Press Briefing Transcripts

Weekly 2009 H1N1 Flu Media Briefing

October 20, 2009, 12:00 p.m.

• Audio recording (MPEG)

 

Operator: Welcome and thank you for standing by.  At this time, we're in the listen only mode.  During the answer and question session, you were press star one to ask a question.  You may begin, sir.

Dave Daigle: Thank you.  I thank everybody for joining us on the room and on the air.  I'm Dave Daigle with CDC’s Media Relations.  Today, Dr. Ann Schuchat from the National Center of Immunization and Respiratory Disease will give the first of two weekly updates on 2009 H1N1.  She’ll take questions from the room and the phone.  Thank you.

Anne Schuchat: Hello, everyone here and on the phone.  Today, what I want to do is give a little snapshot of what's going on with disease and update on antivirals as well as about the seasonal flu vaccine and H1N1 vaccine program.  We are continuing to see widespread illness around the country, and, of course, gave a fairly detailed update on Friday based on our Fluview data which is at our website.  And what I wanted to do today is provide a little bit more detail about what we've been seeing this fall from September 1st to October 10th.  We have instituted a slightly different kind of reporting system where states provide aggregate reports of laboratory-confirmed hospitalizations and laboratory-confirmed deaths.  These are not complete reporting.  We don't have reporting from every single state.  And we know that we’re missing cases.  So the numbers will be underestimates of the full amount of disease that the H1N1 virus is causing.  But I think it can be helpful in illustrating some of the patterns that we're seeing.  So what I want to talk about today is the age of people who are hospitalized or dying from the 2009 H1N1 virus this fall from September 1st through October 10th.  We have data now from 27 states that are reporting hospitalization information on lab-confirmed cases.  This is a set of about 4,958 hospitalizations that we've seen in those states just since September 1st.  More than half of the hospitalizations are occurring in young people under the age of 25.  We are seeing 53 percent in people under 25 years of age.  39 percent of hospitalizations are in people 25 to 64 years of age.  And only 7 percent of hospitalizations are occurring in the elderly.  This is really, really different from what we see with seasonal flu.  With seasonal flu, about 60 percent of hospitalizations occur in people 65 and over.  And here, we're only seeing about 7 percent of hospitalizations in that age group.  Just illustrating that this H1N1 virus is disproportionately affecting the young, and of course, that's one of the reason that they've been a target population for the vaccination effort. 

I want to also mention the deaths that we're seeing in the states that are reporting laboratory-confirmed deaths.  Again, these are just since September 1st so they don't include everything that happened before that.  Again these are underestimates.  We have 28 states that are reporting laboratory-confirmed deaths.  And what I have is information on 292 deaths.  That number is not important, but it's the proportions that I'm going to describe which are important.  Almost a quarter of deaths are occurring in young people under the age of 25.  Specifically, 23.6 percent of the deaths are in that age group.  About 65 percent of the deaths are in people 25 to 64 years of age.  And just 11.6 percent or 12 percent of the deaths from H1N1 since September 1st are occurring in seniors 65 and up.  Again, this is dramatically different than what we see with seasonal flu.  With seasonal flu 90 percent of fatalities occur in people 65 and over.  It is almost completely reversed here. Nearly 90 percent of fatalities are occurring under thing age of 65.  We are using this data to see how things have changed since the spring and essentially this is still a younger person’s disease. Fortunately, seniors seem to be spared and now we think we understand a bit about the immunology of that and our statistics are supporting that.  I want to move on and talk about antivirals.  Yesterday, we issued updated health advice for providers related to antiviral use in treating people with suspected flu, H1N1 or the seasonal flu strains.  We really want to stress how important early treatment with antivirals is in people who are high-risk or people with severe presentations.  In such patients, we don't want docs to wait for the lab confirmations.  The time it will take to get the lab tests back shouldn't be waited for.  If you have a person who is severely ill or a person with risk factors like pregnancy, asthma, diabetes, very young children under 2, and you suspect flu, we recommend any viral medicines be given promptly. 

