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Weekly 2009 H1N1 Flu Media Briefing

November 12, 2009, 1:30 p.m.

Operator: Welcome and thank you for standing by.  At this time all participants is in a listen-only mode.  During question and answer you can press star one to ask a question.  Today’s conference is being recorded.  I’m turning the call over to Glen Nowak.  You may begin, sir.

Glen Nowak: Thank you, and thank you all for being here and calling in.  I apologize for the delay.  We were trying to let more people call in due to the number of folks still in the phone cue.  Today’s press briefing on H1N1 will be conducted by Dr. Anne Schuchat.  Dr. Schuchat is the director of the National Center for Immunization and Respiratory Diseases at CDC.  She'll be providing an update on where we stand with respect to vaccine as well as providing CDC's estimates related to the pandemic and the United States.

Anne Schuchat: Good afternoon, everyone.  It’s a pleasure to update you this afternoon.  You know, since the emergence of the 2009 H1N1 virus, we've been talking about the laboratory confirmed cases, hospitalizations and deaths, potentially giving an incomplete picture of the story of this pandemic.  Today I’ll be sharing estimates that we hope will provide a bigger picture of what's been going on in the first six months of the pandemic.  I’m going to be sharing estimates for the picture through October 17th. I think these estimates really stress how critical our vaccine recommendations are in the priority groups we've focused on.  I’m going to touch on three areas.  First a quick update about the vaccine program.  Secondly highlighting one of the groups that's very hard hit with influenza complications, people with diabetes.  Lastly I’ll expand on the estimates that we have for you today. 

The picture of the vaccine supply first today we have 41.6 million doses of influenza vaccines that are available for the states to order.  We believe that will be somewhat less than what the manufacturers had expected to reach at this point.  It’s very difficult to predict with vaccine production for influenza.  41.6 million is more than we had before but not as much as we hoped to have by today.  Again, it's an imperfect process both producing vaccine and then projecting how many doses you'll have at any one point.  Seasonal flu vaccine continues to be distributed.  The update for today is that 94 million doses have been distributed of the seasonal flu vaccine.  Last week it was 91 million.  That’s continuing to progress.  Manufacturers have told us to expect us to have 114 million doses by the end of the year.  We’ll see if we make that prediction they have made for us.  The immunization efforts with this supply continue to be focused on the target population, priority groups, pregnant women, health care workers, children and young adults up to age 24, adults 25 to 64 with chronic conditions and parents and other caretakers with small children and children under six months of age.  These are where the states and local cities are focusing vaccination efforts.  We do expect and have seen a variety of approaches to getting vaccine into the path of where priority populations are.  States and cities are really in the best position to know how to reach their population.  Many are doing school located clinics, map community clinics, health care providers, hospitals, clinics, employer-based clinics, a variety of approaches that do make sense when you have as many groups to cover as we have.  As the supply increases, we do think that access and convenience and ease of getting vaccinated will improve.  It may take longer in some areas than others, but reminder that all of the states are receiving amount of vaccines proportionate to their population and trying to serve their populations as best as possible. 

Next I want to turn to diabetes and flu.  November is American Diabetes Month.  This is a chance for us to remember that diabetes is a common condition and that there's much that people with diabetes can do to improve their health particularly in light of the H1N1 influenza challenges.  People with diabetes have an increased risk of severe illness from any flu. And when people with diabetes get flu, it can be more difficult for them to manage their blood sugar.  They can suffer high or low blood sugar.  Paying special attention with flu when you have diabetes is important.  People with diabetes account for about 12 percent of all of the hospitalizations we've seen from the H1N1 influenza virus.  If we focus in on adults, 19 percent of those people who have been hospitalized have diabetes.  We know that people hospitalized with H1N1 influenza who have diabetes have a good chance of ending up in the intensive care unit.  One in four hospitalized patients with diabetes did require intensive care unit management.  So this can be a very severe illness in people with diabetes.  But there are several things that people with diabetes and their caretakers can do to improve their health during this difficult flu season.  Certainly we recommend people with diabetes get vaccinated with H1N1 influenza vaccine.  They should receive the shot, not the nasal spray.  And they should receive the vaccine as it becomes available in their communities.  It’s very important for people with diabetes to be vaccinated.  People with diabetes who have fever and cough or other symptoms of respiratory illness like flu do need to check with health care providers because we recommend antiviral medicine, Tamiflu or Relenza for people with diabetes who develop flu.  It's not necessary to wait for test results to come back on influenza testing, it's just important to get prompt antiviral medicine. The third action step that diabetic patients can take in the face of this flu pandemic is to make sure they have been vaccinated against pneumococcal infections.  Pneumococcal polysacharide vaccine has been recommended for adults who have chronic conditions like diabetes and many people with diabetes and other chronic diseases have not been vaccinated with this pneumococcal vaccine.  We have seen with influenza pneumonia, including pneumococcal pneumonia, following influenza.  So in this American Diabetes Month, we really remind people to take care of themselves with diabetes and get those two vaccines, to get care promptly to get antiviral medicines should they develop flu symptoms.  Diabetes is one of several chronic medical conditions that can increase complications of the flu and is recommended in the target population for H1N1 vaccine. 

