Press Briefing Transcripts

CDC Discusses Increase in Hib Meningitis Cases

January 23, 2009, 1:00 p.m. ET

OPERATOR: Welcome and thank you for standing by. We′d like to inform parties you are on listen only until today′s question and answer session. At that time to ask a question you may press star one. Also, today′s call is being recorded. If you have any objections you may disconnect at this time and now I′ll turn today′s conference over to Curtis Allen.

Thank you, you may begin.

CURTIS ALLEN: Yes, thank you Candy (ph).

This is Curtis Allen with the Centers for Disease Control press office. We′re here today to provide you some important information about Haemophilus influenzae type b. That is spelled H–A–E–M–O–P–H–I–L–U–S, new word, influenzae I–N–F–L–U–E–N–S–A–E type b and that is Hib meningitis. I mean Hib disease. I′m sorry. Wait, I may have misspelled it. I–N–F–L–U–E–N–Z–A–E. I′m sorry.

With us today is Dr. Anne Schuchat, that′s A–N–N–E S–C–H–U–C–H–A–T. Dr. Schuchat is the director for the National Center for Immunization and Respiratory Diseases. Also with us is Dr. Ruth Lynfield, L–Y–N–F–I–E–L–D. She′s the Minnesota State Epidemiologist.

We will begin with Dr. Schuchat and then we will move to Dr. Lynfield and then follow with questions. So, with that we will begin with Dr. Schuchat.

SCHUCHAT: Hello. I talked with many of you about a year or so ago about a supply problem that we were having with U.S. manufacturers of the Hib vaccine. It was with one of the manufacturers, the Merck manufacturer of that vaccine and at that time we altered our recommendations for routine vaccination of young children to focus on vaccinating children in the first year of life and deferring the booster vaccine for most children until the supply situation improved.

At that time we hoped that we had a cushion of protection in the country to keep rates down and we prioritized vaccine for those youngest children. Today we want to update you on a situation that′s occurring in Minnesota and in a few minutes Dr. Ruth Lynfield is going to tell you what′s happening in Minnesota.

Before that I want to give you a little bit of background about Hib disease and then let Dr. Lynfield give you the situation there and then I′m going to come back and talk about the rest of the country and what this means for parents and providers and then open things up for some questions from you all.

So, Hib disease...sorry about that, just turning that little ringer off. I want it known that was not my phone but someone else′s phone.

ALLEN: It was mine.

SCHUCHAT: So, Hib disease is a serious infectious disease, primarily of young children. It can present as meningitis which is an infection of the lining of the brain and spinal cord or as other severe syndromes like pneumonia.

Children with Hib disease are typically hospitalized and they′re very ill and one in twenty of them die from the infection. Survivors from Hib can have long–term problems like hearing loss or other neurologic problems. You know, before we had vaccines against this disease there were about 20,000 Hib illnesses each year in the United States. But, a safe and effective vaccination program has resulted in major drops in disease; about a 99 percent drops since the vaccines were introduced in the early ‘90′s for infants.

Currently there are two manufacturers with licensed Hib products in the U.S.; Merck and sanofi. The Merck product has been in very limited supply for the past year and most providers are using the sanofi Hib vaccines either as single component Hib vaccine or a combination vaccine that has Hib together with other products.

The schedule for the sanofi vaccine which is the typical one that providers are using right now is for three doses to be given at two months, four months and six months of age. We have deferred the booster dose which is usually given at 12 to 15 months of age except for very high risk children like Native Americans, children with leukemia or other children who are at greater risk for this disease.

We are optimistic that the supply of Hib vaccine will be greatly increased by next summer and then at that time we′ll be able to reinstitute the booster dose and call children back in for that.

But now I want you to hear from Dr. Ruth Lynfield from Minnesota about a concerning situation in that state.

LYNFIELD: Thank you very much Dr. Schuchat.

I am glad that you are joining us this afternoon and I want to tell you about this situation that we actually are quite disturbed about in Minnesota which is that we have had five cases of invasive Haemophilus influenzae type b disease in young children in 2008.