It's important for people to know if you get a rapid test result and it's negative, it says no flu, you can't really rely on that.  The accuracy of the rapid tests when they show up a negative is not that good.  So if you suspect flu, very important to provide those antiviral medicines quickly.  We think that's really important for patients and including for pregnant women.  We know often the doctors and pregnant women are reluctant.  If you do suspect flu, don't believe a negative rapid test, we really think if you're suspecting flu in the circumstance, then you ought to treat.  Now, we've talked in previous press conferences about the supply of antiviral medicines.  And as you know, we did release 300,000 courses of liquid Tamiflu for children. There were some limitations in some areas of pediatric formulations, particularly this liquid suspension of Tamiflu, so that's been shipped out to all of the project areas or states.  We've also provided some advice to pharmacies and providers about dosing for children.  There's something called compounding which pharmacies can do, that's a way for them to use the capsules that they have and prepare the medicines that they have to be able to treat young children.  We do encourage pharmacies to be able to do compounding so that our pediatric supplies will stretch as far as possible.  We're heartened by the response we're getting from the private sector.  There's been good cooperation.  Some of the major drugstore chains Walgreens and Walmart have announce they're going to be compounding to make sure we really serve the needs of the youngest children around the country and we appreciate their help with it. 

I want to turn to the vaccination program.  Just a little update on the seasonal flu vaccination program.  As I mentioned, we think 82 million doses of seasonal flu has been distributed we're expecting a total of about 114 million doses through the rest of the season, and we've already given out quite a bit.  But we have seen a lot of demand for seasonal flu vaccine.  And we are hearing around the country about places that are really looking for more vaccine.  I need to tell you that there is some more vaccine coming, you know, the rest of the 114 million doses.  And week by week, more doses are coming out, but they may not be where you are or in your community as readily as you'd like.  We've really see an excellent response to the early availability of seasonal flu vaccine.  We began giving it much earlier this year than we do in previous years.  And from coverage statistics that we've recently gotten, it looks like the American public is really stepping up to get the flu vaccine and we think that’s a great thing.  Now is the time for a little bit of patience as more vaccine gets shipped out.  Probably by November, there will be quite a bit more coming out for communities.  There's plenty of time to get your seasonal flu vaccine.  We usually don't see the seasonal strains increasing until December or later.  And so often not until January, February, March.  So I think patience is going to be needed.  And I really understand the frustration that people have with that. 

Now, let me update you on the H1N1 vaccination information.  I understand and share everyone's desire to have more vaccine.  I wish we had more than we have right now, but I do want to let you know that we do have more coming out every day.  We are macking progress.  As of yesterday, 12.8 million doses were available for the states to order.  More than half of that was available in the injectable form.  So that's helpful, with giving us a variety of formulations.  10.8 million doses have been ordered as of yesterday evening.  Now, just to put those numbers in perspective, a week ago, when we talked about those same aggregate state numbers, 9.8 million doses were available for order and 5.8 million doses had been ordered as of one week ago.  So you can see that more has come available for ordering.  And much more has been ordered.  We know that states are working hard to keep up with the vaccine doses that become available to them and direct them to the places where they can be most helpful.  I want to say that orders are being filled quickly.  Vaccine is being given out all around the country in different venues.  It probably feels like a slow start for a lot of people.  But I just want to say I think this is a significant achievement to have what we believe is a safe and very effective vaccine coming available in our states and counties within such a -- you know, just since the April recognition of this virus.  As we've said, we're not cutting any corners in the safety and testing of the vaccine, but this is a big accomplishment.  Yet, we know that people are interested in being vaccinated and can't find as much as they'd like near them.  We're working closely with the states and cities to work out some of the bumps or hurdles that we're seeing. I think this is going to get better every day.  But it's a time where we're really working hard to serve the public. 