Next I want to share with you a little bit of background and the results of our method to estimate the big picture of how much pandemic influenza we have had in the first six months of this pandemic.  Our estimates, we believe, give us a better estimate of how much disease, hospitalization and death there is than we would get by just counting individual laboratory confirmed cases.  These estimates, again, go from April, when this virus emerged, through October 17th, about a month ago or literally the first six months of the pandemic.  Our estimates derive from information from our emerging infections program network.  That is collaboration with ten states, 62 counties in those ten states that collect extensive information on hospitalizations from influenza including details about laboratory testing and age and so forth.  Emerging infection program network is one key source for our estimate.  We also are using data from other surveillance systems like aggregate state reporting of laboratory confirmed hospitalizations and death.  With those two surveillance symptoms primarily as a source that we are then extrapolating to the whole United States and to the entire period of this first six months.  What I’m going to describe isn't a switch or a change from the way we've been counting cases so far, what we're really trying to do is give you a bigger picture.  As many of you know we've been talking about planning to do this for some time and we're finally ready.  We’ve tried this a few different ways.  Really the estimates converge.  We’re feeling comfortable we'll be giving you appropriate estimates today. 

These estimates will give a single number and then a range, a lower and upper estimate around each number.  And I want to tell everyone who is rapidly taking notes that the numbers I’m going to give you are under the CDC website under media information place.  So for April through October 17th, we estimate the 22 million people have become ill from pandemic influenza.  We estimate 98,000 people have been hospitalized so far through October 17th.  And the upper and lower estimates on hospitalizations are from 63,000 to 153,000.  We estimate that 3,900 people have died so far in the first six months of the pandemic from this virus.  And the estimates there are from 2,500 up through 6,100 people having died so far.  We’ve been talking a lot about this pandemic being a younger person’s disease, that it's disproportionately affecting children and young adults and relatively sparing the elderly, very different from seasonal flu.  So I also want to give you some estimates for cases, hospitalizations and deaths for different age groups.  So in children under 18, we estimate 8 million children have been ill with influenza, 36,000 hospitalized, and 540 children have died from this pandemic influenza.  In the first six months of the pandemic for adults 18 to 64 years of age, we estimate 12 million cases, 53,000 hospitalizations, and 2,900 deaths.  For people 65 and over, we estimate about 2 million cases, 9,000 hospitalizations and about 440 deaths.  That’s a lot of numbers.  Again, I remind thank you we've posted those numbers on our website so you can look in more detail. 

The website also has additional information about the methods that were used to derive these estimates for those who are interested.  We will be updating the toll that the pandemic has taken these estimates about every three to four weeks.  We don't think we'll be able to do this every week because it takes some time for information to be filled in, chart reviews involved and other data collection but we're expecting about every three to four weeks to be able to update you on the full illness, hospitalizations and deaths the virus has had.  Going forward, we are making progress and we know how important vaccination is.  We appreciate the really hard work that the state and local health departments, private health care provider community has been doing to put vaccine in the pathway of priority populations, every dose of vaccine we get is critically important in protecting another individual.  I want to thank the state and local public health workers who are really doing a tremendous job in the face of a very challenging pandemic.  I know it's been challenging and we're really there with you every step of the way I hope.  I want to also remind people that vaccine safety is a big priority for us.  We are mounting a comprehensive effort to be aware and evaluate reports that we get.  We haven't so far seen anything that is of concern or extra concern but we're reviewing reports that we get every day and we will be updating you on information when new information that's critical comes to light.  We are going to continue to have challenges with this pandemic.  I think it's important for us all to remember it's a marathon and not a sprint.  But more vaccine is being ordered and delivered and used every day.  And that's very important, because I think we all remember that it's the virus that's the enemy here and it's what's bringing our challenges.  But together I am sure we'll be able to get through this.  I’d like to now go to questions.  I think we can start in the room.  Mike. 

Mike Stobbe: Hi, Mike Stobbe from AP.  Doctor, did you say 540 children, and you were reporting what about 120 recently.  That’s quite a jump.  I thought the CDC was keeping careful track.  Could you tell us a little bit more about how that number jumped so dramatically.

Anne Schuchat: That's right.  As of last Friday we reported 129 children had been reported with laboratory confirmed H1N1 influenza.  Additional reports have come in about pediatric deaths from laboratory confirmed influenza where typing information wasn't available.  We know that a number of the deaths that we're seeing are occurring outside the hospital where testing is not possible.  We know that not every patient with influenza gets a diagnosis of flu.  For instance, many people can have a bacterial pneumonia following a flu illness and may or may not be recognized as having flu.  We don't think anything has changed.  We think is our 540 number is a better estimate for the big picture of what’s out there.  We think individual reports we're getting through the national pediatric death notification system are vitally important.  That system gives us additional detail about underlying diseases that children have, about issues like the bacterial pneumonia problem.  With that system we think we can make sure that our guidelines are right and on track.  We do think for influenza it's virtually impossible to find every single case with a lab test.  So the estimation method we are using now we believe gives a bigger picture, a probably more accurate picture of the full scope of the pandemic.  Another from the room?

Diane Davis: Thank you, doctor.  Diane Davis from WSB in Atlanta.  With these numbers seeming to triple literally overnight, should the public's level of concern be affected?  It’s fair to say when they hear this, they will be quite alarmed.  What is your message to the public, parents and adults, when they hear these new numbers?

Anne Schuchat: Influenza is serious.  Vaccination is the best effort to protect one's self or one’s family.  These estimates give a bigger picture of what's going on and they really reaffirm the priority recommendations we've given.  We focus vaccination on younger people because they are disproportionately affected with the virus.  Things haven't really changed from last week to this week; we just feel that we're finally able to update the public on how big a toll this virus is having so far.  Of course, this is just the first six months and I am expecting all these numbers unfortunately to continue to arrive. Again in the back? 

Joanne Silberner: I’m Joanne Silberner, National Public Radio.  Thank you.  There is some resistance among some doctors out there to the vaccine.  Do you have any idea how much resistance?  Are you monitoring that?  Do you have a sense of how many doctors are reluctant to recommend the vaccine? 

Anne Schuchat: We have been carrying out a number of different monitoring efforts, including some surveys of providers.  We were interested whether providers were going to sign up to give out the H1N1 vaccine.  I have to say we have a very good uptake of providers that do want to be able to offer it.  We don't necessarily have as many providers in every group that were interested.  In particular we've been really encouraging obstetrician-gynecologist to offer vaccine in general, including H1N1 vaccine because they have reach such an important population.  I hear the same reports that others do about individual providers that really are skeptical about the vaccine.  I just think it's critical for the consumer, the public, to get good information.  Usually your health care provider is a good source.  What I would say is influenza is really serious and the vaccines that we have are the best way to protect patients. 

Joanne Silberner: A sense of numbers is it 1 percent of doctors, 10 percent of doctors, do you have any sense of numbers? 

Anne Schuchat: No, I don't.  Sorry.  One from the phone please.

Operator: If you have a question on the phone line press star one.  First from Steven Smith from Boston Globe.  Ask your question.

Steven Smith:  Hi, Dr. Schuchat, I have two questions.  The first regarding pediatric death, this figure and estimate of 540, that's several multiples higher than what has been seen in the previous seasons of influenza tracking.  So I’m wondering at this point are you able to say definitively that this passage is producing more serious illness in more children than seasonal strains we've seen since 2004 when the tracking began, began more earnest.  Secondly unrelated question, I’m wondering what you are hearing about Tamiflu stockpiles in the business community and what your concerns are about inappropriate spending.

Anne Schuchat: Thank you for your question.  It’s important to compare apples to apples.  The pediatric death reporting in 2004 focuses in on children with laboratory confirmed influenza infection.  Looking at the same system, pediatric death reporting, not the estimation method, I’ve already seen a larger number of deaths than we've had for several years.  I do believe that the pediatric death toll from this pandemic will be extensive and much greater than what we see with seasonal flu.  It would be better to compare our 129 number with the previous years of around 40 to 88 or so deaths each year than to look in on that 540 number.  There are many ways that we talk about the toll that seasonal flu has on the population.  Often those are derived from models, retrospective reviews of data, where we talk about 36,000 deaths, 90 percent of which occurrs in seniors, those figures would be more comparable to what we're talking about here, with our estimation method, although those are described from a different approach than we're describing.  If you think about, that only about 10 percent of the seasonal flu deaths occur in people under 65, that would be about 3,600 deaths. We do think we are having a pretty severe amount of deaths so far from the H1N1 virus.  The numbers I’m giving are only through the first six months through the middle October.  We have had a lot of disease since then and we'll probably have a lot of disease going forward.  Hopefully mitigated by vaccination effort. 

Second was about stockpile in the business community.  I want to mention to people for several years, there has been pandemic preparedness efforts going forward.  State, cities, the business community, the public and private sector really looked into their own myths and tried to figure how we can be ready when something happens.  From my knowledge, I believe a number of companies actually looked at what to expect and thought maybe we better get ahead of this and prepare some antiviral stockpiles for our workers as really that private-public partnership responsibility.  I don't have updated information about how many businesses have done that, but I believe that practice started several years ago with all the preparations around the H5N1 bird flu situation.  Another from the phone.

Operator: Steve Sternberg, USA Today, you may ask your question.

Steve Sternberg: Hi, Dr. Schuchat, there's an echo on the line so it's a little hard to hear.  I want to ask how states are deciding who to vaccinate against the backdrop of this vaccination shortage.  Which of the priority groups are the highest priority given the estimates you've seen?

Anne Schuchat: Thank you.  The question about priority groups and whether there's any subpriorities that are more important than others.  The Advisory Community for Immunization Practices met in July and came up with target populations that accounted for about half of the U.S. population.  Then they also went through a subprioritization effort where they came up with a smaller group of people.  When we survey the states and large cities about how they are addressing the target population, some are focusing on the subprioritization group, 42 million total population targeted, and it involved children six months of age through five years.  And then five years old to 18 years old with chronic conditions.  Not all healthy school-age children.  It didn't involve children 18 to 65 who had chronic health conditions.  It did include health care workers.  It did include pregnant women, parents or caretakers of young babies.  Basically by excluding healthy school age children and chronically ill adults, you got to a much smaller population.  One of the problems with that subpriority effort is that not all vaccine formulations can be given to everyone.  About a fourth of the vaccine supply that we have right now is live attenuated vaccine or the nasal spray and that can only be given to people who are healthy and between the ages of two and 49.  So some of the states and cities found if they focused too much on that subpriority group, they couldn't optimally use their formulations. 

We have not given strict recommendations that states need to do the subgroups or total groups.  What we had heard from the states and provider community was it was important for them to have flexibility.  We do know from surveying city and county health departments vast majorities are reaching out to priority populations through providers who serve them, through hospitals, through mass clinics initially targeting young people and pregnant women and through some specialty clinics that would reach people with asthma, diabetes, cancer and so forth.  So there's a mix of activities out there, which is probably very good, because a rural area and a city really could not be served by exactly the same method.  Places with large health plans are getting vaccine and able to target the population that has those underlying conditions but really just a variety of efforts are out there.  Another thing to say is that going forward, as we get more and more vaccine each day, the risk of focusing too narrowly may mean you're not able to address using all the doses that you get.  We know that in the first couple weeks, many states were turning people away who were in line because there wasn't enough vaccine at the clinics for all of them to be covered.  They really focused on just the people in line who were in the priority groups. Another question from the room. 

Reporter: Hi.  French TV.  In France the vaccination just updated yesterday, only 20 percent of the population wants to get vaccinated. In the United States people are curing for the vaccine.  What do you think of that?  The FDA and the CDC say the vaccine is safe but some people, some doctors, some specialists say it was made in rush, the time was too short to retest it.  And more than that, the pharmaceutical company asked not to be prosecuted in case of side effect.  How can we trust you if even the pharmaceutical company is unsure.

Anne Schuchat: Thank you for those questions.  The consumer demand for vaccine varies substantially.  So it doesn't surprise me that in France the general population interest is different from our general interest in the U.S.  Even in the U.S., community to community or week to week, we have seen some variations.  We have had a lot of disease here in the U.S.  Of course it started earlier here before it was a problem in France.  So it doesn't surprise me that Americans in general are more concerned and more interested in being vaccinated.  We also have a very high immunization coverage rate in the United States.  So parents in particular are used to getting their children vaccinated against life threatening diseases.  All that is good news.  On the other hand, as you mentioned there are many in France and here who wonder about the safety of vaccine.  What we really say over and over again is what we know.  We know that these vaccines are being used exactly the same way as seasonal flu vaccines.  In the U.S., 100 million people get flu vaccines every year.  They have a very good safety track record.  We know no medical intervention can be promised to be 100 percent safe.  We have enhanced our safety monitoring system to be ready if we find problems, to take action quickly.  The most important thing for consumers here or France is that we are as transparent as possible with what we know and when we know it.  At CDC and HHS we're committed to that. A question from the phone?

Operator: Dan DeNoon with WebMD.  You may ask your question.

Dan DeNoon:  Thank you for taking my question.  Dr. Schuchat, in the MMWR, CDC editorial talks about the numbers reported between August 31st through the end of October and talks about flu activity being substantially above historic levels and talks about ILI higher than its peak in any flu season since record keeping began.  Can you put this in perspective?  What do historical levels mean here? 

Anne Schuchat: We've been tracking influenza for decades.  We have some systems that go back really to 1958.  Others of our systems are newer.  What we are seeing in 2009 is unprecedented.  People know we haven't had a pandemic since 1957.  So it's not surprising that what we're seeing is unprecedented.  To have very high rates of influenza-like illness in September and October is extremely unusual.  So I think the report in the MMWR focuses in on that.  When we look back year after year, we don't see a fall from this.  Another question from the phone? 

Operator: Karen Garloch, Charlotte Observer, you may ask your question.

Karen Garloch: Thank you, doctor, for taking my question.  Back to the issue of the high-risk groups.  We’ve had a little bit of controversy in our community because some of the clinics have offered the vaccine to healthy people, even though they were targeting high-risk groups.  When healthy people came through they were given or opened it up a little bit to parents of children or faculty.  The health officials here say that is OK with the CDC.  You have said not to turn people away.  Is that what you would say to people who are worried about not getting it in the high-risk group? 

Anne Schuchat: This is a really challenging issue.  In general we think that vaccine that is not given doesn't do anybody any good.  But being able to regulate the supply and demand match really is a local matter.  Advisory Community Immunization Practices and CDC guidance is really for local and state and health care providers to do the best that they can to vaccinate people in the priority groups.  When the priority groups have been met, the demand in that group that been met, to continue to vaccinate others.  Now, in some communities there has been very little demand for vaccine among the priority groups.  Two key things there.  We recommend urging better outreach to the priority population so they are well informed about how to be vaccinated and about the risks and benefits therein.  We also think there may be some places additional people can be vaccinated more promptly.  One of the key features I think in the public health community is to focus on vaccinating and not turning people away, putting the bulk of the effort on getting people vaccinated who need to be vaccinated.  There’s a variety of practices out there and we're really trying to support states and cities in managing this.  In an individual provider office the vaccines are being given according to our Advisory Committee Immunization Practices recommendations but we're not in there policing what each doctor is doing.  Next question from the phone? 

Operator: Lisa Schnirring, CIDRAP news, you may ask your question.

Lisa Schnirring:  Hi, thanks so much for taking my question.  I know that last week the CDC predicted at the last press briefing that 8 million more doses would be available in the next week.  I’m just wondering, how much less did we actually get over the week?  And is there a reason, if you're hearing from the manufacturers of another problem or just wondering if you could characterize why it's less and how much it's less.

Anne Schuchat: Yes, thanks.  Last week we did mention that we had been led to expect about 8 million doses this is week.  Based on what we have today, we aren't expecting to meet that estimate that the manufacturers gave us.  I think there are a variety of reasons that it's difficult to be exactly right in terms of what the manufacturers expect to have from week to week.  Some of the steps involved with vaccine production happen really at the last minute.  There’s lot release testing you do before the vaccine can leave the plant.  If the lot release comes out a certain way, everything goes forward.  If they come out other ways you have to look into things in more detail.  There’s also transport.  When something leaves the manufacturers it needs to get shipped to where it's going.  Sometimes the shipping doesn't go perfectly.  We’re told a little bit of a problem might have been some side effects of the storm that some of the country went through in slower shipping.  I think it is really challenging.  Going forward, one of the reasons we haven't wanted to project weeks into the future is because it's very difficult to be right.  This week we are expecting that we will not receive 8 million doses.  We’re expecting it to be substantially less than that that comes in by the end of tomorrow.  But I won't know until tomorrow what comes in.  Time for another question from the room?  Do we have one in maybe not?  Okay.  Then I guess time for one more question from the phone.

Operator: Stacey Singer, Palm Beach Post, you may ask your question.

Stacey Singer: Hi, thank you.  I’d like to hear a little bit more about the methodology you use to arrive at the new figures as much as you can tell me.  And also I would like to know if the new figures give you better information about the death rate of this particular strain of pandemic flu and how it would be compare to previous pandemics.  Thank you. 

Anne Schuchat: Yeah.  Let me sketch out the methods in some detail but there will a lot more detail on the web.  We’ve posted a summary of the detailed method for people to pour over.  Essentially we're using the Emerging Infection Program Network as our first source for hospitalization data.  We correct the numbers that we get from the Emerging Infection Program Network based on underdetection.  That would be things like a person is in the hospital for flu but they don't get a test for flu so they can't be lab confirmed.  Or they get a test for flu but the test says they don't have flu, we know the tests aren't perfectly accurate so a certain number of patients who really do have H1N1 flu have a negative test result.  Those are the sorts of correction factors.  Then what we do is look at a ratio of hospitalizations to deaths.  We get that ratio of hospitalizations to death from our aggregate hospitalization and death reporting activity that about 30 of the states are contributing to.  That helps us know if we have this many hospitalizations how many deaths should we have.  We’re actually doing that adjustment for different age groups to be as precise as we can.  That’s how we go from hospitalizations in the Emerging Infection Program Network to correct for underdetection to nationalize in terms of the full population, and then to adjust for the death to hospitalization ratio. 

To get the case figures, we actually use essentially a reporting factor that we publish in a paper by Carrie Reed and others in the Emerging Infectious Diseases journal that talked about if you have this many hospitalizations, how many cases would you have.  I think it’s a factor of about 222.  And that’s because not everybody who is ill seeks care.  Not everybody who is ill is hospitalized.  We know there's quite a lot of illness out there that doesn't lead to hospitalization.  In terms of the way to relate, what we're seeing to deaths, previous pandemics, in terms of a death rate, I don't have that answer for you.  We can look into that and see if we can get you that in a follow-up.  I think that was the question.  Sorry, might not have understood the question.  What does this look like compared to previous pandemics.  The estimates I’m giving you are the first six months.  This is April through the middle of October.  We have a long flu season ahead of us.  In typical seasonal flu we see disease from December to May, it's only November.  So exactly what we will see as a full toll of illness from this pandemic is very difficult to say.  I can say, though, that what we're seeing with this H1N1 virus is nowhere near the severity of the 1918 pandemic.  That caused much larger numbers even six months in.  I think projecting out forward is difficult.  And we're really keen to get vaccine given as rapidly as possible to those in greatest need so we can limit the full toll this pandemic takes.  So thank you, everybody. 

 

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