This is the highest number of cases that we have had since 1992 when conjugate vaccine for infants became widely used. We also had one death and the last time we had a death in a child due Hib disease was in 1991. Among the five cases, three of the children were un–immunized because parents either refused the vaccine or wanted to defer the vaccine until the child was older.

One child was a five–month–old infant who had received a dose of vaccine at two months and at four months but hadn′t completed the primary series. So, that child was under immunized. Another child, a 15 month–old child had received the primary series however that child did develop meningitis at age 15 months and then was diagnosed with an immunodeficiency. So, that child was a vulnerable child. So what we are seeing here is a drop in herd immunity likely related to the vaccine shortage.

The story is a little more complicated though because when we went and looked at our immunization registry in fact we found that not only 12 to 15 month old children were not getting their booster as recommended during this shortage but in fact some of our infants were not completing the primary series. When we looked at seven month–old children, 18 percent fewer received their Hib vaccine compared with pneumococcal conjugate vaccine or diphtheria tetanus and cellular pertussis vaccine. So, infants are not receiving their primary series.

In a few minutes Dr. Schuchat and then Kirsten Ehresmann from our immunization program will talk a little bit about what we will be doing to remedy this situation.

I also just want to add that what is a couple of other features about these cases; one is that none of the children attended childcare. These cases occurred in five different counties in Minnesota and there were no epidemiological links. The way we conduct surveillance in Minnesota is that when a laboratory identifies Haemophilus influenzae in a blood culture or in a culture from spinal fluid or some other sterile site, it is reported to the Department of Health.

Thank you. At this point I think that the conversation will go back to Dr. Schuchat at CDC.

SCHUCHAT: Thank you, Ruth.

You know, what does this mean for parents and for providers and reporters and really for our country? I think there are several points we want to make sure you hear.

Parents, who wondered whether the Hib vaccine was really necessary, need to know that the disease is still around. It′s a very severe disease and we have safe and effective vaccines available that can protect their children. The situation where community protection was available and un–immunized children had relatively low risk of disease does not appear to be holding right now. We think it is likely there is increased exposure in Minnesota at least.

Although there is a limited supply of vaccine right now, we really want people to know that we have calculated, we′ve been talking with the manufacturer and we are fairly confident that we have enough vaccine for the basic protection. But it may take a little bit of time to smooth out the distribution system so that there′s vaccine where we need it at the right time. But in general we do have enough doses right now for that primary series. And as you heard from Dr. Lynfield, several of the cases in Minnesota had received no vaccines. Not because there wasn′t vaccine in the office.

Doctors who need more vaccine will be handling more questions about this but they can work with the company or with their health departments to arrange for more doses. CDC is working with the public health and healthcare system to address this challenge. Minnesota has a very good surveillance system. They′re part of a national network of ten states, the Emerging Infections Program Network where extra efforts are made to find all the cases of diseases like Hib so they have recognized this problem. We don′t′ know whether this problem is occurring in other states. From what we′ve looked at so far we aren′t aware of other clusters or other increases but we really want to heighten the awareness of doctors that it′s very important that they report cases to their health departments so that the health departments can look into the situation and do the appropriate testing to see whether there is a type b case or not.

So, the situation in Minnesota might be isolated or it might be the beginning of a worse trend in other places and we′re working hard to find out which of those stories will be the right one.

Of course we′ll be planning to update you as we know more. We do expect a much better supply of vaccine next summer where we hope to be reinstituting that booster dose and calling children back in to get the vaccine, the booster vaccine but in the meantime, if parents are not sure whether their children have gotten the full primary series, we really want them to take steps to be in touch with their providers and finish up the primary series.

If parents haven′t gotten their children vaccinated, parents of children under age five should make sure their child is vaccinated particularly is they have not received any doses of Hib vaccine. You know you weren′t sure whether this was an important vaccine or not, I truly want parents to understand how serious this disease is, that this is a very safe and effective vaccine. We′ve had experience with this for almost 20 years now in the United States in babies and we do believe we have enough vaccine for children to get the basic protection.

We are bringing this to your attention now to be on the precautionary side, to get the word out and to find out whether the problem is bigger than we think it is but of course any death from a vaccine preventable condition is just tragic and we really want to prevent any more.

I think we can probably take questions and then address some of the Minnesota as well as the national concerns now. Is that right?

ALLEN: Yes. Is there anything else you′d like to say, Minnesota?

MALE: Yes, Curtis, thank you. Here in Minnesota we would just like Kristen Ehresmann who′s our section manager for immunization, tuberculosis and international health to just say a few words about the immunization and vaccination situation in Minnesota and then we′ll turn it back for questions.

For the folks on the line, that′s Kristen, K–R–I–S–T–E–N Ehresmann, E–H–R–E–S–M–A–N–N.

KIRSTEN EHRESMANN: Thank you.

I just want to point out again that looking at the data for our Minnesota immunization registry we identified that about 18 percent of seven month olds had not received the necessary third dose of the Hib vaccination series although they have received other doses that would have been given at the six month time frame. And so right now in Minnesota our goal is to ensure that all infants born since the Hib vaccine shortage has completed a primary three dose series of Hib vaccine. We′re working with the CDC and sanofi pasteur to get our Hib containing vaccine allocations increased and we expect to have enough vaccine to both cover those children who need to complete their primary three dose series as well as those who are continuing on schedule.

We estimate that we need an additional 37,000 doses of vaccine to catch up the babies who have not completed their series at this point and that would be above and beyond our normal allocation. In the past 24 hours we have communicated with healthcare providers across the state so that they are aware of the situation and know that they need to be ordering additional vaccine.

We ask that parents would check their immunization records to see if their baby does need to catch up on their vaccination. If you have a child who′s less than 12 months of age and has not received three doses of vaccine, you should contact your healthcare provider and schedule an appointment. I want to point out as Dr. Schuchat said that vaccines are very safe and effective and we had a death in Minnesota from a child who was unvaccinated. We want to encourage parents who have delayed or refused vaccinations to reconsider as delaying and refusing vaccinations does result in serious consequences like Hib disease and in this case a death.

Hib vaccination not only protect your child but also babies who haven′t completed their primary series or infants who are unable to be vaccinated because of immune system difficulties or who are undergoing chemotherapy. Thank you.

ALLEN: OK, thank you. Candy (ph) let′s open it up for questions please.

OPERATOR: OK thank you and as a reminder for questions on the phone, please press star one and our first question comes from Brian Thompson. You′re line is open and state your affiliation please.

BRIAN THOMPSON: Kansas Public Radio. And I would like to first ask a technical request here and that is to if you would please speak into the phone rather than into the speaker phone because I′m having some sound quality issues on this end.

And what I wonder about is Haemophilus influenzae b, isn′t that a disease of itself? So what is the distinction between that and the meningitis that occurs with it and then I believe I heard the number of five cases of an invasive type in Minnesota so is that yet a third distinction? And I would like to know if that′s really what we′re concerned about, you know how do we draw any kind of conclusion as far you know concerns for other states based on five cases.

ALLEN: OK, I think Dr. Schuchat can take that.

SCHUCHAT: Yes, thank you for those questions. Haemophilus influenzae b is a bacteria that can cause several kinds of serious syndromes that we group together as invasive disease. A common type of those syndromes is meningitis. Other kinds of presentations are clinical presentations of disease are pneumonia and something called epiglottis which is a severe infection of the upper airway.

Your question about five cases in Minnesota and what does that mean for other states is an excellent one. We, so far, have not seen an increase in cases in other states although the Minnesota situation is a clear increase from their previous years of good surveillance. We now are calling on doctors and health departments to let us know, doctors letting their health departments know and then health departments through the usual reporting to us so that we can understand whether this is a more widespread problem or something just isolated to the Minnesota population. We really want parents throughout the country to know how important it is to check their children′s immunization records and realize that this bacteria is not gone; that it′s around and it can cause serious disease and vaccination is the best way to reduce their child′s chances of a real nightmare.

ALLEN: Thank you. Next question please.

OPERATOR: OK, thank you. Next, David Brown you′re line is open and state your affiliation.

David Brown: Yes, I′m with the Washington Post. It′s a little bit unclear to me how many of these cases are the result of refusal to vaccinate their children? You know and perhaps an anti–vaccine point of view completely independent of the supply issue.

ALLEN: Dr. Lynfield?

LYNFIELD: Yes, thank you Dr. Brown for that question.

Three of the cases occurred in children who were not immunized because the parents did not want their child immunized. Two occurred in parents who refused immunization. One occurred in a family where they deferred immunization until the children were around five years old.

I think you have another component to your question.

SCHUCHAT: Yes, Ruth let me add on.

As Ruth has said three of the five cases were not immunized. I think your question gets at whether we think this problem is because parents are refusing vaccine or we think this problem is because there′s a shortage and we actually think that both factors are relevant. The shortage could be contributing to an increase exposure to the bacteria in the community but the resistance to vaccination would increase the risk of an individual child upon exposure of getting disease.

Whether we will see this anywhere else is going to be a combination of factors. How much of the bacteria is circulating and whether children are immunized or not. At this point it′s quite possible that there′s more bacteria circulating than there used to be but I want everyone to remember what we saw with measles. These diseases are in other parts of the world and can be a plane ride away. The Minnesota situation may or may not relate to changes in exposure in their own community but clearly every child who came down with this terrible disease was exposed to the bacteria.

ALLEN: Do you have a follow–up David? Next question please.

OPERATOR: The next question we have Daniel DeNoon. You′re line is open and please state your affiliation.

DANIEL DENOON: I′m with WebMD, thank you. Dr. Lynfield I missed the percentage there. You said you′re looking among 18 month old kids in your look back and you saw that a certain percentage fewer got vaccinated. What was that percentage?

LYNFIELD: Oh, I will restate that. And I′m sorry....can you hear me clearly because I have a microphone and then there′s a speakerphone and so maybe people are not able to hear what I say. Can you hear me?

Daniel DeNoon: I′m hearing you clearly now.

LYNFIELD: OK. What it was is that we looked at our immunization registry data during the shortage looking at seven month old children so these are children who should have received three doses of Hib vaccine okay, because during the shortage the primary series could only be completed by a series of three Hib vaccines and when we compared seven month old children who received Hib vaccine with the children who received two other vaccines at that same age, 18 percent fewer received Hib vaccine. Therefore we interpret this as a manifestation of a shortage of vaccine that providers did not have vaccine in the office to vaccinate these infants and in fact we have heard from our pediatricians, our family physicians, and the nurses at the clinic that they don′t have enough vaccine in certain areas of the state.

SCHUCHAT: Just to add onto that. Again the situation in Minnesota is the focus of the call here, but in our discussions with the manufacturer and our review of the public sector vaccine that we have and we are providing, we do believe that nationwide we have an adequate supply for the primary series for the basic protection as we′ve been talking about but not for the booster dose. For the situation in Minnesota, is one that we′re working closely together with to meet these problems. But in terms of the country as a whole we haven′t yet heard that kind of challenge. We do think there are some practice issues that we want to remind providers about. The sanofi vaccine that is the main one being used right now is a three dose primary series. The Merck vaccines that used to make up about half of the market but is no longer very much available were the two dose primary series. So, we want to make sure providers and parents know in using these newer vaccine formulations from sanofi, they have to give three doses to get the primary protection.

ALLEN: Next question from the phone, please.

OPERATOR: OK, thank you. Miriam Falco, your line is open and state your affiliation.

Miriam Falco: Hi, CNN Medical News. My question is for the doc from Minnesota. Number one, do you know how many children in Minnesota aren′t getting any vaccinations at all? And is there an exemption for....is there a way parents can get out of getting the Hib vaccines since this is one of those that are really, really important?

LYNFIELD: Thank you very much for that question. I′m going to let our immunization manager Kristen Ehresmann answer that.

EHRESMANN: Minnesota does have an exemption in our childcare law that allows parents to opt out of vaccination based on conscientious objection. So, there is an option for parents to choose not to vaccinate their children as it relates to our childcare law but as Dr. Lynfield mentioned earlier when she was describing the cases, none of these five children were in daycare so that law would not have affected them. When we look at our exemption rates and they are somewhat difficult to measure; historically we have had a couple of key surveys that have indicated Minnesota′s exemptions when we looked at all kindergarteners in the state and we saw that exemption rate increase from the early ‘90′s to early 2000 from 1.5 percent to about three percent. We′re not exactly sure what the rate is currently but we do know that there are a number of parents who have chosen not to vaccinate in Minnesota.

ALLEN: OK, let′s take a couple of questions from the room in Minnesota. Do we have any questions in Minnesota?

FEMALE: Can you talk about...

LYNFIELD: I′m sorry, can you state your name and.....

MALE: You don′t have to repeat.....

MARTINA (ph) (INAUDIBLE): Martina (ph) (INAUDIBLE), Associated Press. I′m wondering if you can talk a little bit more about Merck and why the providers in Minnesota are using Merck and why they haven′t switched over and is this what′s happening in other states and if so, why?

EHRESMANN: The providers across the country choose vaccinations based on their preference. And so what we found looking at our immunization data was that our providers for their private practices were choosing the Merck vaccine at a higher rate than the product produced by sanofi prior to the shortage. So, when the shortage occurred in Minnesota, obviously the impact would be greater for those providers that had used the Merck vaccine because they would not necessarily have had you know extra stores of vaccine and that type of thing. So, we do think that Minnesota was harder hit because of the preferred use of the Merck product. Does that answer your question?

SCHUCHAT: Let me just add on. I think across the nation before the shortage, there was about a 50/50 split and the public purchased the vaccine that CDC organizes buy both products. CDC has been working very closely with the manufactures, with FDA and with the state programs to work out allocations of vaccine to really minimize the disruption that this supply problem has. And I thin that what we′re seeing in Minnesota is a need for extra attention and we are quite committed to work carefully with the state to address the local problems.

ALLEN: Do we have another question from Minnesota?

EHRESMANN: Let me just clarify. Did that answer your question?

MARTINA (ph) (INAUDIBLE): I guess underlying question I have is, is this showing up in Minnesota because we have a problem with our vaccine or is it showing up because of the better surveillance?

EHRESMANN: I think that it′s probably a combination of factors. Our registry data suggested that we did have a higher proportion of providers that used the Merck product and so as Dr. Schuchat said, we need to work on our allocations to make sure we have adequate vaccine but definitely Dr. Lynfield can talk more about our surveillance but we have an excellent surveillance system in Minnesota that contributes to detecting disease.

SCHUCHAT: Let me expand on that. I think in Minnesota we′ve seen a few things in terms of the description and we don′t have necessarily the same situation elsewhere. Minnesota is one of ten states with the extra special surveillance who may have an earlier awareness of what′s going on both for disease and for immunization because through their registry review they were able to look at what was going on in 2008.

So, regardless of which vaccine they were using before the shortage, I think a very important finding that Dr. Lynfield stressed was that many children who had gotten two doses of Hib vaccine did not actually get their third dose even though they apparently got other vaccines at the right time. The issue of disease is that at least for ten states that are in a strong active surveillance system, Minnesota appears to be unusual. But the other states may or may not have problems that we haven′t detected. For coverage, we don′t know yet of other states that like Minnesota have this drop–off in this third dose. But the third point is that remember, three of the five cases in Minnesota are in people with absolutely no vaccine and as we shared with you during our measles discussion, our national figures for vaccination rates are still quite high and most children get most of the vaccines but there may be clustering of un–immunized people that are occurring in areas that we don′t detect with our nation or state level tracking.

So, if there are other communities where there are other individuals who haven′t been vaccinated and the Hib strain is circulating like it obviously is in Minnesota they will be just as vulnerable as these children in Minnesota have been. So, it′s truly a multifactorial story. A shortage situation that may have limited the cushion of protection we had in the community. A surveillance situation where in a few weeks we may have better information about the rest of the country and as this winter season evolves we may or may not see up ticks elsewhere. And then this issue of resisting or refusing vaccines which we take very seriously; as a doctor and a public health leader it′s very important to me for parents to have good information to make the best choices possible for their children. Hib disease is very severe. A vaccine against Hib is very safe and highly effective and I really want every parent to know that when they make their healthcare choices.

ALLEN: OK, Candy (ph) let′s take a question from the phone.

OPERATOR: OK, thank you. Next Mike Stobbe, your line is open and state your affiliation.

MIKE STOBBE: Hi, it′s Mike at AP. Thanks for taking the question. First just to clarify, from these five cases, three didn′t get any vaccine because of parental decision. One child was five months old and the other had other circumstances so none of these cases did a child not get vaccine because there was a shortage, is that correct?

LYNFIELD: That is correct. I should say they did not lack their primary series. What has been recommended during the shortage is that children not get the booster dose at 12 to 15 months of age.

ALLEN: OK. Next question from the phone please.

OPERATOR: OK, thank you. Next, Jennifer Corbitt your line is open and state your affiliation.

JENNIFER CORBITT: Yes, I′m with Dow Jones. One question I had on the five cases, did they all have meningitis or not necessarily?

EHRESMANN: No, they didn′t. Three of the children had meningitis including one whose disease was complicated by what′s called a subdural empyema which is actually a collection of pus in the brain. So, it′s very severe. One of the children with meningitis died. And then we had a child who had pneumonia and a child who had epiglottitis which is the disease that Dr. Schuchat had mentioned can result in a swollen throat, closing off the airway.

ALLEN: Why don′t we take a couple of questions from Minnesota? Minnesota.

MALE: I just have one question. Can you tell us what part of the state...was it in the metro here? Were they all here in the metro or were they scattered throughout the state?

LYNFIELD: They were in five different counties. One of the counties is considered part of the seven county metro. The other counties were in the central part of the state.

ALLEN: It is important to note that these were not connected. Is that correct?

LYNFIELD: That is correct. They were not connected. In fact we did molecular sub–typing on the strain and although two of the strains appeared to be similar and there was another one that was related, there were two completely different strains. They varied temporally and they had no connections that we could detect between each other epidemiologically.

ALLEN: So, another question from Minnesota?

FEMALE: Was the child who died (INAUDIBLE)?

LYNFIELD: Yes.

FEMALE: Can you say how old?

EHRESMANN: I have that information I′ll pass around.

LYNFIELD: I would just say that the child was old enough to have received immunization, had not received immunization and very sadly and we feel horrible about this as we do about all the cases but certainly about a death and our sympathies go out to the family and that′s why it′s so important that the message that Dr. Schuchat said, gets out to parents that this vaccine is safe. This is a very dangerous infection. We have a tool to take care of it. Doctors who were seeing patients 20 years ago all have very vivid images of young children coming in with these horrible infections, some of whom died. And I can′t emphasize enough how important it is to use this tool in our toolbox. This is a preventable infection. We have to get this message out to everybody that we can to use this vaccine.

ALLEN: OK, we′ll take another call from the phone, please.

OPERATOR: OK, thank you. Carrie Walker (ph) your line is open, and state your affiliation.

CARRIE WALKER (ph): Hi, I′m with Pediatric News. I have a question about what physicians and pediatricians should do in order to make sure that they have adequate supplies of the sanofi vaccine.

SCHUCHAT: You know, pediatricians and family physicians are used to ordering vaccines from the companies and they′re used to the provisions from the health departments of the public sector vaccine so they should use those routine mechanisms. If they order from sanofi it′s the same way as always. The company is eager to work with them and we do believe that you know the appropriate request can be met. The idea is not to you know stock up on vaccine for 12 months but to make sure that there′s sufficient vaccine in your office so the children who could come in any day can get vaccinated. So, I think that this is going to take a little bit of time to smooth it out but that′s basically the recommendation. For Minnesota we′re working especially closely with the health department and the company to address those needs.

ALLEN: OK, one more call from the phone, please.

OPERATOR: Thank you. David Brown, your line is open and state your affiliation.

DAVID BROWN: Yes, it′s David Brown with the Washington Post. First of all can the speakers please identify themselves it′s really hard to know who′s talking? I don′t recognize all the voices. What is the absolute coverage, not the relative compared to people who you know are getting the pneumococcal at seven months but what′s the absolute coverage for Hib in Minnesota? And does this mini outbreak of these cases suggest that there′s an unexpected waning of immunity that three doses aren′t enough to suppress it in express circulation in the community or in fact is it the fact that there′s probably a lot of people who have no immunity, have gotten no vaccine explains the likely circulation?

SCHUCHAT: David, this is Anne Schuchat. Let me begin and then let Dr. Lynfield continue with the Minnesota situation.

Unfortunately there′s a little bit apples and oranges here. The national estimate for Hib vaccine coverage with at least three doses is based on our national immunization survey and looks at children between 19 and 35 months of age. Our information for the 2007 survey was that national coverage was at 92.6 percent. The statistics that Dr. Lynfield was talking about was with a more recent look at seven month olds. She may be able to give you additional information but I don′t want you to compare the 92.6 percent at 19 to 35 months with these more recent looks at seven month olds.

The second part of your question was bout waning immunity. There is no evidence that waning immunity is a problem here. Three of the children had no vaccine so they would have no vaccine induced immunity. You need either vaccine or exposure to the bacteria that you survive to basically get immunity. So, these children were totally unprotected. A waning immunity in the picture would look quite different than what we′re seeing here. So, I think Dr. Lynfield could give you more information about absolute immunization coverage in Minnesota.

LYNFIELD: Dr. Brown, this is Ruth Lynfield and Kirsten Ehresmann will give some of those statistics but I do want to mention and I don′t know if this was behind your question or not but, we do think that when there are high immunization rates among children in a community that there′s herd immunity. And it may be that because of the shortage that that herd immunity has dropped and it′s being first manifest in un–immunized or under immunized or vulnerable because they can′t produce a good immune response; so those types of children. one think we are going to do in Minnesota is to survey young children. 2,000 young children in Minnesota to try to determine the carriage rate for Hib and that might lend some insight to getting a sense of this issue.

EHRESMANN: This Kirsten Ehresmann and let me just give you specific data. This data is taken from the Minnesota Immunization Registry and what we looked at was, we looked at doses of vaccines that children would normally be getting and then compared the DTAP vaccine, the Prevnar or the pneumococcal vaccine and then the Hib vaccine and what we saw was that for instance, when 97 percent of children received one dose of the DTAP vaccine then 96 percent had received the Hib vaccine. So, that was very similar for the first dose. For the second dose 86.3 percent had received the DTAP vaccine and 82.4 percent had received the Hib vaccine.

So again, very similar so you would be expecting that these children are coming into the office and being vaccinated with both of these vaccines simultaneously. And then when we looked at the third dose, that was where we saw the difference. So while 63 percent of the children had received their DTAP vaccine at seven months, only 46 percent had received the Hib vaccine and that is where we′re getting that difference. So, those kids were coming into the office and we would have expected them to have a similar vaccination picture but they did not get the Hib vaccine and that′s what suggests to us that they weren′t completing three dose series and there was not adequate vaccination for them.

ALLEN: OK, we′ll have one more call from the phone and then take a couple of questions from Minnesota.

OPERATOR: Thank you. We have one last question from the phone. Mike Stobbe your line is open and state your affiliation.

STOBBE: Hi, from AP, thank. The child that died, was this a boy or a girl and also was that a case where the parents deferred vaccination or was it one where they said flat out no?

LYNFIELD: Mike, this is Dr. Lynfield. I don′t really feel comfortable answering those questions. What is important here is the parents did not want the child vaccinated at that age and the child had invasive Haemophilus influenzae disease and died from the infection?

ALLEN: Thank you. Do we have a couple of questions from Minnesota? And then we’ll close this out. Minnesota?

MALE: I think we’re done.

ALLEN: Ok, thank you. Anne Schuchat has one more thing to say.

SCHUCHAT: Yes, I do want to let people know that we′re expecting later on MMWR with more details on this will be on our Web site and we also want people to know that our Web site at www.cdd.gov/vaccines there′s a lot more information that might be helpful for parents and we′ll be adding on to what′s available there.

ALLEN: I would like to add to that there will be a transcript on the Web site later this afternoon at CDC.gov/media and the MMWR will be posted later this afternoon, and there′s additional information not only for providers but for parents on the Web site that is up now. And that is at cdc.gov/vaccine.

Thank you very much for joining us today and if you have any additional questions you can contact the press office at CDC at 404–639–3286 or the Minnesota Department of Health. Doug Schultz S–C–H–U–L–T–Z at 651–201–4993. And again thank you very much for joining us.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES