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Flu Telebriefing with Dr. Keiji Fukuda

October 31, 2001

CDC MODERATOR: Hello, and welcome to the Influenza Telebriefing Update. Our speaker today is Dr. Keiji Fukuda. Let me spell his name for you. His first name is K-e-i-j-i, last name F-u-k-u-d-a. He's a medical epidemiologist in our Influenza Branch here at CDC.

Dr. Fukuda is going to discuss our current flu recommendations for this year's season, give an update on the influenza vaccine and also give a report on the latest influenza surveillance data.

Dr. Fukuda?

DR. FUKUDA: Thanks, KD.
Good morning, everyone. Let me say a few words about influenza and some of the current recommendations for this year, and then we'll just throw it open for questions.

Influenza, I think as all of you know, is viral disease, and it's an infection that anybody can get, but there are certain groups of people who are at higher risk than other people for developing severe complications, and these are things such as pneumonia. And these complications can lead to things like people getting hospitalized, and in certain cases they can lead to people dying.

On average, in the United States, we see over 20,000 people die from influenza every year, and we see approximately 114,000 people get hospitalized from influenza. So it's a major, major public health problem in the United States every year.

Now influenza vaccine is the major way that we have to reduce the complications from influenza, and so every year the Advisory Committee on Immunization Practices and CDC give out recommendations on how influenza vaccine should be used.

And this year, as in every year, the focus of vaccinating people against influenza really focuses on those groups of people who are at highest risk from developing severe complications and health care workers. The groups of people that are at highest risk from serious complications include the elderly, that is, people who are 65 years and above, and then those people who have certain chronic medical conditions, particularly heart and lung conditions, but also things like immunodeficiency diseases and other conditions such as pregnant women who will be in the second or third trimester of pregnancy. So we recommend and focus our vaccination efforts on that group of people because they're the ones that are most likely to get seriously sick.

We also are recommending health care workers get vaccinated first because these are the people who have close and frequent contact with the high-risk people, particularly when they're very vulnerable, and health care workers can transmit infections to these high-risk people. So we also recommend vaccinating health care workers.

So the message has been this year to focus on vaccinating those groups of people, especially through October. Now, as we go into November, it is also recommended that we vaccinate other people, and particularly healthy people who are between the ages of 50 and 64 years of age, and then other people who are in close contact with high-risk people. Again, this is to help to decrease transmission of viruses to the high-risk people.

Now to other important--there are a couple of important things about influenza vaccine this year. One of them is that we are going to have more vaccine available than we've ever had before. We're going to have approximately 85 million doses of vaccine available, and these will be available through sometime in December, probably about mid December. But the vaccine, as you know, the distribution this year has been somewhat delayed compared in previous years.

Now through the end of October, we will have gotten out a little bit over half of the vaccine supply. So that means that substantial amounts of vaccine will be coming out in November and in December.

Now another thing that I want to emphasize is that the optimal time to get vaccinated is usually October and November. However, it's clear that every year after November there really are substantial numbers of people who ought to get vaccine who remain unvaccinated. And so we're really, really trying to get the word out that physicians ought to continue their vaccination efforts through November, through December, as long as vaccine is available. I think this is a very important message to get out to people.

Now so far we are pretty early in the influenza season. The activity that we have seen in the country has been pretty low and pretty much limited to sporadic cases. The mortality levels and the influenza-like illness levels associated with influenza have all been at baseline or lower levels.

There have been some viruses that have been isolated this year, and so far they predominantly appear to be influenza A viruses. We have limited information, but based on that limited information, so far it looks like the vaccine match with the circulating viruses is good.

So I think that I will stop at that point and throw it open to questions.

AT&T MODERATOR: Ladies and gentlemen, if you do have any questions, please press the one on your touch tone phone. You will hear a tone indicating you've been pleased in queue and may remove yourself from queue by pressing the pound key. If you're using a speaker phone, we do ask that you please pick up your handset before pressing the number.

First, we will go to the line of Maggie Fox with Reuters. Please go ahead.

MS. FOX: Hi, thanks. Boy, I'm surprised to be able to ask my question. It's hard to get in on these CDC conferences. Anyway, thanks for taking our questions.

You just answered my question, actually, by saying that there hasn't been much. I wanted to ask you how much flu has been seen this year. And also, on a kind of lighter note, I'm told everybody in the world is washing their hands a lot more than they normally would because they're scared of anthrax, and I'm wondering if you think this might have an effect on the flu rates this year.

DR. FUKUDA: Maggie, in terms of the levels of flu, it's pretty much what I told you. There have been 12 states in the U.S. that have reported sporadic levels of flu activity. Otherwise, the other states have reported no levels of flu activity. And so, again, we're pretty early in the season.

As for washing your hands, I'm not quite sure it's going to affect levels of influenza activity, but I think the improvement in general hygiene will be good for everything else.

MS. : Could I follow up on that?


MS. : Everything I've heard from infectious diseases people is that if you want to prevent transmission of the flu that you should wash your hands, that hand washing is one of the primary ways to prevent it. Am I wrong on this?

DR. FUKUDA: No. You know, washing your hands is one of the major things that we can do for any infectious diseases. It's one of the major things that we can do for any infectious diseases. It's one of the major ways that we transmit influenza virus--or transmit many infections. But influenza viruses are transmitted primarily through the air, so when somebody gets sick and they're infectious and they cough or they sneeze, they send viruses into the air and people breathe them in, and they get infected.
It's also possible to transmit influenza viruses directly on your hands, by touching other people and so on. But, really, the major way that we transmit influenza viruses is through the air.

MS. : Thanks.

AT&T MODERATOR: And for our next question we go to the line. Helen Chickering (ph) with NBC News Channel. Go ahead, please.

MS. CHICKERING: Yes, we've heard a lot of differing opinions from various health officials about why we should get the flu shot in light of the anthrax scare and that symptoms of the flu can mimic or are similar to anthrax. Is there a recommendation? I've just, you know, heard a call for more flu vaccines in light of the anthrax scare. What are your thoughts about that? And what's the message to the public?

DR. FUKUDA: Helen, thanks for asking this question. This has really been one of the more confusing things for everybody this year.
I think that in terms of flu vaccine, I think the message is pretty clear. You know, the reason you get vaccinated against influenza is to either prevent your chances of getting influenza or, if you get influenza, it's to decrease the severity of the disease. The vaccine is protective against influenza. It is not protective against other viruses. It is not protective against anthrax.
So there are amply--ample good reasons to get vaccinated with the flu vaccine, but it's to prevent influenza, and it's not to prevent anthrax.

MS. CHICKERING: I think, though, to follow up on that, that people are not--know that it's not to prevent anthrax, but it's to prevent the symptoms that mimic anthrax. And to follow up on that, are you concerned as we get into flu season and people are coming down with the flu and the similar symptoms, especially in areas like Washington and New York, that they will be rushing to their emergency rooms worried that they have anthrax? And are we prepared--are emergency rooms prepared to handle that?

DR. FUKUDA: Yeah, again, this is a sort of complicated series of issues and questions, but let me try to tease them out.

I think that it's really important to understand that, you know, every year there are tens of millions, if not more people, who develop so-called flu-like illness. You know, these are the things that we think of commonly, you know, like fever, muscle aches, headaches and so on. And those flu-like illnesses are caused by a whole variety of different agents, and some of those agents are influenza viruses, other agents are common cold viruses, and then many other viruses, such as adenoviruses and so on. So the--you know, so the flu vaccine is going to reduce the people--the number of people who develop influenza, but there is still going to be lots and lots of people who develop these flu-like illnesses from these other viruses.

And even people who get vaccinated against influenza still stand the possibility of developing flu-like illness either from getting infected by these other viruses or because the influenza vaccine is not a hundred percent protective against influenza itself. And so I think that we really don't want to sell the idea that if you get vaccinated against the flu that it's going to either decrease your chances of getting anthrax, or that if you get vaccinated against the flu, we don't want to have the implication that, you know, if you do develop a flu-like illness then you ought to be more worried about anthrax.
And so this has been very confusing to people, but I think that the bottom line is that, you know, we want to--we want people to get influenza vaccine to prevent influenza. But even after we get that vaccine out there, there are going to be lots of people who develop flu-like illnesses for other reasons, and that this--developing those flu-like illnesses doesn't need to increase your worry about anthrax.

MS. CHICKERING: Are health systems or hospitals prepared to handle people who may be coming in panicked, anyway?

DR. FUKUDA: Well, you know, I think that we all recognize that there is a high level of concern about anthrax throughout the country, and then typically we recognize that throughout the year, but particularly in the fall and in the winter months, that lots of people go to hospitals, anyways, for influenza-like illnesses. And so, you know, every year for the past many years we recognize that some hospitals in some cities frequently, you know, just get inundated with people coming in for respiratory illnesses. And I expect that that will be the same this year as it has been in other years. There are things that hospitals can do, however, and you know, to give you an example, a couple of years ago in Los Angeles, there was a season, the 1997-98 season when a lot of hospitals in Los Angles became overrun by people with respiratory illnesses. And one of the organizations down there, the Health Care Association of California, which is a health care industry, really came up with some common-sense recommendations for hospitals which I think would be useful for other hospitals to consider this year.

And some of those suggestions were that hospitals during these periods when they get inundated with respiratory patients is that they consider doing things like reducing or eliminating elective surgery. They can consider relaxing the staff-to-patient ratios, you know, within the limits of their state licensing agencies. They can develop ways to identify and bring in extra staff to help out with the patients. They can set up walk-in flu clinics to try to triage the patients. They can take extra care to immunize their staff so that they have more staff available.

And so I think that those kinds of steps this year can really help some of the clinics and hospitals out there to handle the--the seasonal rush of patients that we always see.

CDC MODERATOR: Thank you. Can we have our next caller, please?

AT&T MODERATOR: That will be from the line of Lara Meckler from Associated Press. Go ahead, please.

MS. MECKLER: Following up on that same line of thinking concerning the anthrax scare, it seems like there are a lot of doctors out there who are--forget about the issue of flu, that's always there, there will always be people who get the flu, we'll always have to deal with that. But there is a unique situation this year, which is that people are coming into their doctors' offices scared that they actually have anthrax. And doctors--I heard from doctors who are frustrated because they don't know what to do. They don't want to tell someone they're going to be fine when in fact we don't really fully understand who does and does not get anthrax. At the same time they don't want to bow to the pressure to just give everyone antibiotics who wants them.
Could you speak specifically to the unique issues that doctors are facing this year due to the anthrax scare and the fact that the symptoms do resemble flu sometimes?

DR. FUKUDA: Sure. And this can be a very difficult issue. I mean I think that in the first place I think we all have to recognize that in some instances it can be difficult to tell the difference between early inhalational anthrax cases and then flu-like illness cases from other causes.

But I think that if physicians out there evaluate all of the relevant epidemiologic and clinical information which is available, they really have a very good chance of coming up with the accurate diagnosis. And here are some specific points.

First, in terms of the epidemiologic information which can be considered, I think the first thing to remember is that again every year we see tens of millions of people develop flu-like illness from, you know, a variety of causes, including common cold viruses and flu viruses and so on. This happens every year, we expect to see it. There are lots of people who develop these things.

By contrast, I think that we have to remember that very few people have developed anthrax. There has been an awful lot of attention on the cases, but the bottom line is that there have been few cases, and these cases generally have occurred in a limited number of communities within a limited number of groups. And so the message for the epidemiologic information is that anthrax really has not been diagnosed in most parts of the country, whereas we expect to see millions and millions and millions of flu cases all over the place.

MS. MECKLER: But let's assume that you have a doctor in New York or Washington. Right now we have somebody who died this morning from it [inaudible] somebody who wasn't a postal worker and, you know, she had anthrax. I mean how do you--what do you tell a doctor to tell a patient who thinks they are the next person just like that person?

DR. FUKUDA: Well, I think when you get the individuals and get sort of like the clinical cases, I think that one of the more helpful things to remember is that among the cases that--of anthrax that have been seen so far, you know, these cases have not presented with rhinitis or a runny nose. And whereas when people develop the common cold, having a runny nose is really is a very common symptom. And so again, one of the things for physicians to look out for and to tell their patients when they talk with them on the phone or see them, you know, if you're developing something which feels like a cold and you have a runny nose, you know, this is very likely to be the cold.

MS. MECKLER: Have you heard from doctors who are facing this dilemma? I mean is that something that you guys hear from?

DR. FUKUDA: Sure. We hear from lots of people all over the country, both physicians and state health departments, and --

MS. MECKLER: What are they telling you? What are they saying?

DR. FUKUDA: Everyone is wrestling with this issue, and people are looking for ways, you know, how do we tell the differences between these cases? And there are a couple of other things which are helpful.
You know, there are--are some tests, rapid tests which can be done to distinguish influenza cases in some instances. These are tests which can give you an answer in about 15 to 30 minutes, so they can be useful in doctors' offices. These tests are commercially available.

But in pointing that out, I also want to point out that these tests are not appropriate for every patient. Sometimes they overdiagnose infections, sometimes they underdiagnose infections, and they generally have to be used within a few days of when people get sick.

And so I think like any other medical test out there, you know, there are some patients for whom the tests are appropriate and many other patients for whom they are not appropriate.

The bottom line is that it's a difficult--difficult issue to sort of wrestle through but, you know, we sort of have to use common sense in this kind of problem. The common-sense things tell us that for most people in most places in the country, the vast likelihood is that we are going to be dealing with colds or influenza.

It is true, though, that in certain situations--you know, for example, if you were a physician in New York City, you have a patient who is a postal worker, then we have to think about that person differently. You know, we take them in the epidemiologic context, and we might treat that patient differently and be more aggressive about the work-ups and think about the treatment differently.

And I so think--

MS. MECKLER: Although isn't that changing? I mean aren't we less confident to rely on that, given the most recent case?

DR. FUKUDA: Well, you know, I think that right now we are pretty early on, we are learning about the epidemiologic information, and I think that as we get more epidemiologic information and we understand the sort of spectrum of how the anthrax cases can appear, then understanding of how to approach patients will change.

You know, we did that with the HIV epidemic, for example. And I think that our understanding of things will evolve. But this is where we are right now.

MS. MECKLER: The last thing, do you think that given the anthrax scare, it's even more important for people to get the flu shot this year so that it reduces the pool of potential really scared people about anthrax?

DR. FUKUDA: Again, I think that--

MS. MECKLER: I mean I know it's important every year, but is it particularly important now?

DR. FUKUDA: Again, I want to very clearly make--get across the message that we're trying to point out that--the first group of people that we're most concerned to get vaccine into are those people who are at high risk of serious complications for influenza. And then there are other people who should be getting--

MS. : [inaudible].

DR. SAKUDA: You know, these are people who are in the 50 to 64-year-old age group, the groups of people who are in contact with high-risk people. But we're not telling people to just indiscriminately go out and get vaccinated.

CDC MODERATOR: I'm gonna have to move on.

MS. : Okay.

CDC MODERATOR: We have several callers. Thank you.

AT&T MODERATOR: We next will go to the line of Shankar Vendatum [ph] of Washington Post. Go ahead.

MR. : Dr. Sakuda, thanks for doing this press conference; appreciate it.

I have another question that's sort of related to the concern over anthrax. You'd mentioned a little while ago that the flu shot does not protect people a 100 percent from the flu and that there are a number of other viruses that produce flu-like symptoms, that are not the flu.

Would you be able to tell us what proportion of flu-like symptoms are because of the flu and what proportion of flu victims are likely not to get the flu because of taking a vaccine, and, in other words, would this subgroup of people then be reassured about anthrax concerns because of getting a flu shot? And I have a second question after that.

DR. SAKUDA: Okay. The flu vaccine can be up to about 70 or 90 percent protective against influenza and so that means that in a good year, when there's a good match between a vaccine and the circulating viruses, if the person has a pretty good immune system, vaccine can be very protective, but not a 100 percent protective, and so some people who have gotten vaccines still can go on to get influenza infection.

Now the second thing is that if we look at all influenza-like illnesses during the year, flu-like illnesses that happen, less than half of those will be due to influenza viruses themselves.

A minority will be due to influenza viruses and a majority of those influenza-like illnesses will be due to other viruses.

Now I think that when people get vaccinated against influenza, they have decreased their chances for getting flu, but they can also still get infected by these other viruses.

You know, they can get infected by cold viruses, and so, you know, I think that we want to separate the idea that getting vaccinated increases or decreases your chances or your worries about getting anthrax. These are just two separate issues and we really don't want to mix them up. I think that would be unhelpful to people out there.

MR. : Just to follow up on that issue, Dr. Sakuda. You did say that the flu vaccine is gonna protect against some proportion of people with flu-like symptoms, in other words, the people who actually influenza. Wouldn't that subgroup then be reassured about not having anthrax?

DR. SAKUDA: No. What they will have done is they will have decreased their chances for getting influenza but it won't have affected any of their chances either for getting anthrax or not getting anthrax. They're just two completely separate issues.

MR. : Okay. You had talked about seeing, a doctor in New York City seeing a patient who's a postal worker, somewhat differently than the doctor who's seeing some, another kind of patient.

Wouldn't that same concern sort of be applicable, you know, perhaps to everyone in New York or everyone in Washington where anthrax spores have been found in dozens of places.

I mean, isn't that, from an epidemiological perspective, isn't that concern warranted?

DR. SAKUDA: Yeah. I used the example of a doctor seeing a postal worker. New York City is I think a good example of someone that we would agree, would look at different. But, again, I agree with you that we should take the epidemiologic information into consideration, and in places where anthrax cases have appeared, then I think the physicians will be looking at their patients somewhat--and I think that's entirely appropriate; makes sense.

CDC MODERATOR: Thank you, sir. The next caller, please.

AT&T MODERATOR: That'll be from the line of Gina Collata [ph] with New York Times. Go ahead, please.

MS. : Hi. Thank you very much for taking my questions.

I was wondering about the flu vaccine. You had said that there's a delay this year compared to previous years. Why is there a delay, and then I was wondering if you could also tell us how many companies are making it and how does that compare to previously? And you said there's more this year than ever but I was wondering how much more.

DR. SAKUDA: Okay, Gina, good question. This year we're gonna be having about 85 million doses of vaccine distributed by about mid December, and so in last year, we had about 70 million doses of vaccine, and in the year before that, we had almost 77 million doses of vaccine come out, and if you look at the amount of vaccine that's been distributed in the U.S. over the past two decades, you know, there's sort of been an increasing curve of vaccine and 85 million doses is clearly the most that we've had distributed before.

MS. : Why is there a delay in getting it going this year? Why are you--for example, you mentioned that until November, which I guess starts tomorrow, you wanted to have--you would like to see the vaccine distribution restricted [inaudible] very highest risk.

Why don't we have it earlier?

DR. SAKUDA: You know, compared with last year we're down one manufacturer.

MS. : Which one is that?

DR. SAKUDA: Parkdale is no longer producing influenza vaccine for distribution in the U.S. and so that means that we're left with three manufacturers, and one of--

MS. : And who are the three?

DR. SAKUDA: The three that are left are Wyeth Lederle, Aventis Pasteur, and Evans Vaccines.

MS. : Okay.

DR. SAKUDA: And basically these companies are really having to ratchet up production, increase production, sort of change their vaccine manufacturing capacity to try to make up for the vaccine, and in doing so, they're actually able to go and produce more vaccine than they have in the past but it's taken a fair amount a time and effort to ratchet up the vaccine production, and so, you know, that's really been the major reason for the delay in getting the vaccine out this year, but it also is--you know, that effort is what's leading us to have more vaccine than we've had available in the year.

MS. : But it sounds like the message you've been giving out is that people who are not in these high-risk groups should not have the vaccine, at least now.

DR. SAKUDA: Well, the message that's gone out is that because we're having a delay, should take that early vaccine and get it to the people who need it the most, the high-risk people, and now as we're entering into November and December and there's been vaccination efforts focused on the high-risk people, we're saying that, you know, vaccine is now--you know, much more vaccine is gonna be available for other people. So continue your efforts to vaccinate the high-risk people, but it can, you know, the efforts can be broadened to include these other groups.

CDC MODERATOR: Thank you, Gina. Next caller, please.

AT&T MODERATOR: That'll be from the line of Tom Corwin [ph] with the Augusta Chronicle. Go ahead, please.

MR. CORWIN: Thank you, Dr. Sakuda. Have you offered a prediction on what sort of flu season we can expect and also is the delay due to the problems with Wyeth-Ayerst in their Marietta, Pennsylvania plant?

DR. SAKUDA: Boy, Tom, every year I get asked about making a prediction and I always give the same answer which is no. I mean, it's just--flu is one of those really unpredictable diseases, where, if you make a prediction you've just got such a good chance for being wrong. So no, we're not predicting what kind of year it's going to be.

The basis for the vaccine distribution delay again has been, you know, due to the efforts of the industry to ramp up their production capacity. I really can't speak to individual plants. I really don't know about the issues at individual plants.

AT&T MODERATOR: Next we go to the line of Jonathan Bore with Baltimore Sun. Go ahead, please.

MR. BORE: Hi, thanks for taking my call. I'm going to do this in two parts, so if you can come back to me, I would appreciate it.

In spelling out the various tiers of people who should get vaccinated, you don't seem to be mentioning young healthy people, and as you look around us, employers and even grocery stores are offering vaccine to all comers. Are you specifically not recommending that young health people get vaccinated?

DR. FUKUDA: No. We're not--we're not specifically recommending against that group to get vaccinated, but the--you know, the philosophy that the Advisory Committee on Immunization Practices and the CDC has had for a long time is that again there are certain groups of people who are at high risk for complications, and they're that people who are most likely to get seriously ill if they get infected by flu viruses, and so let's protect that group of people. I mean, that's been the overriding philosophy for many, many years, and that continues.

However, it's--you know, there is also a quite permissive element to the CDC and ACIP recommendations, and, you know, many people who do not fit into those categories also wish to avoid getting influenza, and so, you know, I think that for anybody who wants to avoid getting flu, including healthy young people, then, you know, we think that you should consider getting vaccinated against the flu, but I want to make the distinction that, you know, we really focus on those people who are most likely to get sick, and then we are not specifically recommending that anybody else avoid getting flu vaccine.

MR. BORE: Okay, thank you. The other question, actually, has a major anthrax tie in. A lot of us are wondering what--in the anthrax arena--why some people might be getting anthrax, whereas others don't, whether there are differences in susceptibility that have to do with genetics or biology or ongoing health conditions. I'm wondering if there's anything about flu susceptibility that might shed light on the anthrax question?

DR. FUKUDA: Those are pretty difficult questions, and I'll really have to defer on the anthrax side. You know, I'm not an anthrax specialist and I can't really answer those things, and I think that--but just speaking generally again, you know, we have a limited amount of experience with the anthrax cases, and so I think that it's very difficult right now to say to what extent the experience with other infectious diseases applies directly to the anthrax cases right now.

AT&T MODERATOR: Next we go to the line of Robert Cook with Newsday. Please go ahead.

MR. COOK: Every year or every few years it seems we get a new flu coming out of Asia. Is there any hint of anything on the horizon we're going to get a new bug coming through?

DR. FUKUDA: Well, we watch pretty carefully for new viruses coming out. There's an extensive global network of laboratories maintained by the World Health Organization. There are probably about 140 laboratories in the United States that participate in that effort in addition to CDC, and so lots of laboratories looking for those new viruses.

So far we have just a limited number of viruses on the scene in the United States, and we don't have--we don't have any new viruses yet that are looming as the next new big virus, but we're certainly keeping an eye out for that.
MR. COOK: The Asia A has been around for, what, 5 or 10 years or something like that?

DR. FUKUDA: Well, I'm not sure what you mean by the Asia A. There are Influenza-AH3N2 virus. There are Influenza-AH1N1 viruses. And, you know, these viruses continually evolve. They mutate and form into new strains, and every once in a while one of the new strains tends to become one of the dominant viruses circulating in the world.

MR. COOK: Well, the woman that gave me my flu shot yesterday said that this was a 5-year-old vaccine or 5-year-old strain is why I raised that. It's a well-known strain that we're combatting this year then?

DR. FUKUDA: Yeah. Again, as I mentioned early in the program, we only have a limited number of viruses that have been identified so far in the U.S., but of the ones that have been identified and looked at carefully, you know, the match with the viruses and the vaccine is pretty good.

The vaccine for the United States is formulated every year, so there's a selection process where, you know, there's a decision made as to what goes into the vaccine, and that's done every year in the United States.

MR. COOK: All right, thank you.

AT&T MODERATOR: And next we will go to the line of Mary Ellen Butler with U.S. Medicine. Go ahead, please.

MS. BUTLER: I just had a quick question just about whether or not demand for flu vaccine is rising and doctors around the country are having to tell maybe younger healthier people to come back in later weeks. Is that part of why you're stressing these recommendations now?

DR. FUKUDA: Well, I think that, Mary, if you look over the long run, influenza vaccine demand in the country has clearly risen, and this is particularly true over the last decade or so, and I think that demand for vaccine will probably continue to increase, and this is true both among people who--the groups of people who have high-risk conditions, and also among healthy people, that population.

But, you know, again, the recommendations that we're stressing, you know, to really focus on high-risk people, that's really driven by the fact that they're the ones who are most vulnerable, and the strategy for focusing on that group of people first, and then widening the group of people for whom vaccine is recommended as we head into November and December, is driven by the fact that we had a vaccine delay to deal with this year. And so it's really to deal both with that delay and also to make sure that we cover the most vulnerable population.

MS. BUTLER: Okay, thanks.

AT&T MODERATOR: We have a question in queue from the line of A.J. Hostettler with Richmond Times Dispatch. Go ahead, please.

MS. HOSTETTLER: Hi, Dr. Fukuda. Last year we saw a lot--got reports of doctors all over the country who couldn't get flu vaccine at all, even for high-risk patients, and there were a lot of reports about price gouging. This year there are already reports of physicians who are unable, and telling their patients that they're not going to get any vaccine at all. What is the CDC doing to try to match physicians with available supply, and is the CDC going to use its influence to try to prevent the price gouging that we saw last year?

DR. FUKUDA: Well, there's been a tremendous amount of work done over the past year, I can really say actually over the past two years now, you know, because of the delay last year and the delay this year, and so again, a huge amount of work has gone on behind the scenes with CDC and other federal agencies working with the manufacturers, distributors, various medical organizations, physicians, state health departments and so on to come up with ways to deal with the vaccine delays to get the message out there that, you know, we really need to focus on vaccinating these high-risk people.

So I think this year we have a delay situation which is moderate. You know, certainly less severe than the delay situation that we had last year. And I think that it's clear that there are still physicians and vaccine providers who are having difficulty getting vaccine, or vaccine has not gotten to them yet. But I think that the message, and what we're hearing is that the delay is less severe than last year, and that--you know, the message we want to get out to people again is that there's a lot more vaccine coming out in November, and there's a lot more vaccine coming out in December, and so that, you know, physicians--you know, we should have plenty of vaccine for this year.

Again, we're going to have a lot more vaccine available in previous years, and more vaccine is coming out this month and next month, and so I think that everyone's working pretty hard. I can certainly say that on the federal side, and we're working with the manufacturers closely this year. I know that they've been very cognizant of the problems caused by the delays and that they've also been working very hard to try to get at least some vaccine out to all of the docs out there.

MS. : What about the issue of price gouging from the distribution--

DR. FUKUDA: There have been reports of price gouging. You know, it's--it's a complicated distribution system. You know, the vaccine manufacturers some--sell some of their vaccine directly to physicians, but they also sell some of the vaccine to distributors and then distributors sell it to other distributors. It's a complicated system, and it's clear that there have been reports of price gouging that have occurred this year. And, clearly, some people are having to buy vaccine at inflated prices. And this is--this is a practice that all of us have worked pretty hard to discouraged. But, again, it's a private market system out there, and CDC doesn't have any direct control over how much the vaccine costs or what people can sell prices at.
We have worked very hard, again, behind the scenes, to get the word out to people that we would strongly discourage that kind of practice. But it is a free market system.

MS. : Thank you.

AT&T MODERATOR: Next we go to the line, Anita Manning with USA Today. Go ahead, please.

MS. MANNING: Thank you very much for taking the call. Keiji, is the CDC going to do anything to help clinics and physicians who may have smaller practices afford some of the rapid flu diagnostic kits that you mentioned? And the second part of my question, which is sort of an entirely different question, is: How is this flu season--I know you won't predict how this flu season will be, but can you say how it's comparing with the previous seasons in terms of the amount of disease at this point in time compared to last year?

DR. FUKUDA: You know, Anita, I--I'd have to go back and look at previous seasons. But, you know, as you know, the influenza seasons are so widely variable. And this is--this is very early. This is October. And typically we don't see activity begin to pick up until November or December. But, again, in some years, activity can not pick up until we get in January or February. And it's just so unpredictable.

So I think at this point it's very hard to say whether this season looks late or early compared to other years. It's simply so early that we wouldn't in most years expect to see appreciable flu activity now.

In terms of the first question that you asked, I don't know of any--of any plans for federal purchase of these kinds of kits for--for physicians' offices. And I think that one thing that we will try to do is provide as good information as possible about these kits and their use. But no plans to purchase kits for private offices.

MS. MANNING: How extensive are they? Can you characterize that for us?

DR. FUKUDA: Again, generally, the kits are priced so that a test costs about $15 to $20, and most of these kits are set up so that they have about 20 tests per kit. But, again, you know, the prices vary by manufacturer, and a person would have to call the individual companies to find out the exact prices.

MS. MANNING: Thank you.

AT&T MODERATOR: And next we go to the line, Robert Hagar from NBC News. Go ahead, please.

MR. HAGAR: Dr. Fukuda, is there any concern that the demand could be exacerbated by the thing that you've been talking about, we all have the issue that--that you're kind of keeping in check that people have the notion that it might be important to get a flu shot to avoid confusion if they present with signs and they've got anthrax. So is there any worry on your part that that could make demand worse?

DR. FUKUDA: Sure. I mean, you know, I think that, again, I recognize by reading the various newspaper reports and listening to the radio and so on that there have been mixed messages going out, and--and people are quite confused about--about the issues. And when people become confused, you know, they can, you know, go to--go to clinics to find out from their doctors about what's going on, and that this can increase the number of visits and put a lot of pressure on--on physicians and health care systems. And so I think that, you know, we want to work really closely with--with the various news agencies to make sure that--you know, we get out a reasonable--reasonable message out there that--that people, you know, really need to use common sense when thinking about these flu-like illnesses, and, you know, hopefully we can calm some of the fears out there.

MR. HAGAR: A second question. You've chosen your words very carefully that you want people to take the flu shots to avoid the flu. I'm wondering about the high-risk groups. I heard the Postmaster General get asked at the hearing yesterday, as Senators were saying, well, shouldn't all postal people get flu shots. And he said, well, he was asking the CDC for guidance, that maybe they should, and my own organization, NBC, because of our risk, personnel people are saying get the flu shot. But do you discourage that sort of thing? I mean, it surely sounds like what you're trying to do.

DR. FUKUDA: No. Let me clarify that to--again, you know, the longstanding recommendation and push for vaccinating people by CDC has really focused on those people who are at high risk for complications. I mean, I've said this several times, and I've said it because it's such an important message to get out there. But, you know, one of the other things that CDC and the Advisory Committee on Immunization Practices has pointed out and said in its recommendations for many years, that for people who wish to avoid influenza, and also for those groups of people that perform essential community services, that if those people wish to avoid influenza and its disruption, then, you know, flu vaccine ought to be considered.

So I think that when we look at the postal workers, for example, you know, this is a group of people who has, you know, really suffered from--from the whole anthrax episode. They clearly perform essential services for the country. So I think that if the Postal Service wants to go ahead and recommend influenza vaccine for its staff and workers, then, you know, this is an action that CDC would support.

MR. HAGAR: Okay. Thanks very much.


AT&T MODERATOR: Our next question comes on the line, Victoria Elliott from American Medical News. Go ahead, please.

MS. ELLIOTT: Yes, hi. I was wondering if you had any concern about physicians not being able to prioritize their patients, because there have been some surveys done by the AMA where physicians said that they really didn't know how to prioritize their patients, you know, to get the flu vaccine.

DR. FUKUDA: Well, I think that, you know, the--the failure to be able to prioritize, you know, reflects a couple different things. I think one of them is that, you know, patient offices or physician offices are just so busy and they have to deal with so many patients. But the other thing is that I think that, you know, we just need to get the--high risk and who ought to get vaccinated, and I think that we can do a better job of getting that message out there. But I think that, you know, the groups of people that are at high risk, these are reasonably easy people to identify. These are people who have chronic medical conditions. These are people who are elderly, but the role that we have is to try to get that message out there.

MS. : Do you have any tips on how to target the high-risk people?

DR. FUKUDA: Within physicians' offices or you mean more broadly?

MS. : Yes, within physicians' offices and then more broadly.

DR. FUKUDA: Well, I think more broadly, one, I think that, you know, the media is an invaluable group of people for getting that message out there. I think that if you can help to identify in your articles, you know, who is at high risk, and again I'll clarify that. These are elderly people, 65 years and above. These are people who have certain chronic medical conditions, particularly heart and lung conditions. These are people who have other conditions like diabetes, immunodeficiency diseases, pregnant woman who are going to be in the second and third trimester of pregnancy. These are younger people such as children who have conditions such as asthma, you know, that this is the group of people who ought to be getting vaccine under any condition.

I think you guys can do a really invaluable service by getting that information out there. I think that within physicians' offices, you know, there are a variety of ways, and they can contact CDC for help on some of those ways. For example, the National Immunization Program has done a good job of identifying ways in which high-risk patients can be identified. But I think that by using, you know, computerized medical records and so on, offices can set themselves up so that they can identify high-risk patients within their practices.

CDC MODERATOR: We have time for one more question.

AT&T MODERATOR: Thank you, and that will be from the line of Frank James of the Chicago Tribune. Go ahead, please.

MR. JAMES: Yes, hi there. I know that it's still fairly early in the flu season, but I wanted to ask if there have been any deaths, you've had any deaths that have come in that have been related to flu.

And, also, we can expect that there will be thousands of deaths this year, if this year is like past years when it comes to the flu, but I'm wondering what is the CDC going to do to make sure that the deaths that we see, the thousands of deaths definitively from flu and that there aren't anthrax deaths that were in those numbers?

DR. FUKUDA: Well, let me talk about the first part of your question first, in terms of deaths. We don't monitor individual deaths. What we do is look at sort of the overall picture in the country, and so at this point I can't tell you definitively whether anyone has died from influenza or not. I don't have that information.

In terms of what CDC or how we figure out whether there are anthrax deaths occurring among those influenza statistics, you know, this is what the medical system does. There are an extremely good group of physicians out there, and they are the ones who see the individual cases, and they are the ones who make the diagnosis of whether we're dealing with influenza or we're dealing with anthrax or we're dealing with some other respiratory diseases.
And so, you know, it's that group of physicians out there that have identified the cases that we know of so far, and they are the ones who are largely going to be doing the real work for distinguishing between anthrax deaths and deaths from other causes.

MR. JAMES: I'm just wondering, if I can follow up, what the likelihood is of physicians in some instances being mistaken and calling, scoring some deaths of flu deaths when they could be anthrax deaths? I'm just, again, I'm hypothesizing that there will be thousands of deaths going forward from flu, right? And so I imagine that, again, this could be a problem, but maybe it's not going to be a problem. But I'm just wondering, again, can you speak to--if I can follow up what the likelihood is of--it would depend on the level of the work-up that a physician would do, wouldn't it?

DR. FUKUDA: I mean I really can't speak to the probability right now. I mean all I can say is that we have had a small handful of deaths from anthrax and then, you know, in a typical year we will expect to see a large deaths associated with influenza, but again, you know, we have limited information on the anthrax situation, and so it's very difficult to give you any kind of probability.

MR. : To date, there have been no deaths from flu, though, is what you're saying?

DR. FUKUDA: I don't know of deaths from flu, but again, we don't monitor individual deaths. What we do is look at death statistics and aggregate.

MR. : Well, that's what I mean. I mean that's what I'm talking about. So there have been--when you look at the statistics, there have been--again, there's no--have you had any deaths from flu so far in this flu season?

DR. FUKUDA: Well, again, you know--

MR. : Again, looking at the aggregate. I mean--

DR. FUKUDA: What we do is that we look at the death data which comes in from a large group of offices in the country that report vital statistics.

MR. : Right.

DR. FUKUDA: That's for the country. And then we look at the number--you know, we sort of estimate what number of deaths we expect to happen, and then when we have more deaths occurring and we know that there are influenza viruses circulating, then what we are able to tell is that there is an increase in deaths that are associated with influenza.

So, again, we don't follow individual deaths.

MR. : Right.

DR. FUKUDA: And we don't call up doctors' offices and find out which people have died in their offices and so on, so it's very difficult to sort of answer the question in the way you're asking it.

MR. : Well, again, I understand you don't follow individual deaths. I'm asking about an aggregate.

DR. FUKUDA: No, on the aggregate, what I can tell you is that there has not been an increase in deaths. There has not been--you know, we have not gone above that sort of expected threshold of deaths.

MR. : Okay. So there have been flu-related deaths so far in this flu season, which is still early, but there--

DR. FUKUDA: Again, let me make sure you get this straight. As we go into the year, we have a sort of baseline number of people who we expect to die from pneumonia and those kinds of deaths. And then during the year, when we see influenza viruses, we frequently see that number of people dying from pneumonia and influenza-related causes to increase above that baseline.

MR. : Okay.

DR. FUKUDA: And so far we have not seen an increase in those deaths above the baseline.

MR. : Okay.


CDC MODERATOR: Thank you all for being on the telebriefing. The transcript from this conversation will be available online later this afternoon. Just go to and click on "In The News."

AT&T MODERATOR: And, ladies and gentlemen, that does conclude your conference call for today. Thank you for your participation and for using AT&T's Executive Teleconference Service. You may now disconnect.

[End of Briefing.]

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