. We know that every year, there are cases of paralysis, Guillain-Barre syndrome, there are women who have miscarriages, there are people who have sudden death. In all of those situations, we need to know very clearly how many we would expect if the vaccine doesn't cause any problems whatsoever. In an average flu season, just as an example, around 500,000 pregnant women get vaccinated. That's important, because pregnant women are more likely to get severely ill from flu. So, it's a way of protecting them and ensuring that they have a healthy pregnancy. Among those 500,000 women, if they hadn't gotten vaccinated, we would have expected more than 1,000 miscarriages within a week after vaccine. If they hadn't been vaccinated. If they're vaccinated, we expect about 1,000, 1,500 among 500,000 women who are vaccinated. That's the kind of number we need to track and understand to see whether when we do see adverse event reports, because we know there will be adverse event reports, they're occurring at a higher rate than expected or not. In the coming weeks and months, with school resuming, we do expect to see more cases. We're seeing it now. We expect that will continue. How long? No one can predict with certainty. Influenza is unpredictable. That means we need to monitor closely and be willing and ready to adapt to different approaches.

One of the challenges is preparing our health care system for the likely increase in the number of people who will seek care. We know that there are lots of things that can be done to reduce the spread of flu, and that needs to occur. But for most people with the flu, there's no reason to see a doctor or go to the emergency department unless you're severely ill. For example, you have trouble breathing or you have an underlying condition, such as diabetes, pregnancy, heart disease, lung disease. For people who do have an underlying condition, it's important to be seen promptly if you get a fever. That could make the difference between being severely ill and recovering well. Treatment in the first 48 hours can make a big difference in hastening your recovery. We also know that as of now, not only has the virus not become more virulent or more deadly, but we haven't seen lots of drug-resistant strands. So, the drugs that we have available are still very effective against the virus at this time. The big picture is that there are two things we can do to reduce the impact of flu. One is, reduce the number of people who get infected. And a second is, reduce the proportion of those who get infected who get seriously ill. To do that, vaccination is our strongest tool. With vaccine not yet here, what we can do now is to reduce the number of people who get severely ill-- stay home if you're sick, cover your cough and sneeze and wash your hands frequently. That means that workplaces, for example, should increase the availability of teleworking, to the extent possible, and we should encourage people to stay home if they're sick and employers should not penalize workers for staying home if they're sick during flu season, nor should employers require a note from a doctor to return to work, because the doctors will be very busy taking care of people who are sick with flu. In order to reduce the number of people who become severely ill from flu, prompt treatment of people who have underlying conditions or severe illness is very important.

Flu is unpredictable. Flu season is just beginning. It is very unusual to see flu continue through the summer, as it did in the U.S. this year. It is very unusual to see this many cases this early in the year, but only time will tell what this flu season brings. What we're doing is everything in our power to be as prepared as we can for the things that may occur in the coming weeks and months. I'll now be happy to take questions.

Glen Nowak: Betsy?

Betsy McKay: Thanks, doctor. Betsy McKay from the "Wall Street Journal." I was really interested in these bacterial infections, because most of the reports up until now have been about viral pneumonia. So, I just wondered if you can comment on this. You know, is this bacterial pneumonia or what kind of bacterial coinfections are they? And is the upshot of this that more healthy children may be at more risk of severe disease? I also wanted to ask separately, if I could, how significant you think these findings are in China and from Novartis that one dose of vaccine may be sufficient?

Thomas Frieden: So, taking the last question first, we look forward to seeing the data from China and elsewhere about vaccine efficacy. It's very important, and as soon as we see it, it will help us inform the policies here. But fundamentally, we need to look at the U.S. vaccine and how that vaccine does in the trials that are under way. Bacterial pneumonia is a known complication of flu. This is one of the things that is often problematic. The findings that we're releasing today really are not unexpected. This is what we see with seasonal flu. It's quite similar with H1N1 influenza. It's, I think, primarily of importance to doctors to know that if someone has had the flu and they come back with a high fever a little later, it's important to think that it may be a bacterial pneumonia and to treat for that. It also emphasizes the use of pneumonia vaccination for all people for whom it's indicated, including children and the elderly.

Glen Nowak: Operator, we'll take a question from the phone.

Operator: Thank you. Miriam Falco, CNN Medical News. Go ahead.

Miriam Falco: Thank you for taking the call. Looking at these pediatric deaths, since that's something that people are very shocked by, what more can you tell us? I know you talked about the bacterial infections, but what is the message you want to get out to the parents who are saying, you know, my kid's sick, I need to go to the doctor, even though that's not what you're recommending? What was the most concerning data that you found within the MMWR report?

Thomas Frieden: It's important to put the report in context. In New York City, for example, where we have the big picture on how many people got infected, hundreds of thousands of people got infected, and the overwhelming majority of them had moderate illness. They didn't require testing. They didn't require treatment. And they did fine. If children have underlying conditions-- and two-thirds of the children in this report had conditions such as muscular dystrophy and cerebral palsy-- it's very important that they be treated promptly. And if a child is severely ill, if they're having trouble breathing, if their fever comes back after it went away, if they are having difficulty keeping fluids down, then it's very important to get treated promptly. But your question is an important one. This is a real challenge, and we need assistance from the media as well as the public to understand this balance between saying on the one hand, the overwhelming majority of people with H1N1 influenza are going to do fine, they don't need testing, they don't need treatment. On the other hand, if you either have an underlying condition or you have severe illness, it's really important that you get treated promptly. That's a complicated message, but getting it right is not only going to be important for helping people stay healthy, it's going to be very important for making sure that our hospitals and our emergency departments are available to the community and to the people who really need the treatment.

Glen Nowak: Operator, we'll take another question from the phone.

Operator: Thank you. Denise Grady, "The New York Times," please go ahead.

Denise Grady: Could you please explain again what you said about the numbers of miscarriages that would be expected if people were vaccinated, not vaccinated? I could not quite follow that, please. Thank you.

Thomas Frieden: The basic point is that certain conditions occur whether or not vaccination happens, and we need to anticipate that those conditions will occur after vaccination even if they're not caused by vaccination. In 1976, for example, there was an increased rate of Guillain-Barre syndrome. That occurs, depending on the age of the population that you're looking at, somewhere around 1 per 100,000 people as a routine or a norm, even if there's no vaccination. So, we need to recognize that there are baseline rates of things like neurological syndromes and miscarriage. In an average flu season, around 500,000 pregnant women get vaccinated. In that group, there will be miscarriages. Those miscarriages, even if you gave placebo vaccine, you gave nothing that would cause a miscarriage, you would expect more than 1,000 miscarriages in the one week following vaccination for those 500,000 women. So, if we see that after H1N1 vaccination, that doesn't imply that there's a problem with the vaccine. What we need to see is whether the rates that occur are higher than would occur if no vaccine had been given, and with that, only time will tell. I think the bottom line here is, we will look very, very carefully to see whether there's a problem with this vaccine in terms of safety. We don't anticipate that there will be. It's produced in the same way the flu vaccine is produced each year. It's a new strain, just as we put new strains into the flu vaccine each year, and flu vaccination has a long-term, very good safety record with literally hundreds of millions of doses having been given.

Glen Nowak: Operator, next question?

Operator: Thank you. Our next question comes from Helen Branswell, the Canadian Press.

Helen Branswell: Hi, Dr. Frieden. I was hoping I could get you to talk about something you touched on earlier, the balance of identifying when people need to seek care. Some people will, you know, think they're fine and then start to get worse and need to go see a doctor, and they may be outside the 48-hour optimal treatment window for antiviral drugs. Is CDC recommending that doctors think about treating with antivirals-- start treating with antivirals, later than 48 hours, if it looks like somebody's developing severe disease?

Thomas Frieden: If someone is severely ill, then they should be treated even if it's more than 48 hours, but the most benefit, the most good is done if the treatment is within the first 48 hours. Can we take some questions from the room?

Glen Nowak: Sure.

Brooks Blanton: Hi, Dr. Frieden. My name is Brooks Blanton. I'm a producer at FOX News. I just want to ask a little bit more about the vaccination that Novartis and Sinovac in Chinese and Switzerland, they’ve announced they have a one-dose vaccination. Is that something we'll see here in the United States? Are we going to be able to have a one-dose vaccination as opposed to two?

Thomas Frieden: We need to look at the data as it comes out. I believe the Novartis study was done with an adjuvanted vaccine, a vaccine that has another material added to it to boost the immune response. We don't anticipate that we will be using adjuvanted vaccines in most of the scenarios that we anticipate now, although that could change, and we would expect that the likelihood of needing two doses with a vaccine that's not adjuvanted is higher than with an adjuvanted vaccine. And for the data coming out of China, we'll have to review it. For seasonal flu for kids under the age of 9, we currently use two different vaccine doses. So, it's very likely that, at least for kids, two doses are going to be required, but only time will tell. This is one of the things-- our basic message here is we're going to look at the data. We're going to understand the situation as well as possible and provide the best possible advice for people to have the best options to take to protect themselves and their families. Question in the room?

Harry Stanler: Harry Stanler, CBS Atlanta News. A lot of parents are very concerned about this. If they feel that H1N1 starts or they learn that H1N1 starts popping up in their school or their daycare center, if they don't feel that the school or daycare center is taking the necessary precautions, should they pull their kids out?

Thomas Frieden: We hope that schools will continue. Kids need to learn. Parents need to work. There's a lot that happens at schools that is very important. We've had a handful of schools close, most of them just for a day or two. If your kid is sick, please keep them home. They'll get better quicker and they'll not infect people around them. Schools should ensure that kids who are sick are separated and sent home with a parent or caretaker, and that kids cover their cough, cover their sneeze and wash their hands. If those simple steps are taken, the number of people who become infected will come way down, and when vaccine becomes available, schools will be an important location to give the vaccine in many parts of the country.

Glen Nowak: Question in the room? Operator, we'll take another question from the phone.

Operator: Thank you. Our next question comes from Maggie Fox, Reuters. Please go ahead.

Maggie Fox: Hi, thanks, Dr. Frieden. I want to ask this. 36 children who died, how does that compare to a typical influenza season? I know there's no such thing, but can we give just kind of a range? What's given in the report is more given in percentages. And can we talk about the compressed time period during which these deaths took place? Thanks.

Thomas Frieden: Child deaths from influenza are really tragic, and they're one of the things that has prompted us to recommend broad-based influenza vaccination for children even before H1N1 came around. Each year, there are on the neighborhood of 50 to 100 deaths from influenza among children in this country. In this year, only time will tell what that number is. The flu season this past year was very unusual, very unusual because you had first a normal flu season, which was a relatively mild season. Then you had H1N1 influenza. So, these deaths are outside of the normal time period. And again, only time will tell what will happen in the fall and winter. The take-home message from this study, I think, is that particularly kids with underlying conditions need to be treated promptly if they develop fever and first on line or at the front of the line for vaccination when it becomes available.

Glen Nowak: Thank you. Operator, another question from the phone?

Operator: Thank you. Steve Sternberg, "USA Today," please go ahead.

Steve Sternberg: Hi, Dr. Frieden. Thanks for taking these calls. There was a note in the report on influenza in the southern hemisphere that struck me. It said in Argentina and Chile that among hospitalized cases of acute respiratory syndrome, kids up to 4 years of age were the most affected. However, both countries report that only a low percentage of cases, 20% to 30% in this age group, represent the '09 H1N1, whereas more than 70% to 80% represent respiratory syncytial virus. Can you explain and expand on that?

Thomas Frieden: In parts of the country and the world where flu is spreading, it has been very important within the hospital, for hospitalized patients, particularly for patients in intensive care units, to determine what type of infection they have. And the testing for influenza not only is it not necessary for most people who have only moderate or mild illness, but for those with severe illness, it's not sufficient, because there are many false negative tests from the available tests. So, in areas where there are large numbers of people in intensive care units, doing very vigorous investigation to figure out what's making them sick is quite important. And we have seen in different parts of the country, different parts of the world that it isn't always H1N1. It can be other things. And only testing at that intensive care unit level of care can determine that.

Reporter: I just had a quick question. In the southeast, what are you seeing? I know we're seeing a lot of flu activity. Do you attribute that to the return of schools earlier than the rest of the nation or what do you attribute that to?

Thomas Frieden: We're seeing a lot of H1N1 influenza scattered around the country, particularly in the southeast, and the most likely explanation for that is that schools started earlier. Here in Georgia, we have relatively widespread H1N1, and that, again, is most likely because we had the schools starting earlier. It may also be that some of the parts of the country that had less of H1N1 in the spring may see more of it now. But only time will tell. This is one of the many things that we have to monitor very carefully so we can figure out what's going on and adjust our approach based on what's actually happening.

Glen Nowak: Operator, we have time for two more questions from the phone.

Operator: Thank you. Robert Bazell, NBC News. Please go ahead.

Robert Bazell: Thank you for taking the call. I just want to follow up on the Institute of Medicine report on the N-95 respirators. As you well know, there's not a lot of them in a lot of health care facilities, and maybe even only a week or two supply in many hospitals. And there's some in the strategic reserve, but given that there is a potential shortage of these if there were to be a very large outbreak of disease, how would you like health care workers to respond to this information and how do you think they should respond?

Thomas Frieden: We have just received the Institute of Medicine report. We're studying it carefully. Their charge was specifically not to consider either economic or logistical concerns, such as supply. And as we look at guidance for health care facilities, we'll be looking at this carefully in the coming days to weeks. I think we have time for one more question.

Operator: Thank you. Mike Stobbe, "Associated Press," go ahead.

Mike Stobbe: Hi, thank you for taking the questions. First, in the pediatric death report, the bacterial coinfections, do you know where the kids picked up those infections? Were those hospital-acquired infections? And given the proportion of kids under 5 or over 5, is it clear yet, is swine flu deadlier to school-age children than seasonal flu is?

Thomas Frieden: So, for the first question, most of those infections were picked up in the community rather than in the hospital. The kids came in with the infection. In terms of the relative severity of seasonal versus H1N1, I think the jury is still out. So far, it is not more severe. We don't know that it's less severe. Clearly, the number of deaths -- we’re now at more than 500 deaths from H1N1 influenza in the country in all age groups -- emphasizes that influenza can be a very serious disease. That's why it's so important that we take every step at our disposal. That means staying home if you're sick, covering your cough and sneeze, washing your hands, and if you are severely ill, trouble breathing or have an underlying condition, get treated promptly when you have a fever. And when vaccine becomes available, make sure that we get as many people vaccinated as want to be vaccinated. Thank you all very much.

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