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CDC 2009 H1N1 Flu Media Briefing

Thursday, April 1, 2010.

Operator: Welcome and thank you all for standing by.  All participants, your lines are in listen-only mode.  During today's question and answer session, you may press star 1 on your touch-tone phone.  Also today's conference is being recorded.  If you have any objections, you may disconnect at this time.  And now I will turn today's conference over to Glen Nowak.  Thank you.  You may begin.

Glen Nowak: Thank you all for joining us this afternoon.  Today we have Dr. Anne Schuchat, director of CDC’s National Center for Immunizations and Respiratory Diseases.  And she's going to be giving you some brief opening remarks and will be available to answer questions about a couple of the articles in today's MMWR that deal with H1N1 and specifically vaccination coverage.  And so I will turn this microphone over to Dr. Schuchat for some brief opening remarks and then we will follow back with questions and answers.  Dr. Schuchat? 

Anne Schuchat:  Good afternoon, everyone.  And happy April Fool’s Day.  The 2009/'10 flu experience has been unique.  Almost a year ago we detected a new influenza virus and soon after that asked manufacturers to produce a vaccine against it.  After they had already begun producing the usual trivalent seasonal flu vaccine, we planned, and the state and local health departments executed a large national vaccination effort against the new flu strain.  And today I want to update you on the results of two surveys related to flu vaccination. 

One of them focuses on health care worker vaccination with both seasonal and the H1N1 vaccine.  And the second survey provides state-level vaccination coverage information for the H1N1 pandemic vaccine.  First I want to just briefly tell you where we are with the disease.  I want to apologize if it's hard to understand me because I just got back from the dentist and my mouth is a little odd. 

The virus is still circulating.  And people do continue to get sick.  As we mentioned earlier this week, Georgia and a couple other southeastern states are seeing increases in disease right now.  So people are continuing to be hospitalized and die from this virus.  And we believe that vaccination continues to be a good idea to reduce the risk of influenza and its complications.  We have not seen seasonal flu strains in substantial numbers at all, and that's a really good thing.  But we, of course, don't know whether we'll see them emerge in the weeks or months ahead.  Next I want to turn to the health care worker vaccination survey which is reported in today's MMWR.  This report describes an innovative approach to surveying health care providers using the internet.  And it queried more than 1,000 health care workers about seasonal and H1N1 vaccination.  It importantly showed certain strategies that led to a greater chance of people being vaccinated, and that's something that we can learn from.  The survey estimates that vaccine coverage among health care workers was 62% for the seasonal flu vaccine which is much higher than what we've seen in other types of surveys in previous years.  They estimated 37 percent of health care personnel were vaccinated against the 2009 H1N1 virus.  Overall 64.5 percent of health care workers had received one of the two vaccines.  Those who care for seriously ill patients were more likely to be vaccinated than those not working with seriously ill patients.  This was true for both seasonal flu vaccination and for the H1N1 vaccination.  So people who were working in intensive care units or on burn units or with obstetric patients were more likely to be vaccinated.  To me this emphasizes the idea that influenza vaccination is a patient safety issue.  And it is a good idea for healthcare workers to be vaccinated to protect their patients.  Health care providers who worked for employers who either recommended or required flu vaccines were much more likely to be vaccinated compared to those health care workers whose employers did not have a formal policy on flu vaccination.  The differences were great for seasonal flu vaccine, if the employers required the vaccine; there was almost a threefold higher likelihood of vaccination.  And for employers who recommended the vaccine, there was almost a twofold higher likelihood of vaccination.  These data suggest that having a systematic approach as a health care institution to vaccination is a good way to make sure that your health care workers are protected and are really able to protect their patients from the spread of flu. 

Next I want to turn to the national surveys that looked at the state-specific influenza vaccination against the H1N1 strain.  In general, these -- this survey that we're reporting describes great success with children and greater success with the ACIP target population than with the general population.  It also shows wide variation between the states and something that we can learn from in terms of the states that did the best for understanding how to really achieve better coverage in future years. 

Overall the country did an extraordinary job of responding to this new influenza strain, but there is room for improvement going forward.  We can learn from the states that had the most success and try to translate that across the country.  We estimate that between 72 to 81 million people were vaccinated against the H1N1 strain.  And we estimate that between 81 and 91 million doses of H1N1 vaccine have been administered.  Those data go through about mid-February.  And so they may not be the same as the final tallies that we get because these same surveys are going on.  So I don't think it's critical to focus on the exact numbers but to give you sort of that ballpark of where we estimate that we were by the time of February.  When we look at the state-specific information, there was large variation among the states.  In fact, a threefold difference between the states that got the highest coverage and the states with the lower coverage.  The median estimation of influenza -- of the H1N1 vaccination coverage -- in all of the states was 23.9 percent or just about one in four people received the H1N1 vaccine.  Rhode Island had the highest of all states coverage.  They achieved 39 percent coverage among all ages.  The lowest coverage was in Mississippi with about 13 percent coverage.  Among children, we also saw wide variation.  Children under 18 years of age, the median coverage was about 37 percent.  This ranged from a high of almost 85 percent in Rhode Island to a low of 21 percent in the state of Georgia.  Four states in New England really did an incredible job, and I want to congratulate them for the success of their efforts.  The New England states of Rhode Island, Vermont, Massachusetts and Maine all achieved greater than 60 percent coverage among children.  Three of these four states carry out school-associated vaccination campaigns, and while it's premature to conclude that this is the reason for their success, I think there's a compelling story there and something that we'll be evaluating more carefully. Coverage was higher in the people who were in the ACIP initial priority groups.  Our Advisory Committee for Immunization Practices identify groups that we recommended receive vaccine early on in the program when vaccine was in limited supply.  And as a nation, we achieved better coverage in that target group than in the general population.  With a median of 33 percent of people in the target groups receiving vaccine.  The survey results that I’m sharing come from two different surveys.  The H1N1 flu survey and the Behavioral Risk Factor Surveillance System survey.  Those two surveys queried a lot of people by telephone.  The H1N1 survey included cell phones as well as land lines.  And in all, these survey results come from 214,316 people who answered questions about their H1N1 vaccine experience. 

It is about a year since we've recognized this virus, and so I think it's a good time to step back and think about what we've learned from this experience.  I think state and local health departments, health care providers, schools, businesses and the general public really came together in extraordinary ways to promote prevention and take steps to reduce the spread of flu and to encourage and provide seasonal and H1N1 vaccination.  The Health and Human Services and CDC recognize how important it is to be able to produce large amounts of vaccine in a rapid fashion.  And we're evaluating ways to do better in the future in terms of investments that could be made in vaccine development and research efforts.  We all know that if we had had more vaccine earlier, more people could have received vaccine, and we could have prevented more disease.  We know that we did prevent disease complications and deaths with our programs, but if we had had larger amounts of vaccine sooner, it would have been better.  Remembering where we were a year ago and where we are now, it's a good time to take stock.  There is much that we can be proud of as a nation and many opportunities for us to learn and do better.  And I look forward to answering your specific questions about the surveys and the data through February. 

Glen Nowak: Operator, we'll switch and take questions. 

Operator: Thank you.  Once again for questions, press star 1.  Please record your name to be introduced.  Again, press star 1.  One moment for your first question.  Thank you.  Our first question is from Joanne Silberner, NPR.  Your line is open.

Joanne Silberner: Yes, thanks.  The question is about the recent upticks in Georgia.  You mentioned that Georgia was one of the lowest in terms of vaccination rates.  Can you tell me how big the recent jump was and whether it can be related to the low vaccination rate? 

Anne Schuchat: Georgia has had regional disease for several weeks now.  And since December 1st, they've had 357 people hospitalized for influenza in the state and 22 deaths.  The last couple weeks they've had more hospitalizations each week than they've had at any time since last October.  So they had an early rise in disease in late August and September.  And then by October when a lot of the rest of the country was seeing an increase in cases, they were at a calmer period.  And now really since -- during February and March, they've really seen a big jump in disease.  They are, as you've noted, one of the states with lower immunization coverage.  Could that be related?  It’s possible.  It may be that there are more people susceptible to the virus in Georgia, and that could contribute to the upticks that they are seeing.  But it's also possible that they're just a herald of what may happen in other states.  And we really don't know.  Unfortunately, with influenza, there are always the many things that we don't know about the predictability and exactly why we're seeing the patterns we're seeing.  One thing we do know is that the vaccine is very safe.  It’s effective.  It’s in very ample supply around the country.  And the best way to take the mystery out of the situation is for people who are not yet vaccinated and are at risk to take advantage of the available vaccine.  Next question, please. 

Operator: Thank you.  Next question, Miriam Falco, CNN news, your line is open. 

Miriam Falco: Thanks for taking these questions.  I’ve got two, as I usually do.  Sorry.  Number one, how many doses of vaccine are likely to be thrown out, and when are they expiring based on the -- I’m referring to the Washington Post article.  I’m wondering if you have any more info.  And regarding the states, the successful ones were all very small states.  Do you think geography has something to do with it?  Do you think that they have such good vaccination rates or because when the vaccine was available, that part of the country wasn't being hit as hard by H1N1, unlike the south, for instance, and they didn't have vaccines?  To what do you attribute the success in some states and the lack of success in others, and how will that come together to avoid throwing away millions and millions of doses of vaccines the next time something like this happens? 

Anne Schuchat: Those are great questions.  I think that it's premature for us to know exactly why some states did much better than others.  But there are several factors that are likely contributors.  Certainly when disease was on the upswing and it was very visible in the community, there was a lot of concern.  And it was natural for there to be great demand for vaccine.  So because New England saw disease on the upswing really in November, I think that they were able to take advantage of that demand with ample supply by then.  There are some states that have more experience with large-scale influenza vaccination year in and year out.  There are a number of states that have been doing pilot efforts with school-located vaccination.  And some of those states, I think, had an easier time implementing their plans.  In general, we think that the school-located vaccination efforts were important, and many of the states also did mass community clinics which seemed to be successful for their population.  We have a lot more to look through and analyze and evaluate.  And we are looking forward to learning from the science of this experience, identifying the best practices.  It may be that the state estimate of coverage and how well things worked misses the local patterns because I believe in some states some parts of the state did much better than other parts of the state.  We know that our public health system is a quilt, really, of many different groups contribute to the strength of the public health system.  And from my perspective, it's extremely important that we strengthen that infrastructure in every community so that one is really best served when we have emergencies like this one.  Our next question.  Oh, sorry.  The question about the expired vaccines.  Most of the vaccine has not expired, and some of the vaccine will expire by the end of June, and some of that vaccine won't expire even till 2011.  What we're suggesting right now is that providers, pharmacies, health departments hold on to their vaccine as long as it hasn't expired and keep offering it.  We may see situations like what we're seeing in Georgia where ongoing vaccination could be very beneficial.  And so what we're really asking is for this vaccine to continue to be used.  Now, when we get the new seasonal flu vaccine next fall, it's likely that this particular vaccine can be put aside.  But we don't know exactly when the seasonal flu vaccines will become available.  And in what quantities.  And we would hate to see a lot of disease in august and everyone having thrown out their H1N1 vaccine, and thus not having the seasonal flu vaccine arrive yet.  So we think that it's important for the vaccine to continue to be used.  Do we expect to use all of the vaccine?  No.  It’s unlikely that all the doses that are out there in doctors' offices and pharmacies and health departments will all be used up.  But we made a conscious decision to have more than enough vaccine instead of less than enough vaccine.  Next question. 

Operator: Thank you.  Mike Stobbe, Associated Press, your line is open. 

Mike Stobbe: Hi.  Thank you for taking the questions.  I have two like Miriam.  First, thank you for congratulating four new New England states on their success, and you mentioned three of them had school-based clinics.  Can I understand, then, that Georgia and Mississippi and some of the states that were on the lower end of the scale did not do school-based vaccination clinics, and do you know why not?  My second question had to do with the health care workers.  I was wondering, the high, I guess it was 62 percent for seasonal and 37 percent for swine.  Hasn't the government recommended since the '80s that everyone get vaccinated, do you mind saying a little bit more about why rates continue to be as low as they are? 

Anne Schuchat: Thanks.  Those are both great questions.  I don't have the specifics about the lower coverage states and whether or not they did school-located vaccination efforts.  But one thing to say is that many states did them in part of the state but not the entire state.  And this was often decisions that were based on community partnerships.  The schools were interested in doing them in some communities the school preferred that the vaccination be done elsewhere in other communities.  But this is why we're really doing large-scale evaluations to understand what strategies worked best.  There may be some approaches to school vaccination that were more successful than other approaches to school vaccination.  So I can't answer the details of all of the states in the lower numbers there.  The health care worker vaccination is a very important issue.  You’re right that it's been years that we've been recommending health care workers be vaccinated against flu.  What I would say is that we have a unique opportunity right now with greater attention to patient safety.  We’re really trying to improve our health care system with many, many different efforts.  And we've been able to show that focused attention to practices and processes in the health care environment can really improve patient safety.  We can save lives by attending to the things that matter for patients.  And vaccination is one of those things.  And I hope that with this renewed attention over the past few years and the new interest and awareness about influenza, that we can really do a lot better in the years ahead.  It is clear from the research that a systematic practice and policy on the part of our healthcare institution can make a big difference in things like vaccination.  Our next question, please. 

Operator: Thank you.  Tom Maugh, "LA Times," your line is open. 

Tom Maugh:  I find the low vaccination rate among health care professionals almost scandalous.  If we can't get these people to get vaccinated, how are we going to convince the public at large? 

Anne Schuchat:  Thank you for those comments.  I think there are a lot of myths and misperceptions that we need to overcome, and health care workers may really be a microcosm of the general population.  I think people are now learning more about how serious influenza can be -- both seasonal influenza and, of course, this pandemic strain.  And that the health care environment is one where infections can spread.  We are having greater awareness about how safe flu vaccines are and their effectiveness which can vary but is generally pretty good in healthy adults like health care workers.  So I think that there are probably a lot of strategies that could improve this.  And we were pleased that for at least seasonal influenza vaccination among health care workers, the survey, the internet panel survey, showed higher results than we've seen in previous surveys in previous years.  Maybe we're at a tipping point.  Maybe it's a time where consumers and patients and their health care workers are vaccinated and the institutions will pay attention to the practices.  We would love to see health care institutions report the coverage that they achieve and really start competing with each other and publicizing their results so that patients can know, you know, that's a hospital that really received a higher rate of protection among their health care workers.  These are a lot of strategies to be explored in the future.  Our next question. 

Operator: Thank you.  Brian Hartman, NBC, your line is open. 

Brian Hartman: Yeah, with ABC.  Hi, Dr. Schuchat.  Back to the vaccine's disposal, how does one dispose of all these vaccines?  Is it retrieved from the doctors' offices?  Do you give them guidance or protocols on how to do it?  Also with manufacturers.  And I guess the same question, the third part of it, is the disposal in any way bad for the environment? 

Anne Schuchat: Those are great questions.  The seasonal flu vaccine is typically, at the end of the year, often the provider will send the doses back to the manufacturer.  They are able to collect the excise tax back if they do that.  There's sort of a standard way that it's done every year because of the unusual program, because the federal government organized the H1N1 vaccination efforts, we are right now in the midst of planning the recovery of doses, strategy.  And so that hasn't been finalized yet, but it's under planning stages.  But remember, every year there's extra seasonal flu vaccine out there at the end of the year, and it's taken care of according to the state or local regulations.  There’s really nothing special about this H1N1 influenza vaccine.  The five companies that made the influenza vaccines against H1N1 are the same five companies are the same five companies that make seasonal flu for the U.S. market.  And it was produced and licensed in exactly the same way.  So there's really nothing special except that it happens that the U.S. government procured all of this vaccine, so we're working closely to get guidance out in the near future so the docs and the health departments will know the approach that should be taken.  Next question, please. 

Operator: Thank you.  Beth Galvin, Fox 5 News, your line is open. 

Beth Galvin: Hi, Dr. Schuchat.  Thank you for taking my question.  I think you've dealt with this a little bit earlier, but I want you to talk to me again about Georgia’s low vaccine coverage, especially among children.  Is there any early idea of why? 

Anne Schuchat: I think it's still a puzzle.  It is important to say that Georgia experienced disease earlier than a lot of the country.  And so by the time that the vaccine became available, I think there was less public interest in vaccination and in the flu than there was back in August or September.  That said, I think there's a lot that we have to learn.  And one thing, not pointing to Georgia, but really looking at the country as a whole, is to say that our public health infrastructure has really been challenged.  And our economy has been in difficulties this past year or two.  A lot of job loss around the country in the public health sector and in some of the partner sectors.  And it's been a pretty challenging time for people to get the regular business done as well as the extra duties.  So I think that, you know, whether that is a factor in some of the states that weren't able to do as well as other states or whether there's just more of an experience with the mass vaccination efforts in some of these states than others, I can't say.  Next question. 

Operator: Thank you.  Next question, Betsy McKay, "Wall Street Journal," your line is open. 

Betsy McKay: Hi, Dr. Schuchat.  Thanks.  I actually just have a couple of follow-up questions on questions that were asked earlier.  One is, on the school-based clinics, three New England states, can you tell us which other two besides Maine had school-based clinics and also do you know how many states or how much of the country did have school-based clinics?  The other question I wanted to ask was about vaccine again.  Can you remind us how many doses actually have been or were shipped, and how much have been filled and finished?  In other words, how much vaccine is out there? 

Anne Schuchat: Okay.  Sorry.  For the school-based clinics, I know that Rhode Island also has school-based clinics in addition to Maine.  I’m not actually sure whether it was Massachusetts or Vermont that had the school clinics.  We’ll check on that and try to get that for you.  I missed your second question as I was trying to remember. 

Betsy McKay: I’m sorry; I asked a lot of them.  One was do you know how much of the country did have school-based clinics?  And the other is how much vaccine has been shipped and how much has been filled and finished?  In other words, how much vaccine are we talking about that's still out there? 

Anne Schuchat: Sure.  Right.  Okay.  So in terms of the country, probably something like 40 of the states did -- I believe it's almost 40 of the states that did at least some school-based clinics.  It may not be 40 states because it might be that it's 40 grantees which include some of the bigger cities.  But the majority of states did at least some part of their state carried out school-located clinics.  Some states like Maine and Rhode Island did the entire state.  You know, we know that they really were quite aggressive.  In Rhode Island, they organized it with their medical reserve corps.  In Maine, they had a tremendous partnership between the pediatric communities, public health community and education sector and really, you know, took off with that partnership.  Now, in terms of the doses, we have shipped out to the states or doctors' offices or pharmacies about 126 million doses of vaccine.  I believe the estimate for the number of doses that were filled and finished and released for U.S. use is 162.5 million.  So the difference between that 126 million and the 162.5 million is that we have some doses at our central distributor and some still being kept for us at the manufacturers just to reserve this available, if there's going to be any -- you know, we wanted that reserve in case there would be a third wave or a huge demand later than, you know, we had seen.  So the 126 million that were shipped out, I don't know how many of those doses that happen to actually have been administered are still available.  You know, when we have a multidose vial sometimes and not every one of the ten doses gets used and sometimes it's discarded before all ten doses are used, some of the vaccine might not have been maintained in the right temperature limits, and people might have discarded it because it wasn't handled or stored appropriately.  We don't have a system now that can tell us how many doses are in that part of our distribution system.  So that's something that we may need to get in the future, but we don't right now have that awareness.  Okay.  Next question. 

Operator: Thank you.  Bob Roos, CIDRAP news, your line is open.

Bob Roos: Thank you.  Dr. Schuchat, I wondered if you could say a little bit more about how the vaccine coverage rates in the states for H1N1 compare with the past data on seasonal flu vaccination coverage.  That’s one question.  Also, I just wondered for the H1N1 vaccine doses that don't expire until next year, is there any possibility a mechanism that would, say, could be actually used in the seasonal next fall, a seasonal vaccine? 

Anne Schuchat: Okay.  So, let me do the second question first.  There is vaccine that is -- the companies produced bulk antigen, but they didn't fill and finish the vaccine.  And it is theoretically possible that some of that antigen could be the H1N1 component of a trivalent vaccine.  So plans around that particular decision are under discussion between the Department of Health and Human Services and the individual manufacturers.  So that one of the advantages of storing as bulk antigen is there's a longer shelf life really.  Once you put stuff into vials or syringes, the clock starts ticking on the expiration, but the bulk antigen remains potent for a long time.  The other question you asked was to compare the past years.  It’s a little bit difficult to do that, but I want to give you a little information.  One of the reasons it's tricky to do that is because we use different survey approaches in different years.  But first I want to give you some information about children.  In the 2008/'09 influenza season, we estimate that coverage among children under 18 was about 24 percent.  And, of course, we're estimating that the coverage in that age group now for the H1N1 seasonal -- sorry, the H1N1 vaccination was 36.8 percentage (Editor’s Note: This is a correction), so that's a big jump.  The 2009/'10 season of seasonal flu, we actually -- that data hasn't been formally released yet.  But we do see that this year with the H1N1, we did better than we've done in past years.  Recommendations, of course, have changed for children.  But we haven't had as high rates of coverage in children over the years as we see, for instance, in the elderly.  In the adults with high risk conditions, we saw -- what was our coverage for H1N1?  We saw a median of 25% in that group.  And in the seasonal flu, that is probably -- let me see if I can find the information about that.  You know, it's a little hard to compare, but in the younger adults with high-risk conditions, it's a similar range.  In 18 to 49-year-olds with high-risk conditions in past years, we've done about 25 percent -- or 25 to 30 percent.  So it's in the same ballpark.  Consistent with the idea that the H1N1 vaccination effort was more successful for children than it was for high-risk adults or other adults.  With seasonal flu, the groups that we always do the best in care of the elderly where we usually see between 65 and 70 percent coverage.  Of course, the elderly weren't in the initial target group for the H1N1 vaccination effort.  But what we saw with them was a median of 22 percent coverage with H1N1 vaccine which was actually much higher than what we saw in healthy adults under 65.  The elderly, 22 percent of them, were vaccinated compared with only 14.4 percent of healthy adults under 65.  Consistent with the idea that the elderly are used to getting flu vaccines and wanted it, and once it was their turn, they did show up in greater numbers than other healthy adults.  We have time for two more questions? 

Operator: Thank you.  Next, Amy Burkholder, CBS news, your line is open. 

Amy Burkholder: Yes, hi, doctor, quick question.  Do you agree with the Washington Post’s assessment that we stand to see about 70 million doses go unused and that they would be discarded?  And second, what evidence does the CDC have at this point that the H1N1 virus is mutating? 

Anne Schuchat: It's very difficult to say how many doses of vaccine will go unused and be discarded.  What I can say is that every year seasonal flu vaccine with the seasonal flu vaccine efforts, some vaccine is discarded.  And it would be a surprise if we didn't have greater numbers discarded this year than in the seasonal flu vaccine effort.  We really made a conscious decision to be prepared and to assure that we would have more than enough vaccine instead of less than enough vaccine.  In terms of the flu virus changing or mutating, we continue to test influenza viruses every week.  And we have not seen signs of mutation.  That doesn't mean that this won't happen over time.  We know that influenza viruses do change.  And with the more -- the more and more people that are exposed and infected with influenza viruses, the more likely it is that the strains will adapt and change.  So far from all the virus surveillance that we're doing right now, the strain that's in the vaccine is still a perfect match which means that getting an H1N1 vaccine right now is still a good idea to protect you in the months ahead.  And that the strain that's been selected to the seasonal vaccine formulation for next fall remains the right strain in terms of the H1N1 component.  And so just to follow up on that earlier question about which states in New England did school vaccination, Maine and Rhode Island and Vermont did school vaccination and Massachusetts didn't.  So Massachusetts was able to achieve that high coverage in children without the school-located efforts.  The last question, then? 

Operator: Thank you.  Sally Kidd, Hearst TV, your line is open. 

Sally Kidd: Yes, Dr. Schuchat thanks so much for taking our questions.  As you know, many people waited in long lines to get the vaccine during the shortage.  And now they are hearing there's plenty of vaccine and, in fact, some of it may eventually need to be thrown out.  So how do you respond to that?  What is your message to them? 

Anne Schuchat: I think we have a lot of room for improvement in terms of communities valuing vaccination.  We really have an opportunity for a culture change right now -- that vaccines stay alive.  They keep people healthy and out of the hospital.  They keep people at work and at school and we saw people lining up to get vaccines this year, something we hadn't seen probably since the polio era.  That was a good thing in terms of understanding that vaccines are life-saving and important.  I hope we can build on that experience and really protect more and more people in the years ahead. 

Sally Kidd: What I mean, could the government have done a better job in its vaccine procurement or distribution efforts or estimating, you know, how much would be needed? 

Anne Schuchat: You know, there's always room for improvement.  And one of the factors right now is across government at the federal, local and state level; we're all looking critically at our experience to learn how we could do better.  And I think it's important to also be realistic that it would be impossible to perfectly match supply and demand.  We have to decide; do we want to have more than enough or less than enough?  And we basically had discussions saying that this was about protecting the American public and safety was important.  It was -- I think our director, Dr. Frieden, said, there will probably be one thing that is certain.  We will have more supply than we need and less supply that we need, and having exactly the right supply will probably happen for 12 seconds on one particular day.  And so we see this with seasonal flu, and we saw this with the H1N1 vaccination effort.  And I think this is one of the challenges.  But really in terms of the key part of your question, could we do better?  Absolutely.  And I think all of us are committed to doing better in the future.  Thanks, everybody.  And enjoy the holiday. 

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