It's very important that states and communities are ready to use the vaccine doses as they become available.  And to use them effectively.  But flu seasons can be very long.  We're just in October right now, and we expect to see illness from H1N1 for several more months, and may see that in the spring.  We wish we had more vaccine and more hadn't given by now, but we're in this for the long haul.  I know there are a lot of people wondering about the vaccine and wondering about whether or not it's safe.  I appreciate the questions that people have and the need to get answers.  I want to remind people that not being vaccinated or not having your children be vaccinated does put them at risk.  And the delay in being vaccinated is also a decision to continue to be at risk for the virus.  So as you're waiting for the vaccine to become available in your communities, this is a great time to get your questions answered and make sure you know what you need to know to make good choices for your kids and for your family.  There's a lot of good information on flu.gov.  Information about warning signs in kids and safety questions about vaccines.  And there will be more and more information coming about where vaccines will be offered in particular states and cities.  The states need some time to plan their venues based on when vaccine is coming out to them.  But keeping looking at that site and more will be coming ought in days and weeks ahead. 

Just to summarize, the hospitalizations and deaths continue, and they're continuing in younger people than we would see in seasonal flu.  Each one of these very severe cases is tragic for the family and hard for us in public health to see.  We are working really hard with the government in the private sector to address this threat.  Antiviral drugs are a critical part of the response to the flu problem.  And urgently needed and people with severe disease are people with risk factors.  And not waiting for that test result is the advice right now for clinicians who are seeing people where they really do think it's flu.  I want to just end by saying how much I appreciate the effort of providers, pharmacists, in the public health front line in working together on this response.  We are all trying to make sure that we reduce illness and death and spare the country the worst of this pandemic.  And it's a time where our efforts need to be doubled to really protect people.  I think with that, I'm going to turn to the phone for the first question.  Then we'll come back to the room.

Operator: Thank you, we will now begin the question and answer session.  If you would like to ask a question, press star one.  Again, press star one to ask a question.  One moment, please.  The first person is Elizabeth Weise with USA Today.  You may ask a question.

Elizabeth Weise: Thank you so much for taking my call.  My question is there’s been a concern -- kind of two opposing concerns.  One that there would be so many people lining to get the H1N1 vaccine, that people might start to panic that it isn’t enough, or that people might not show up to get the shots.  The states have got the shots. What sort of uptake are finding once the state health department actually get the vaccine in hand?

Anne Schuchat: You know, we're seeing lots of different stories.  I think we've talked before about flu is local, and I think flu demand and supply is somewhat local as well.  In many of the states where vaccine has been available there's been tremendous demand for it.  Lines of people coming in to get vaccinated or health care workers lining up to protect themselves in order protect their patients.  I think we're in early days and in some places there will be fits and starts to closely match where the vaccine can be used effectively or efficiently or where the demand is.  But I do believe we're getting this better every day.  So expect the distribution to look a little different everywhere.  And things to get a little but smoother every day.  We're working really closely with the states and cities and are sharing best practices.  We heard the state of Maine has a fantastic school located -- clinic for a program that's directed for seasonal flu that they're adapting to H1N1 flu and we're really trying to share their best practice with other states.  I was in Memphis and watched the health care workers being vaccinated there.  It was heartening to see so many nurses and Docs line up for the vaccines.  I think this is an area where we are really trying to work together to get the best practices out there.  And to make sure we anticipate which areas will need some more help and how we can help with that.  So I think that people do seem to want to be vaccinated.  And in fact, wish more of them could be vaccinated sooner.  We're at that point where every day more vaccines are getting out of there, but more people want to be vaccinated today than can be, unfortunately.  Let's take a question from the room.  Mike.

Mike Stobbe: Mike Stobbe from AP.  Doctor, you gave us hospitalizations and death data. Do you have additional breakdowns of the age groups do you have young children versus teenagers?  And do you have separate from ages, breakdowns of pregnant women or obese?

