CDC News Conference Transcript

Influenza Update

January 8, 2004

DR. JULIE GERBERDING: Welcome to this briefing on influenza, with just a note of appreciation for the media. This last year has brought many emerging infectious diseases and many other health issues to town, CDC, and other health agencies, and while our partners in the state and local health departments have been doing a terrific job, we also know that fair and accurate reporting of what's going on really helps people put emerging events in context, and so thank you for all you've done in the past year to get the word out to the public. We really do appreciate your reporting.

Today, I am here to provide some context on the current influenza outbreak. We are cautiously optimistic that at least in some parts of the country influenza may have peaked. We see that 38 states now are reporting widespread activity. That's down from forty-two last week. But there's still plenty of flu out there and we are still encouraging people with flu-like illness, who meet the criteria for concerns, or complications to seek medical attention if they do develop the illness, and for the rest of us who don't have chronic conditions, it's important to pay attention to the differences between influenza and colds, so that we don't make unnecessary trips to the health care system and handle our illness with the usual over-the-counter medications.

We also know that flu is unpredictable and even though we're hoping that we're past the peak for this early phase of the season, in past years we have seen flu come back and we've also seen new strains emerge late in the season. So it's still important to be vigilant and we will be continuing our activities at CDC to make sure we're doing everything possible to minimize the consequences of flu this year.

One of the things that we're doing is developing a new campaign to help children do the things that will prevent transmission of colds and flu in all kinds of settings but particular schools. So I'm pleased to announce the Germ Stopper campaign.

Many of these materials will be up on our Internet today. These materials will be available for schools, for churches, for any venue where children gather or parents gather, because the advice here would apply to adults just as easily as it would apply to children, and basically this campaign is based on the concept that flu and colds are mainly spread through close contact, through coughing and sneezing, and through transmitting the germs on hands, and so there's a strong emphasis on that old-fashioned intervention, good hand hygiene, and so we're hoping that this will just be a reminder, in schools and other public places, to take the simple steps that really do make a difference in preventing transmission of these infectious diseases.

We are concerned about children. Today's Morbidity and Mortality Weekly Report does report that 93 children have died of flu so far this year, and that's a very, very sad and sobering figure.

We don't have the data from previous years to really understand whether this represents an increase in the consequences of flu compared to previous outbreaks, or whether this is something unique to this year's flu season.

But we will be undertaking the necessary studies to find out in the future.

We also have had very good cooperation from states and health departments who are reporting these deaths and other serious encephalitis complications of flu, and so we'll learn more about this as we go forward this year.

But in the meantime, we are making some specific recommendations to clinicians, in particular, recognizing that children with chronic medical conditions are at increased risk for hospitalization and death, and so to have a very low threshold of suspicion for thinking about flu in children with underlying medical conditions, and also to test for influenza in communities where the disease is present, so that children can be diagnosed, and then, if it's appropriate, be treated with the antiretrovi--or the antiviral therapies.

And in addition, because some of the children have died from complicating bacterial pneumonia, to think about bacterial pneumonia, to test the child to make sure that the infection is sensitive to the antibiotics that would be indicated if there was a complicating pneumonia, and to be alert for drug-resistant bacteria because that has been a problem in some of the children with complicating illnesses.

So there are steps that clinicians can take and also steps that parents can take, particularly if you're a parent of a child who does have some other medical condition such as asthma or immunosuppressive disease, or kidney disease, or heart disease. If your child develops a high fever and flu-like symptoms, to be sure to consult with your clinician early to make sure that the child is not at risk for a complication of influenza.

Let me talk a little bit about another emerging infectious disease that is on our minds again this fall, and that is SARS, this respiratory syndrome. We do know that two SARS cases have been identified in China, one case is documented to have SARS through laboratory testing in a reliable laboratory. The other person, right now is a suspect case, but infection has not confirmed to be SARS. Both individuals are doing well medically and that's certainly good news.

The Chinese health officials have taken all appropriate steps to isolate the patients and to monitor their close contacts for evidence of illness, and so far no secondary cases have been identified, so that's also very good news.

But we are taking many steps here, at CDC, to continue our preparedness effort, as we've been doing all along since the epidemic was first recognized last year.

Today we'll be updating again our preparedness and response plan. This is an ongoing process. We posted this on the Web some time ago. We've gotten a lot of very helpful feedback from experts around the country, actually, around the world, and so we are responding to that and revising our document accordingly, and that will be an ongoing process as we learn the reality of how feasible and how appropriate some of our recommendations are when they go into the front line.

We also have refined the diagnostic for SARS, the diagnostic testing capabilities in our state health laboratories, we've initiated proficiency testing and made sure that the reagents that we're putting out have good quality control, and that our laboratories are fully prepared to do the best job possible at diagnosing the disease if it does emerge.

We've also issued safety guidelines, reminding laboratorians about how to handle SARS or potential SARS specimens, so that we don't have a situation such as occurred in Singapore or Taiwan, where laboratory personnel working with the SARS virus unfortunately contracted the disease.

We also of course continue to collaborate with the NIH on treatment protocols for SARS. We have partnerships with the FDA involving diagnostics and we're continuing to do everything we can to put the latest information out for clinicians, so that those who are responsible for infection control or other SARS case recognition will have the best possible information we have available to assist them.

So two people with SARS in China does not create an indication for travel restrictions. These are unlinked cases and there's no evidence of risk to people other than these individual cases. But of course the Chinese health officials are doing the appropriate things to identify additional cases and they are communicating right and regularly with the World Health Organization.

CDC has one of our top scientists in China, working together with the WHO and the Chinese to evaluate the situation there, and try to understand where the transmission is occurring and how it's occurring. So there's going to be a lot that we'll learn I think in the next few weeks about SARS in China.

But it's just a reminder that we have to remain vigilant and I think we will continue to take the steps necessary at CDC to be good partners with the international community and to protect our folks here at home.

So if there is any news or any change in the level of risk, we would certainly step up to the plate and make those decisions and offer that advice as quickly as it would be indicated.

Let me stop there and take some questions.

I have a question here in the room.

QUESTION: Regarding the run that we had on flu vaccine when these cases started popping up, any incentives that the government is working on to prevent shortages next year for vaccine manufacturers?

DR. GERBERDING: Secretary Thompson has asked us to really deal with three big issues regarding the future of influenza. The first is to identify how we can be sure that the people who most need influenza vaccines get vaccinated. That's absolutely critical. And we know even in a year like this year, where more people probably than ever before have been vaccinated, we still haven't been able to reach all of the people that we think should receive the vaccine. So that's the first thing.

The second thing is what can we do to improve the supply of vaccines so that we have more doses should we have another year where the demand is high and people need vaccine and are having trouble getting it.

And the third thing is an even longer-term prospect, and that's how can we improve the flu vaccine. Ideally, we'd love to have a vaccine that didn't have to be given every year, but in the short run, at least we could identify some manufacturing practices that would speed up production and allow us to be able to scale up production if we ran into a situation where we needed extra doses and hadn't predicted that up front.

So those are the three main things that we're working on at the Department of Health and Human Services, and all of the agencies in HHS have a role to play in this.

We've also engaged our advisory committees to provide external advice on additional steps that might be necessary, and this will be a topic, I'm sure, of upcoming advisory committee meetings that will be held throughout the spring to move this agenda forward.

QUESTION: Dr. Gerberding, I'm John Shirek with WXIA here in Atlanta.

DR. GERBERDING: Good afternoon.

QUESTION: Good afternoon.

Are you able to put into perspective the total number of people who have died because of the flu across the country compared with other flu seasons?

DR. GERBERDING: We have several different ways of conducting influenza surveillance, and one of the things we measure is death due to pneumonia and influenza-like illness. There is always a seasonal trend in those deaths in the United States, and right now the number of deaths this week, this past week, that were associated with influenza-like illness or pneumonia has exceeded what we refer to statistically as the epidemic threshold.

That often happens during flu season, not always, and it's too early to see whether or not the ultimate peak in deaths will be higher than what we've seen in previous years. But just to be very explicit about this, those figures do not refer only to influenza. That's a broader category that includes other respiratory illnesses contributing to death, and so it's not necessarily possible, with the information we have available at that population level, to answer your question exactly.

We also are looking at CDC studies or surveillance methods that we might be able to implement in the future to help us have more specific information about influenza per se. The reason that's important, because it could have a bearing on recommendations about use of the vaccine.

Let me take a question from the telephone, please.

OPERATOR: Thank you. David Wahlberg with the Atlanta Journal Constitution, your line is now open.

QUESTION: Hello. Thank you.

The CDC has requested that physicians report children who die from influenza this season. I'm wondering what the status is of making that a permanent recommendation or requirement or requiring the reporting of deaths among children and healthy people in general or a broader category.

DR. GERBERDING: One of the things that we do routinely is work with our partners in the states to help get consistency about reportable conditions. So we already have engaged the individuals in the Council of State and Territorial Epidemiologists--or CSTE--who are generally the people in states who are the experts in disease reporting, and we've asked them to consider officially making influenza deaths among children a reportable condition in the long run. I think there's enthusiasm for that. They will be meeting and working out the details of the case definition later this year.

In general, we have a very collaborative arrangement with these experts, and we often come to close agreement in a rapid timeframe when something is as important as this is. So I'm fairly optimistic that we will see some changes in reporting, making this a more permanent or a more standardized methodology in the future. We've learned how important it really is to have this information.

Let me take another question from the telephone.

OPERATOR: Thank you. Betsy McKay with the Wall Street Journal, your line is now open.

QUESTION: Yes. Thank you very much.

I wanted to ask, first, if you have a handle right now on what supplies of flu vaccine are like, if there's any left, and if those additional doses that were supposed to be shipped in January have been sent out.

I also wanted to ask about SARS. One of the important--in surveillance for SARS, one of the important clues has been to look for clusters of the disease, but these two cases appear to be isolated, and I'm just wondering if this means you're changing your guidance on what to look for, and are there aspects of transmission of this disease that we may not yet know?

Thanks.

DR. GERBERDING: Thank you. The flu vaccine supply is some good news and some not-so-good news. The good news is that there still is a lot of FluMist, the vaccine for healthy adults and children between the ages of 5 and 18. So people can still acquire FluMist. That vaccine is indicated for people without chronic medical conditions, and it is not indicated for older people or very young children.

We also have distributed some of the vaccine that was procured from Chiron, but we still have some jurisdictions that have not placed their order for that vaccine, and we will be distributing the remaining supply as those orders from states and other locales come in requesting it. We're doing everything we can, obviously, to move that out as quickly as possible.

SARS is a disease that had a pattern last year that certainly helped us predict where we would look first for a reemergence. But as with any emerging infectious disease, we have to be prepared for the unexpected, and I think what we're seeing here in China is a very vigilant health system that's doing exactly what it should be doing, and that is recognizing patients with fever and unexpected pneumonia, isolating them, thinking about SARS, doing a diagnostic test and so forth.

Every epidemic starts out with an isolated case, and so this is the best way to keep this problem from becoming an epidemic. I think it's way too early to say whether these two will be the only cases, but I think we recognize that new patterns of transmission could evolve, and we'll have to stay on top of that. That's part of the job of the team that's over there right now is to really try to get as much detailed information about potential exposures in most of these people and also to assist in the assessment of animal reservoirs or other sources that virologically could be the ultimate source.

We also have a lot of questions about whether or not there is any carrier state of SARS. We have absolutely no scientific evidence to suggest that at all at this point in time, but that is a phenomenon that has occurred with other viruses, and so that's another thing that people will be watching for very carefully.

So we are taking all of the steps we can right now, but I'm sure there will be emerging information, and we'll do our best to get that out there as quickly as we get it.

Let me take another question from here in the room.

[No response.]

DR. GERBERDING: There's not a question here. I'll take another one from the phone.

OPERATOR: Thank you. Maggie Fox with Reuters, your line is now open.

QUESTION: Thank you, Dr. Gerberding.

My question hits on what you just said about the idea of carriers. Can you go into that a little bit more because we're seeing a lot of very extreme reactions in China, all of the Civet cats being drowned, and now there's a big rat hunt. But can you comment about the possibility that somebody who's not really ill is carrying SARS around and perhaps transmitting it to people who are more vulnerable?

DR. GERBERDING: Thank you. We do not have all of the details of the assessment of animals in the Guangdong Province right now, but I think there have been some exaggerated accounts of the steps that the health officials are taking.

They are requesting a ban on the marketing of wild animals in the markets in that province. That's a precautionary step. In addition, animals that are raised domestically, particularly the Civet cats, are being slaughtered so that they don't serve as a reservoir.

Right now, there is no scientific evidence proving that these animals are the source of SARS. They do have Coronavirus infection at times, and the Coronavirus has had some similarity to the SARS Coronavirus, but they are not identical. And so there's a great deal of work to be done to really identify the definite source of SARS. We may not ever be able to identify it for sure, but it's only a hypothesis right now, and I think the officials are taking a precautionary step in the same way that precautionary steps were taken when avian influenza arrived in contaminated poultry farms, et cetera.

Other animals are not the target of specific programs, although the minister of Health did recommend that individuals use rodenticide to try to reduce the rodent population in the remote possibility that they served as a source of SARS transmission.

So I think that these are steps that are being taken right now as a precaution. The science will hopefully emerge as the investigation evolves, and I'm sure we, and others in the international community, will look forward to being able to make more specific recommendations as we have more information.

Let me ask another question from the telephone.

OPERATOR: Thank you. Daniel Yee, with the Associated Press, your line is now open.

QUESTION: Hey, thanks for doing this.

I was just wondering how prepared is the United States for new SARS activity in the country--what has been done, what's been working well since the initial outbreak and what needs to be done, and I was wondering if there's a breakdown in where the child deaths are from statewise.

DR. GERBERDING: Thank you.

We are doing many things in the United States to prepare for SARS. These things have been continuing since the last case was diagnosed from the first round of SARS, and I think we will continue to focus on preparedness as we go forward. The most important thing is really getting the science together in a way that allows us to update and revise some of our initial recommendations.

If you remember, during SARS, almost everything we put out said "interim guidance for this group or that group or this situation or that situation," and as we've been able to develop more precision around the diagnostic testing, the epidemiologic data are coming in to help us more precisely understand modes of transmission here. We have more information about the clinical presentation. So we're turning around that science and then updating our guidance so that the clinicians on the front line who need it the most have the best resources that we can put in their hands.

We are also in much better shape right now than we were at the beginning of SARS, in terms of diagnosis, because we have the laboratory reagents prepared. They're distributed. Labs all over the country are being trained in the proper conduct of these tests, and our capacity to accurately interpret the test results have certainly improved as well.

So I think a lot of things are happening on a lot of fronts, and we will really continue to do everything we can as we watch and hope for the best in China.

The patients who have died with influenza in the pediatric age groups are reported to us by states, but I don't have that information available right now, and I'll check to see if it's in a format that can be provided to you at this point in time. So I would suggest you get back in touch with the media office after the press conference, and we'll do what we can to help supply that detail.

Is there another question from the telephone?

OPERATOR: Thank you. John Lauerman, with Bloomberg News, you may ask your question.

QUESTION: Thanks for taking my question.

How soon do you think the testing or rather the death figures of death among children, how soon might that be available to you, and how extensive might be the information that you would be asking for states?

DR. GERBERDING: The deaths are being reported as they occur. There are various intervals of time between the child developing illness and dying and it officially arriving at CDC because there's often a great deal of investigation that goes on at the local level.

The children that we are aware of so far are children who had some kind of laboratory evidence of influenza. So this is a group that was highly likely to have influenza as at least a contributing or underlying cause of death. There may be other children who have not been diagnosed with influenza using laboratory tests, and we will want to learn more about those children as well. That will most likely not happen any time soon because we'll have to do some special studies to try to sort that out.

We are not done with flu season yet. When we say "optimistic," then, perhaps at least in some areas the season has peaked. It's a long way between where we are at the beginning of January and what usually is the end of flu season. So we will be watching very carefully and looking for the reporting from the states.

The information that's being collected includes information about underlying disease, about vaccine status, and we can find that information ideally dates the vaccine so we can understand how many of these children were vaccinated, also information about the clinical illness, the presentation and other medical aspects so that we can help pull that together and present it to pediatricians and emergency room clinicians and others who might be at the front line of taking care of these very sick children.

So the case reporting is fairly detailed, and that's one of the reasons why it takes us a while to compile all of the information because somebody has to do some extensive interviewing, chart reviewing, and like all kinds of disease detective work, it just takes time to get that all together. We probably have the most complete picture long after the flu season is over. So we'll try to provide periodic updates as we have new information and final reports later.

Is there another question from the telephone?

OPERATOR: Thank you. Anita Manning, with USA Today, your line is now open.

QUESTION: Thank you. Dr. Gerberding, you mentioned ever so briefly that sometimes flu will come back or that strains will emerge late in the season. Is there a pattern of that happening in most flu seasons? I mean, are there two peaks? And I guess that leads into the next question about you mentioned also the current vaccine was being distributed or that it was available and states were ordering it, but what about the pediatric vaccine--I think that was Aventis's--has that all been distributed as well?

Thank you.

DR. GERBERDING: Thank you. I'm going to ask Dr. Nancy Cox here, who's one of our influenza experts, to describe the patterns of flu in past epidemics because she's the person who really has been monitoring that for several years, and I think she can give you a good perspective on that.

DR. COX: Thanks, Dr. Gerberding.

One of the things about influenza is that each different epidemic has its own characteristics: the time that it begins, the time that it ends, how high it peaks, and the populations that are most affected.

When we look back over the past 10 to 20 years of surveillance data, what we can see is that there's not a general pattern that we can say with certainty will occur. So, in some years, we have seen a second wave of disease caused by a different virus. And the most notable instance of that would be the 1992-'93 season, where we had a lot of Influenza B circulating, and then rather later in the year, we had a peak of Influenza A H3N2 viruses that were associated with some excess deaths, but this is more of the exception rather than the rule.

So even when we see a second peak of viruses, we don't always--that may be a much lower peak of actual viruses circulating, and so we can't even see, within the context of influenza morbidity, that we have something going on. It just blends into what we've seen in terms of the [inaudible]. So you have to look at a fine level in order to see that second--it normally doesn't cause a peak in mortality or in morbidity.

DR. GERBERDING: You also asked a question about availability of the pediatric vaccine. The vaccine has been distributed. There are areas that still have a supply of the pediatric vaccine. There are other areas that are reporting some shortages. So it's a variable picture right now. I don't have any more specific information about where it's available, but if people are looking for it, they should contact their clinicians, and the local or state health agencies are the ones who are most informed about where doses are, and they're still taking all of the steps they can to try to make sure that the kids who need it the most have access to it.

Is there another question from the telephone?

OPERATOR: Thank you. Victoria Elliott, with the Journal of the American Medical Association, your line is now open.

QUESTION: --American Medical News.

But the question I had was actually there have been several instances of fraud related to the flu vaccine because of the consumer demand for it this year, and I was wondering how fraud prevention works into planning for future flu seasons or even a flu pandemic.

DR. GERBERDING: It is really unfortunate that in a time where there's a high demand for a product like a vaccine that people can be tempted to take advantage of that demand and engage in some unscrupulous activities. The FDA is right on top of those activities in certainly identifying situations where that may be occurring and intervening with their authority as regulators to evaluate and assess the situation.

This is not a widespread problem. It is not something that has happened in very many locations, but it is something that we are always on the alert for, and I know FDA is certainly on the case for those situations where there has been a suspicion of that.

DR. GERBERDING: One last question from the telephone.

OPERATOR: Thank you. Rob Stein, with the Washington Post, your line is now open.

QUESTION: Yes, hi. Thanks very much.

I'm just trying to get a little bit of a better sense of where we might be in this year's flu season. I know every year is different, and it's hard to know for sure, but in a typical year, would this be about halfway through? And in a typical year, do most of the deaths, do they usually occur early in the season or are they sort of spread throughout the season?

DR. GERBERDING: I'm just going to echo what Dr. Cox said earlier; that there really is no typical year for flu. We knew this year started earlier and was more widespread earlier than we've seen in past years, and so that makes this season already somewhat unique.

But the distribution of morbidity and the distribution of mortality is something that we just really won't be able to compare until the season is basically over. The hints from our various kinds of surveillance suggests, again, that we may be past the peak, but that could be a peak with a very shallow slope, and so we just need to continue to do the best thing that we can, and that is to encourage people with underlying medical conditions to seek early medical care if they develop flu-like illness and to encourage clinicians to think of influenza, especially for those patients, and initiate the appropriate diagnostic and medical treatment to try to reduce the harm from the infection.

Once again, to remind everybody that the vast majority of people who have flu are going to have that annoying illness, but it is not something that's likely to cause severe complications, and there are some very important things that people can do to protect themselves, protect their children, and protect the people that they love from influenza, and that includes respiratory etiquette--covering your mouth and nose when you sneeze or cough and washing hands.

Thank you very much.

[Whereupon, the press briefing was concluded.] 

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