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Weekly 2009 H1N1 Flu Media Briefing

December 1, 2009, 1:00 p.m.

Operator: Welcome and I’d like to thank you all for holding and inform you your lines are in a listen only mode until time for questions and answers at which time you may press star 1 to ask a question.  Today's call is being recorded.  If you have any objection, you may disconnect at this time.  And now I’ll turn it over to Glen Nowak.  Thank you sir, you may begin.

Glen Nowak:  Thank you for attending today's press briefing whether you're here in person or on the phone.  Today's briefing, the update on the H1N1 influenza and H1N1 influenza vaccine is going to be done by Dr. Thomas Frieden. Dr. Frieden is the Director of the Centers for Disease Control and Prevention.  And I will turn the podium over to Dr. Frieden. 

Thomas Frieden:  Good afternoon, everyone.  And thanks for being here.  Today is World AIDS Day and the theme of World AIDS Day this year is human rights and access to treatment.  Health care providers can play a critical role in identifying and helping to confront or reverse the HIV epidemic.  By testing more people, linking them to care, helping people who are positive not only to stay healthy but also not put themselves and others at higher risk by reducing their risky behavior and by ensuring that people are educated and get the treatment that they need.  One of the things that people with HIV benefit from, as do other people with chronic conditions is the H1N1 vaccination. 

And giving the update now, on H1N1, turning to H1N1, I think the basic perspective for today is that we are in a window of opportunity.  We're going from a time where there was lots of disease and not enough vaccines to a time where disease is gradually decreasing and we're having a steady increase in the amount of vaccine that is available.  That leaves a window of opportunity for more people to be protected by getting the vaccine.  The flu virus is unpredictable.  We can't be sure of what will happen in the future.  But we do know that we can provide you with every piece of information that we have about what's going on today.  There's been a decline in activity, but there are still lots of flu.  Flu is widespread in 32 states, and we'll show a slide which will be available on the web that we'll put up now showing flu activity, last year at this time, compared with this year at this time.  And what you can all see is, by the end of November, early December, there was very little flu last year.  This year, we have widespread disease in most of the country.  Although flu is going down, it’s far from gone.  And flu season lasts until May.  Only time will tell what the rest of the season will bring.  There are still lots of kids who are sick and lots of people who are at risk of getting influenza and end up getting severely ill from it.  One question that all of us naturally have is, will we have another wave, or another large number of cases in the months to come, between now and May?  We took an informal poll of about a dozen of some of the world's leading experts in influenza.  About half of them said, yes, we think it's likely that we'll have another surge in cases.  About half said, no, we think it's not likely.  And one said, flip a coin.  We don't know what the future will hold.  What we can do is track very closely so that as the cases develop or don't develop, we can determine where they're occurring and what their characteristics are.  It's important to remember that in the last pandemic that behaved this way, 1957-1958, more than 50 years ago, there was a large surge in cases at the beginning of the school year, then a waning of cases, and then in December, January, February, there was a big increase in the number of people who were severely ill or who died.  We don't know if that will happen this year.  We do know that the vaccine is the best way to protect yourself. 

With the virus changing, it's important that we continue to track it.  And I want to take just a moment to outline some of the ways that that happens here at CDC.  As more people develop influenza infection, there's more chances for the different virus strains to change and evolve, and as more people become immune to it through either vaccination or infection, there's a pressure on the virus to change.  Scientists at CDC's influenza labs work extraordinarily hard and with an enormous level of knowledge and expertise to track what's happening.  We have about 100 people working in our flu lab directly and nearly another 100 who work in areas that closely related to the influenza laboratory work.  We know, for example, through their work, that the virus remains very well matched to the vaccine that we're using.  We also know that even if the virus were to become more deadly, this vaccine would likely work on less parts of it that affect that vaccine change.  In other words, the parts of the virus that make it deadly are different from the parts that the vaccine uses to protect us.  We also know that resistance remains rare.  And recently, there were reports in the press, of a mutation in Norway and other parts of the world that appeared to be associated with more severe infection.  And while there's a lot that we still don't know about this particular strain, there's a lot that our laboratorians or scientists knew very promptly.  We can show on the web and in the next slide, just how sophisticated some of the laboratory work is.  This shows the actual genetic configuration of the virus and receptor cells within the human lung.  And indicating in red, the part of it which changed, and why it meant that this particular virus strain was more likely to be found in lower parts of the lung.  While that may have seemed concerning, in fact, we found this type of virus, our laboratorians have, since the early part of the outbreak, present in less than 10% of the very severe or fatal cases and we know that H1N1 can cause deep lung infections without it.  Also selection of this sample may result from how the samples are collected or handled in the lab.  And we haven't seen any clusters nor have they been associated with resistance or any change in vaccine responsiveness.  So this is all by way of saying it's interesting but at this point, not something that we should be unduly concerned about.  And it's an example of the superb work that our laboratory and really a global network of laboratories that works together to find and find out about H1N1 and other flu viruses are.  And I just want to take a minute to recognize and thank them for their superb efforts. 

With increasing amounts of vaccine available it is a window of opportunity for protection.  There is now nearly 70 million vaccine doses available.  And we're seeing that more people are getting vaccinated.  More people are getting protected.  And as that happens, it's harder for the virus to spread.  Increasing supply should lead to increasing ease of getting vaccinated in many places, but we know it's still far too frustrating.  We know there are lots of people who wanted to get vaccinated who haven’t been able to get vaccinated yet.  We know from polls that 9 out of 10 people who had trouble getting vaccinated and didn’t receive the vaccine, said they would try again.  Now, it's a good time to try again because vaccine is increasingly available. 

We're seeing variability.  Different places are different.  Some states have more virus activity.  Some states have more media coverage of people who are sick.  Some states have a tradition of taking vaccine more than others.  And some states are having experiences where they're getting school kids vaccinated and holding back some of the vaccine from doctors' offices.  Other places are mostly working with doctors' offices and not so much with schools.  So there are differences in difference places.  And those are understandable differences.  There's not one perfect right answer on how to vaccinate.  And one of the things that we do is look carefully at what we know and what we don't and what we can learn about how it works to vaccinate people and what's the best way, for example, to get school kids vaccinated where different areas may have different approaches.  Different ways to get pregnant women vaccinated.  We urge all obstetricians to carry the vaccine and to vaccinate their patients, but we know that’s difficult.  That having a separate system, a new refrigerator, supplies, some of the administrative demands are challenging.  It's hard to get that up and running, so at least every obstetrician should ensure that they know how their patients can get vaccinated easily.  That variability is both a challenge but its also understandable and its one of the things that helps us learn better ways to do it and allows creativity at the state and local levels to reach out to people who are hard to reach and to allow people who may want to get vaccinated but may not go out of their way to get vaccinated.  I think in the coming weeks, we'll see increasing vaccine availability, we’ll see places that have more vaccine they can easily use.  At the same time, we'll see doctors who wish they had vaccine and patients who wish they could get vaccinated.  So it continues to be a challenging time, we continue to have not as much vaccine as we would like to at this point.  And the recommendations of the Advisory Committee on Immunization Practices provide flexibility for local areas to do what's best to protect the people in their community.  I'll also note that there are about a quarter of all of the vaccine that we have available is in the form of nasal spray which is available for people age of 2 to 49 who don't have underlying problems and it believed to be highly effective and its one less shot.  We’ve heard about reluctance on the part of health care workers and others to get the nasal spray, but there's really no reason to be any less confident in it than any other flu vaccine. 

In summary, we don't know what the future will bring.  We do know that we have less vaccine now.  It is a real window of opportunity to get vaccinated in the coming weeks and months.  And vaccination remains our best protection against the flu and for people who are sick.  It's important still to get prompt treatment.  When you're sick with flu-like symptoms, it may or not be flu, but if you're severely ill, by all means see the doctor.  And if you have an underlying health condition such as diabetes or a neurological condition, it's particularly important to see your doctor promptly.  Thank you.  I'll be happy to take questions now, starting in the room.  Mike. 

Mike Stobbe: Mike Stobbe from the AP.  Two questions, one did you say when you were talking about the Norway mutation that it's present in less than 10% of severe and fatal cases? That actually sounded a little high to me.  I also wanted to ask you, um, you and Dr. Schuchat have mentioned the 57-58 pandemic as a model, do you mind talking a little bit more about the similarities and any dissimilarities you have been seeing between now and then? 

Tom Frieden: In terms of the mutation, one of the unique characteristics of this mutation is that it's more likely to be present in the lower lung.  Whether it's present in the lower lung because it was selected out within the body, kind of like a resistance strain might be selected out for someone on treatment or it [sic], our scientists don't yet know.  So it's an area of active investigation by the scientists but it's not something that makes us think that necessarily this is a strain that then attacks the lung.  It may be selected out in the lower lung and we've seen patients who have had this strain in the lower lung and not this strain in the upper respiratory system suggesting that it’s something that may change over time. This is all science and some of it changes and if we understand better, I think the take-home message is, that though this has been associated with some severe cases, it’s probably not the kind of thing that's spreading rapidly from person to person and likely to become the dominant strain or something that should concern us in that way.  So we can put you in touch with our laboratory experts to get more of the details of that.  In terms of 1957-1958, we looked to the past to learn from it.  But if you've seen one flu pandemic, you've seen one flu pandemic.  And each pandemic is different.  Each pandemic occurs at a different time, has a different pattern.  Has a different pattern both of the virus and the communities that it exists in.  So the only way to know what's going to happen with this virus is to track it over time intensely both in terms of the patterns in the community and the patterns in the laboratory.  Next question?  We'll go to the phone.  Any questions on the phone? 

Operator: Our first question is from Helen Branswell of the Canadian Press. 

Helen Branswell:  Thanks very much for taking my question.  If I could get a clarification, please, and then the question.  Dr. Frieden, you referred to the'57 case, and I heard your answer to Mike there about each pandemic is its own entity.  But you kind of implied that because there was a fall and winter wave, we could be seeing, expect to see a winter wave this time, too.  But in '57, the fall wave was the first wave, was it not?  So the winter wave was number two, which is not the situation here?  Is that correct? 

Thomas Frieden: You know it's hard to say.  We know in '57 there was a large fall wave.  What happened the previous spring, I don't think anyone knows for certain.  We're not aware of a wave then.  One of the things you can argue is in so many people have been infected already, maybe there won't be another wave.  Another thing you can argue is that since this virus does seem to spread quite readily, the people who are most susceptible and who generally will get the flu this time of year, many of them haven't gotten it yet.  So you can argue it either way as our informal poll of experts found, but the bottom line is; only time will tell.  You had a question? 

Operator: Next question is from Miriam Falco, CNN Medical News.  Your line is open. 

Miriam Falco: Hi, Dr. Frieden.  Thank you for taking the question.  Two quick questions.  Number one, I think I didn't hear, but what's the number of doses available today?  And when are you coming out with the new estimate that will give a better idea of how many people have died and how many people have been hospitalized? 

Thomas Frieden: There are nearly 70 million doses available.  And our next estimate will come out next week.  End of next week.  At the end of this week, we'll be providing an update on vaccine safety, with information on what we've seen so far in terms of reports and any patterns that might or might not have occurred.  Next question on the phone? 

Operator: You have another question from Helen Branswell from the Canadian Press.  Your line is open. 

Helen Branswell:  Thank you very much.  I was wondering, Dr. Frieden, if you could tell me, is CDC doing serology work to try to get a handle on how many people have actually been infected with this virus?  Because that's one of the big mysteries at this point, really how deeply into the community it actually has gone. 

Thomas Frieden: That's a great question and we're working with some of the commercial labs.  Some of the challenges are how specimens are stored and how long they're available.  It's something we would like to do.  It's not something we expect to have in short order, but it will help us understand what has been happening to see what the infection rates are at different periods of time, of course, challenging with the vaccine and vaccine-induced immunity.  Some of the laboratory work is challenging but it something that we think is well worth doing and we’re undertaking studies to get it done.  In the room?


Beth Galvin: Hi, Dr. Frieden.  Thank you for doing this again.  I'm Beth Galvin with Fox 5.  Can you talk a little bit about when it might be easier for people who are healthy and not in one of these risk groups to get the vaccine?  How much longer do you think they're going to have to wait and let other people go first?  And is it going to be around Christmastime?  Or do you have any idea on that? 

Thomas Frieden: It's hard to predict with certainty when there will be widespread availability of the vaccine.  We're a lot closer to that happening now than we were a couple of weeks ago.  And it’s going to be different in different parts of the country based on how much disease there is, how much demand there is, so supply is increasing steadily and demand will depend on a lot of factors,including how much disease there is and how well we emphasize to people, particularly with people with underlying condition, that it's important to get protected for their own sake and for the sake of their families and the community.  Other questions in the room? 

Diana Davis: Dr. Frieden, Diana Davis from WSB Atlanta.  Do you have any idea how many more million doses should be available? 

Thomas Frieden: We'll be providing that information later in this week in terms of how many we expect for the coming one to two weeks.  Any other questions in the room?  If not, we'll go to the phone.  Operator? 

Operator: The next question is from Sandra Torry, USA Today.  Your line is open. 

Sandra Torry: Hi, Dr. Frieden.  I have two related questions.  One, besides the issue of the slow growth in the eggs, are there other reasons why the vaccine has been so much slower to come out? 

Thomas Frieden: The fundamental reason is we're using a tried and true, but slow, means of growing influenza vaccine.  And the anticipation was that it would take six to nine months to get lots of vaccine available and that's pretty much what it’s taking.  We had a bad break with the vaccine taking longer to grow.  We had a good break with it requiring only a single dose, rather than two doses for everyone age 10 and up.  So I think that's the primary reason.  You can look at other things that could be done to shave a day or week off here or there but fundamentally, it's how quickly it grows.  Next question on the phone? 
Operator: The next is Meredith Cohn from the Baltimore Sun.  Your line is open.

Meredith Cohn: Hi.  I was wondering if you have any kind of estimates on how many people who have died have also had pneumonia, and if you could talk a little bit about the CDC’s efforts to get more people young and old to get the pneumococcal vaccine, and especially if you can't get the H1N1 vaccine. 

Thomas Frieden: One of the complications of flu is pneumonia, and one of the most common causes of pneumonia is pneumococcal.  So pneumonoccocal disease can be severe and people with underlying conditions as well as in the elderly are vaccination rates are not as high as we'd like it to be.  And we're encouraged by the interest there has been in getting vaccinated - against, to be protected from pneumococcus.  We've seen it at least one site, a much higher than expected number of cases and we anticipate or suspect that’s likely related to having been sick with flu.  Flu not only makes you sick but it wears you down and it wears down your immune system so you will be come more susceptible to bacterial infections after that and one of the most common is pneumococcal.  Two more questions on the phone.

Operator: The next is from Todd Neal, MedPage Today.  Your line is open. 

Todd Neal: Hi, thanks for taking my call. There’s been a couple recent reports out of Canada that showed that only one or three samples that were analyzed in the laboratory actually suspected H1N1 cases actually turned out to be H1N1.  Is that similar to what's being seen in the U.S.?  And if so, what should we make of that, what are the implications? 

Thomas Frieden: The testing that we have from H1N1 is far from perfect and testing in doctors' offices is very inaccurate.  So H1N1 is not easy to test for and for most people who are sick there's no reason to be tested.  And a test result positive or negative wouldn't change how you are treated.  For doctors caring for people who are hospitalized and particularly those who are severely ill, it's important to do testing for H1N1, but not necessarily not to treat based on the test.  Because the test can be negative even if the person has H1N1.  Any other question on the phone? 

Operator: The next is from Sharon Kerry, CanWest News Service.

Sharon Kerry: Hi, thanks you for taking my call.  Dr. Frieden, I’m wondering if you could speak about the possibility or the risk of misdiagnosis in the time of H1N1?  There's a recent letter in the British Medical Journal  were doctors warn that many of the symptoms currently recommended as screening questions for H1N1 are also present in early stage meningococcal disease, could you talk about the risks that people might get labeled as having the flu when they actually have something more serious? 

Thomas Frieden: One point that's important is that many people who think they had the flu may well not have had it.  There’s no way to know without a test and even the test isn't completely accurate.  So if you've had the flu, it doesn't mean that you're protected now.  If you think you had the flu, it could have been another virus.  There are lots of other viruses going around, respiratory viruses and if you're severely ill, whether from flu or something else, see your provider right away.  Any final questions in the room?  Thank you for your interest.  Now is the time for increasing vaccine supply and increasing availability.  It’s still frustrating for some people in different places.  We wish we had more vaccine, we understand that it's frustrating.  But with the climbing number of cases, we're far from out of the woods, but we have a window of opportunity to get more people protected in case there's another surge or wave in the future months.  Thank you. 

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