Anne Schuchat: I have more details on the age breakdowns but not the underlying disease or pregnancy breakdowns.  I think probably the easiest thing is to have our press officers follow up with you.  We’re going to be posting on our web the age breakdowns in the following categories, but just cause of time, I don’t want to go through them: 0 to 4, 5 to 18, 19 to 24, 25 to 49, 50 to 64, 65 and older.  We learned last week, we shouldn't give you numbers and not have them on the web.  So we'll get them on the web so you can make nice graphs. And other feedback is welcome so we don’t torture your reporting. So, did you have another question?

Mike Stobbe: Well, I was going to ask you to contrast it with the spring?  You said it's similar.  But do you remember what the numbers were in the spring how similar?

Anne Schuchat: Yeah, it's very close.  I don't actually have those numbers with me.  The situation is quite similar, you know, about half of the hospitalizations are occurring in people under 25.  It's very, very close.  I think the way that reporting's coming in is different.  You may remember that all of the states were individually reporting case back in the beginning, back in the spring.  Now it's really just 27 states reporting a hospitalization summary, according to lab-confirmed hospitalizations.  But we do think this is a young person's disease.  And, you know, just about 10 percent of all of the deaths are occurring in people 65 and up.  That's tiny compared to what happens with seasonal flu.  Joanne.

Joanne Silberner: Joanne Silberner from National Public Radio.  A study came out today in the American Journal of Preventative Medicine about an outbreak in the air force cadets this summer, 19 percent of them were still shedding virus 24 hours after their fever had gone away.  Two questions here, is that a surprise?  And two, what does that mean for the advice that you can go back to school or go back to work 24 hours after your symptoms disappear?

Anne Schuchat: Yes, thanks for that question.  We know that young people can shed virus longer than adults do.  This is known from the seasonal flu literature.  But what’s important to say is shedding doesn't mean that you're spreading.  It turns out that fever is a good marker of infectiousness or ability to spread.  The update of guidance for exclusion from work or school is that people should stay home for 24 hours after their fever is gone without taking anti-fever medicines.  And that really a balance of making sure that most of transmission is prevented.  And yet, we're balancing how long and how disruptive our interventions are.  So we think that that isn't at all surprising and we think our guidance makes a lot of sense.  Let's take a question from the phone.

Operator: You have a question from David Lewkowict from Fox News.

David Lewkowict: You call this is significant achievement, a safe and effective vaccine this quickly.  A "Washington Times" article talked about a study out of Purdue University saying that it may be too late.  In the next couple weeks, we should see the largest number of people contracting H1N1.  And the number of doses of vaccine available to the public just aren't there at this point.  Do you have a comment on the study by Purdue, as well as the article and any other information you can shed on that?

Anne Schuchat: I can't really comment on that particular study, but let me say that it's too soon to say that it's too late.  We think that vaccination as it becomes available is the best way to protect individuals in our communities from flu.  And we do think that there are likely to be illness, including severe illness, for some time in the future.  We may see in any particular community illness going down in the next several weeks.  But we don't know whether it's going to go up again.  You know, in 1957, the pandemic there had early disease around September/October, like what we're seeing here.  They had another big wave after the first of the year. And so I think that as vaccine becomes available, we are so admitted to get it out to the people who can benefit from it.  And I strongly urge people take advantage of that.  It's really much more our focus right now to be responding than to look at sort of second-guessing where we are.  We all wish we had more vaccine available sooner.  But I think we appreciate that it's coming out every day.  And that states are using it.

David Lewkowict: I can follow up. Just one quick question, it also talked about 60 percent of the people that would get H1N1 are going to be asymptomatic, is that true of your findings as well?

Anne Schuchat: The question of asymptomatic infection is what you’re asking about. Influenza can cause illnesses that you see symptoms with, and it can also cause infection without any symptoms.  We don't know yet the amount of asymptomatic infection that the H1N1 virus is causing.  There are some serologic studies that we and other people are doing but I don't expect results from those studies for quite some time.  What I can say is that the vast majority of people are still susceptible to this infection, particularly those under 65.  And we think that even with of the increase in illness and disease that we're seeing right now, still, the vast majority of people are still susceptible and vaccination makes a lot of sense.  Let's take another question from the room.  Okay.

Travis Stewart: Hi, Dr. Travis Stewart.  As an E.R. doctor, I can attest to the fact that the emergency departments in the country are really the front line right now.  A lot of walking well, people with very mild symptoms are coming to the E.R. for information, they are obviously concerned.  What is being done to educate people as to when to seek medical help, when they should go to the E.R.?

Anne Schuchat: There's a self-assessment tool that’s been posted at flu.gov and I encourage people to look at that.  We're also trying to reach out through the public, through a number of partners, to get the word out to people about what are warning signs, particularly for parents.  You have good instincts about your kids, whatever we have on paper, if you're worried, give your doctor a call, that's always good advice.  But to help with the whole general approach to this, we do think that people who are otherwise healthy, without asthma, diabetes, pregnancy, aren't under 2, are likely to do pretty well at home with flu, if your child isn't taking feeding.  If your child can't be woken up.  If the child, the lips are turning blue or gray.  If your child's getting better and then gets worse.  That's a severe warning sign.  It may be a sign of bacterial pneumonia that comes on after an infection and needs prompt antibiotics.  Those are some of the warning signs, but again at flu.gov, there's a whole section for parents and I encourage people to take a look at that.  A question from the phone.

Operator: A question on the phone line?  Betsy McKay with "Wall Street Journal."  You may ask your question.

Betsy McKay: Hi, Dr. Schuchat, thanks.  I've got a couple questions.  One is, I'm wondering if you can talk about, you know, among the healthy people, people with no underlying conditions who are getting this disease, what makes some healthy people get so severely ill while others get mildly ill?  Also, I just wanted to ask you, what your latest guidance is on the use of antiviral prophylactically for high risk patients?

Anne Schuchat: Thanks.  Most healthy people who get flu, the H1N1 virus or seasonal flu will do just fine after a couple of miserable days at home.  You know, staying home, drinking lots of fluids and resting will be enough for most healthy people.  But some healthy people with this 2009 H1N1 virus are having overwhelmingly serious complications.  I think there are two factors there.  One is that this virus, although it doesn't do this usually, it can cause a viral pneumonia, an infection in the lower respiratory tract, not just the upper respiratory tract that can be pretty severe with a pretty overwhelming infection that is very hard to treat even with antiviral medicines.  That's the exception.  Not the rule.  We don't know the factors that leave one person to get that while another person will get a milder infection.  A second explanation for healthy people coming down with really overwhelmingly severe disease is bacterial pneumonias.  Bacteria can sweep in after influenza has weakened our responses and can cause a very strong infection.  We've been seeing these bacterial pneumonias caused by staph, some people have heard of MRSA, or the Methicillin Resistant Staphylococcus aureus, that's around in our communities and it's sweeping in sometimes after the influenza, we've seeing some infections from pneumococcus.  And a key thing people can do is people can get vaccinated against it.  There's a vaccine recommended for people who have chronic diseases like asthma, diabetes, heart disease, kidney disease, liver disease.  We strongly recommend that vaccine.  We have low uptake of that vaccine, but particularly, in a flu season like this one, it's a good idea to ask your doctor if you need it.  That vaccine is available both in the pharmacies and the doctors' offices and so forth.  So I think that probably studies will tell us in the future why this child and not this other child, with this young adult and not this other young adult.  But right now, we do think that the viral pneumonia and the bacterial pneumonia are explanations for a more severe presentation.  Next question from the phone.

Operator: Next question from Miriam Falco from CNN medical news.  Go ahead.

Miriam Falco: Thank you for taking my question.  You answered most of mine. One clarification, the number that you mentioned of vaccine that's available for ordering now, it's 12 million new doses?  Or is this adding -- you started out with 9.8 last Monday.  And now we've moved up to 12.8, I just wanted to be clear on that.

Anne Schuchat: Yeah, thank you.  These are cumulative doses, how much has become available over -- since we've started to offer the vaccine.  The numbers that we're reporting today are 12.8 million total doses have become available for ordering over the course of time.  And so far, 10.8 of those doses have been ordered.  Again, we do expect more every week, and the states are ordering every day.  And we are expecting that by November, there will be a lot of vaccine out there.  And that widespread availability so it will be visible in your community.  You can see it.  You can find it when you check flu.gov, you'll see which places are offering it.  That's probably going to be November, rather than the next few weeks.  I think we have a question in the room.

Diana Davis: Thank you, Dr. Schuchat.  Diana Davis from WSB in Atlanta.  You mentioned 39 percent of the hospitalizations are 25 to 64.  There's been some -- it's my impression that some people in that age group were lower on the list of getting a priority shot.  That's still a hefty percentage.  Will they be higher on the list when more vaccine comes in?

Anne Schuchat: Yeah, the way our recommendations for vaccinations work, everybody 6 months of age to 24 are recommended be vaccinated.  People in the next group, the 25 to 64 year old group, we're recommending that all those people with chronic health conditions, asthma, diabetes, health care workers, people who are workers or caregivers for young babies that they ought to be vaccinated.  So there's a good portion of the 25 to 64-year-old group that’s in the priority population.  But the healthy, non-health care worker, adult, who doesn't take care of a young child wouldn't be in that group.  The states and locals know as soon as we're -- really quickly after we reach the demand in the first priority groups, we should be expanding upwards to the healthy adult group.  Then of course seniors are in the next wave.  Fortunately, seniors haven't been greatly affected by this, although, of course, they have a tremendous seasonal flu greatly affects them and they are strongly recommended to get vaccine.  And we know that they are getting vaccinated regularly now.  And that's the key intervention for them.

Diana Davis: Excuse me, on the antiviral, you gave the same message, really, just a few weeks ago.  Has there been resistance on the part of the health care providers on that message a, giving it rapidly, or do you think there's a lack of information?

Anne Schuchat: You know, there hasn't been resistance but I would say the testing is a little bit new.  For some laboratory tests people think it's black and white.  A yes is a yes and a no, a no.  With the influenza rapid test, a no or negative doesn't always mean a no or negative.  We want to remind people about that.  As the season continues and more and more cases are occurring.  We talked about this a while ago, you may not have seen a lot of disease near you.  So we want to make sure that providers understand about those tests and remember that prompt treatment, even without waiting for a test result, is important.  Let's go back to the phone.

Operator: You have a question from Maggie Fox.

Maggie Fox: I'm wondering about your algorithm about going to seat the doctor?  And it might encourage parents to keep kids home who have other things like strep throat.  In full disclosure, my daughter was diagnosed with strep throat, I almost didn't take her in because the algorithm said not to.

Anne Schuchat: Thank you.  There is no substitute for clinical judgment.  And these algorithms that we and others are offering or being made available through public and private websites, you know, it's a guide.  It's so important for a parent's judgment and intuition to be considered.  I think it's very important that clinicians have clinical judgment.  Really, as a doctor or nurse, you're looking at a person one-on-one and making those decisions.  If you're talking on the phone, you're assessing what you know about that child or that family.  So, yeah, these are tools and guides.  But I think we are trying help people.  You know, it's a time where people have so many questions.  You know, is a cold something I should be extra worried about or not.  We wanted help with navigating that.  You're right, there are a lot of other things out there besides influenza and some of those other things need medical care.

Maggie Fox: May I just follow up on that?  Because I think when you look at the numbers as a percentage of influenza-like illnesses, actually influenza is 29 percent or 30 percent?  Is that right?

Anne Schuchat: There's some qualification about that.  It's about 30 percent right now that are influenza that are from the test specimens.  Some of those others may be influenza, it may be outside the period where the test is accurate.  And some of the tests were based on rapid tests that aren't going to be as precise as a culture would be or a PCR test would be.  We don't think that all the influenza-like illness is influenza, but greater than that 30 percent that we've seen recently.  That will change over time.  In the summer, we were having such an unusual summer with the H1N1 virus that almost everything that was tested was H1N1.  Over the months ahead, other respiratory viruses will probably start to show up as wekk.  Another question from the phone?

Dan DeNoon: Thank you, Dr. Schuchat.  I have two very unrelated questions.  First is, among the people coming down with severe disease at high risk, is there any sense of how many people have a very severe underlying condition like muscular dystrophy or cerebral palsy as opposed to those with a milder risk factor such as pregnancy or mild asthma?

Anne Schuchat: Well, pregnancy, as we've been saying is disproportionately represented.  Completely healthy women have been coming down with horrible, horrible illnesses.  And tragic more deaths than we've been hearing about recently.  Certainly, among the pediatric deaths the severe neurological problems are prominent.  Muscular dystrophy and cerebral palsy.  But of course there are some children totally healthy and some children with conditions like asthma which is well controlled.  I think this is an area where even if you have diabetes that's well controlled, if you have asthma that's well controlled, we want to you think of yourself as a higher risk and recommend that you be vaccinated.  And we want you to check with your provider if you get a fever or cough or sore throat, even with the well-controlled diabetes or asthma, your body may not be able to handle the virus as well as somebody else's would.  Did you have another question?

Dan DeNoon: I did.  In the southern hemisphere and in Canada, we saw indigenous populations very strongly affected.  Are we seeing that same thing in the United States in tribal areas or other indigenous populations.

Anne Schuchat: We are getting information about that.  And our meeting with our colleagues who are caring for people in the native population.  There are early hints that it’s a bit more challenging in those populations.  It's premature for me to tease out whether it due to a higher rate of underlying conditions like diabetes and asthma or due to the distance that some people may have to travel for health care which could lead to worse outcomes if you're not promptly seen or cared for.  I think it's a very important question and we're working closely with partners who care for tribal populations or native populations.  We have time for two more questions.  Let's do one from the phone.

Operator: That comes from Kevin Finnegan from CBS News. Go ahead with your question.

Kevin Finnegan: Thank you, Dr. Schuchat.  You touched on this earlier before, but I wanted to ask you again, is there any evidence that the H1N1 outbreak has peaked in some areas, specifically, in the southwest, and you mentioned a possible second wave?  Are we expecting a second wave of H1N1 in the spring?

Anne Schuchat: I think that there's a couple places in the southeastern part of the U.S. where things look like they're downward trending.  In most other areas, it's upward trending.  And so I think it's too early for us to know, you know, whether those downward trends will be sustained.  I think you know a couple weeks ago, we had a little bit of a downward national trend, and then it was quickly overtaken by several weeks in a row, increase in trends nationally.  In terms of another wave, I have to say, we have been reviewing history recently, we've been looking at the data that from 1957 and 1958, and there's a lot about the fall of 1957 and the spring about 1958 which causes us to be paying attention.  There was a very impressive wave of disease in the spring.  And I think we have an opportunity right now to try to limit the disease we're seeing now.  And protect as many people as we can with the vaccine as it becomes available.  But looking to the spring, I can tell you at CDC, we're planning a long response.  We don't want to let our guard down too soon on this.  And nobody can predict what's going to happen but we're taking that possibility very seriously.  Just one more question here from the room.

Joanne Silberner: Hi, Joanne Silberner again from NPR.  Question about alternative medicines as things go on, we're seeing more and more of them show up on the internet and in other places. Have any of them shown to work or not to work?  And where does that leave people looking for treatment?

Anne Schuchat: I'm not aware of any of those alternative treatments that are proving effective.  I think people probably did see news recently about the FDA really clamping down on some of the false claims that people were making.  I thank the FDA, we really appreciate their effort to be aggressive on that.  Is this no time to take advantage of the public.  The public wants to get better.  They want good information.  And we need to be good stewards of the information that we have.  So I'm not aware of that.  I think we update our guidance when we get new information and we are committed to continue to do that.  Thanks, everybody.  I think there will be another briefing on Friday.

Dave Daigle: Right now, we're planning a briefing for Friday at noon.  Thanks, all.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES