(Constant H1N1 Swine Flu updates including links to current press releases may be seen here)
CDC Briefing on Public Health Investigation of Human Cases of Swine Influenza
April 28, 2009, 2:30 p.m. EST
Before I start, I wanted to call the media’s attention to three new e-mail addresses that we have brought online today to help us manage, as you can imagine, a relatively high volume of media requests. And so we have tried to structure this. And again, we’ve never done this before, so it’s going to be a learning experience for us as well. We’re hopeful this will help us help serve your needs as well. So we have established three new media websites. Or e-mail addresses. The first one is email@example.com. If you work or for print media, we encourage that one. If you work in radio, use firstname.lastname@example.org. Television, use email@example.com. We have people assigned to each of those different e-mail boxes. That’s how we were trying to manage this from a media relations perspective. This afternoon it will be led by the acting director of disease control and prevention. I will turn it over to Dr. Besser.
>> Thanks very much, Glen. Thank you for being with me today for this update on the swine flu outbreak. As I’ve been saying over the past couple days, this is a situation that is rapidly changing. We continue to respond aggressively based on what we know and trying to stay ahead of the outbreak. Our goal remains to minimize the impact of the outbreak on people’s health. So where are we today? I wanted to start with the case update. This is on our website. There are 64 confirmed cases in the United States in five states. 45 in New York, one in Ohio, two in Kansas, six in Texas and ten in California. As I’ve been saying, numbers when it comes to an outbreak like this will change. And through the day you’ll hear different numbers or newer numbers from states. We will continue to update our numbers once a day for consistency. But you will find with that that some of our numbers may lag behind what you’re hearing from a particular state. If you want information about cases in a particular state, the best place to turn for that information is to that state because they’re on the ground. They’re the ones who are working to investigate and implement control measures. There are five — there have now been five hospitalized cases. As I’ve been saying, as we continue to look for cases, as this flu virus infects individuals, we will be seeing a broader spectrum of disease. What we see in the United States, or have been seeing so far, has been milder, has been less severe than what has been reported out of Mexico. And as we continue to look, we will continue to monitor that. So there are five hospitalized cases, three in California and two in Texas. The median age is 16 years to 64 years. We expect to see more cases and will continue to report on those. As we move forward, we may start to move away from specific case numbers and more on to describing states and clusters. The incubation period in the United States appears to be about two to seven days, which is typical for what you see with an influenza virus. I want to take a moment and put this into context with seasonal flu. Many of you are well schooled in influenza and have been covering seasonal flu. But what we see with seasonal flu is that it can be unpredictable. On average, in the United States, each year from seasonal flu, we see approximately 36,000 deaths. And so influenza is a severe infection. It affects different people differently based on their own immunity, their ability to fight infection and factors around the virus. Preventive measures, as we’ve been talking about, can help reduce spread and help protect individuals from getting the infection. Yesterday I talked about the World Health Organization changing the phase from three to four. And I talked about what that means. And from our perspective here in the United States, it has very little meaning. What we do means a lot more than what it is called. And what we’re doing is being very aggressive, looking at what’s going on at the community level and adjusting and adapting our guidance and our actions based on what’s taking place on the ground. Let me review some of the many actions that CDC is involved in around the country. We continue to work with state and local health departments. We have teams on the ground in Texas and in California. We continue to work with the World Health Organization, the Pan-American health organization, Canada and Mexico. Yesterday we issued a travel advisory to Mexico. That is recommending that nonessential travel to Mexico be postponed. For individuals who must travel to Mexico, we posted guidance on things individuals can do to reduce their risk of infection while they are there. We have posted new treatment guidelines. These were developed in conjunction with the infectious diseases society of America and the advisory committee on immunization practices. Those groups have provided us with excellent guidance for treating individuals who have swine flu. It’s important to remember with the guidance documents, because there are a lot on the web, there’s more than a dozen guidance documents that we have put up on the web, and we continue to generate more guidance, guidance is interim. We change our guidance as we have more information. And we’re going to continue to do so. That’s very important. As we learn something, as it could impact on what public health is doing in the community or what individuals can do, we’re going to change the guidance so that people have the most current information right away. We continue to deploy material from the strategic national stockpile. And I talked about this yesterday. It includes antiviral drugs. It includes gowns and masks and things that could be used in hospitals to take care of patients. And this is a forward-leaning step. There are certain states that have cases, and there are many — most of the states have not yet reported cases. But every state has requested their portion of the strategic national stockpile, and we’re in the process of delivering that. And why are we taking this action? We’re doing so because with any new infectious disease, with any emerging infection, you really can’t predict the course. And so this is to ensure that if these drugs are needed, states have them on hand, and they don’t have to wait. There won’t be a delay between the time that they need those drugs and request them and their delivery. People are concerned, and we’re concerned. And concern is a good thing. Concern is especially good if it drives planning and it drives action. And that’s what we’re encouraging people to do. At the personal level. People are concerned, and they say, what can we do to make ourselves safe? What can we do to protect our family? And there’s a lot people can do. Simple things to prevent respiratory infection. Hand washing. We say it every day. People will get tired of hearing it because we are always going to say that. Hand washing, use of alcohol hand gels can reduce the spread of viruses. And if people take that step, that can reduce the risk that they’re going to get an infection. Covering your cough. Not with your hand, but with your arm or your shoulder. That can reduce the likelihood that you are going to transmit a virus. And it’s very important that people follow what we call home isolation practices. What that means is if you’re sick, if you have a fever and you have flulike illness, stay home. Don’t go to school. Don’t send your children to school. Don’t go to work. Stay home. So that you can get better, and you’re going to be less likely to spread the infection to somebody else. We’re asking in areas where there’s confirmed cases — if you are a confirmed case of swine flu, that not only you stay home, but that the rest of the family think about staying home as well. Not because they are sick or definitively know that they’re sick, but because there’s a chance that they could be brewing the infection. And by not spending as much time in the community, they, too, can help reduce the likelihood of transmission. We’re going to see different actions taken in different communities. And people are going to question that and say, is that a good thing? It is a good thing. We expect and we hope that public health professionals are going to tailor their actions based on what’s going on in their particular communities. We are in contact with communities that have had cases. We are working with them and providing our recommendations. But what you’re going to find is that the people on the ground in a community know that community best and are in the best position to help tailor the recommendations and the actions that are taken. So in summary, as we move forward, I want to stress that the label of what we call this means a lot less than what we do. And we continue to be very aggressive. No single action that somebody takes, whether it be the government, a community, a family or an individual, will halt this. But the combined actions that we all take together will reduce the impact on our communities and on our health. It’s a shared responsibility, the things that all of us can do, individuals, families, communities and government. And I want to thank all of you for covering this story and getting the message right. I see time and time again those messages of what people can do. Those are empowering. And at a time where there’s a lot of uncertainty and a lot of concern, empowering people with those messages of what can you do is really an incredible public service. And so I want to thank you for that. And I want to stop now and take your questions. We’ll start here in the room and then we’ll take a couple here.
>> Hi, Doctor. Fox News. Can you report on the Los Angeles coroner’s office is investigating two deaths to see if they might have been caused by swine flu?
>> That is not something I’ve heard. But as I continued to say, as this moves forward, I fully expect that we will see deaths from this infection. They’re seeing many deaths in Mexico, and we’re trying to learn more about that and why the situation in Mexico is different from here. And as we continue to investigate cases here, I expect that we will see deaths in this country. But I don’t have any information on that situation.
>> Okay. My second question is I see the state of Indiana is reporting that they have a confirmed case of swine flu which is not included in your total. Are you guys — how does that work? Are you coordinating with the states?
>> We are. And that kind of gets back to the numbers game that I was dealing with earlier. You know, it depends when that case was confirmed and reported. If it has been a confirmed case and it’s been reported and it was after our deadline for our reporting, you’ll see it on our site tomorrow. So I’d recommend that you go to Indiana on that.
>> Are you involved in confirming?
>> Right now we’re involved in confirming each case. But, you know, the good news is that test kits are coming to states so that confirmation will be able to take place at the state level. The FDA has been very proactive in forward moving in approving test kits for testing for swine flu. That’s going to lead to more rapid confirmation. There’s been a tremendous investment around the country in preparedness. And a large part of that was on the laboratory systems and state health departments. And so we’re quite pleased that the state health department lab system is going to be able to serve that important function.
>> Thanks. Mike from the A.P. Hi, Doctor. Can you tell me more about the five hospitalizations? Like how old were they? Did any of them have underlying conditions? Were there co-infections involved? Why were these people hospitalized? What do we know about that?
>> No, for that I’m going to need to steer you to the folks in California and Texas for information about individual cases. They’re doing those investigations and can provide you with the most up-to-date information. I can’t comment on that. I wouldn’t want to misspeak. It is — you know, one of the critical parts of investigating a new outbreak is looking at cases in the spectrum of disease and trying to see if you can understand why some people have more of a severe course than others. And so there will be a lot of attention, and there is a lot of attention being made to hospitalized cases. But I don’t have information on the specific cases that were occurring in those states. And they can provide that for you.
>> Thank you, Cece Connolly from “The Washington Post.” Can you tell us on if you have working hypotheses why the cases in Mexico have been so much severe. What do we know about either the sequencing there or the medical facilities or the underlying health of the population? Can you give us some of your working hypotheses?
>> You’re hitting on them right there. And at this point we haven’t been able to rule out or rule in any hypothesis. When you’re looking at variation and impact of an infectious agent, you look at the host and see, okay, could there be host differences and why some people in Mexico are getting sicker than people here? You look at the pathogen, and you look at the virus itself and say, has the pathogen, has that virus changed as it’s infected people in Mexico and is now infecting people here? And then you’ll often look at the environment and the context in which the infection is occurring and seeing, has that had some modification on the impact? We’re looking at all those things. So in terms of the host, you’ll look at the immune status of individuals. You’ll look at the age. You’ll look at the gender and see if there’s anything there that can shed some light. You look at the treatment practices and see is there a difference in either how these individuals self-treated when they had an infection, how long people took to seek care, and whether there was a longer delay to seeking treatment. What type of treatment was received when they came initially to the hospital? Was flu something they thought of? Did they quickly get an antiviral? Were there other treatments that were given alongside of that that could account for the differences? So those are some of the theories we’re looking at. Looking at the virus and, you know, the idea that perhaps there’s been a change in the virus would be a very comforting thing if we were able to find that to see that the virus was changing and becoming less virulent, less severe. Right now it’s premature. We don’t have any evidence of that, but that’s one of the things that will be looked at. You’ll look at the virus as it has — what’s called serial transmission. So if someone has that infection, they pass it on to somebody else, and somebody else. If you get viruses along the way and can look at those, that can give you a sense as to whether — as it moves from person to person, it’s changing, becoming less severe, more severe, or no change at all. And that is all very important information in trying to help us predict the course and guide the interventions that are undertaken. Some questions from the phone.
>> Thank you. Again, on the phone lines to ask a question, please press star one. As a reminder, due to the high interest in today’s topic, please limit yourself to one question. Alice Park from “Time” Magazine, please go ahead.
>> Yes, thank you for taking the call. My question is about the vaccine. Could you please update us on exactly where the process is? I think you mentioned you were preparing it. Has that been finalized? And secondly, can you address how things might be done differently in preparing a vaccine this time around than had been done in ’76, the last time we tried to create a swine flu vaccine?
>> Thanks for that question. So when you think about a new strain of flu, one of the things that we look at is how is the best way to control for that right now, and how — what is the best way moving into the future? Right now we don’t have a vaccine that can treat this strain of flu. The seasonal flu vaccine is a great vaccine. But it doesn’t protect against the strain of flu that was not circulating at that time. And at this point we don’t see that there was protective value from that vaccine for this new strain. Moving forward, though, into the future, vaccine is something that we are looking at very intently. And as I said before, we’re growing up that seed stock of virus so that if we decide to manufacture a vaccine, we are ready to do so. And that’s moving forward. We’re moving forward aggressively so that if a decision is made that we need to rev up production to make that vaccine, we would be ready to do so. And so there’s active discussions going on about that. We’re mapping out the decision points. And we are right in line in terms of the steps we’re taking. It will be a matter of us deciding not to make a vaccine rather than deciding to move forward. What we’re doing now is very proactive in terms of growing up the seed stocks for a vaccine. And so if there’s a decision that, yes, we want to turn production towards making this, we’ll be ready to move with that, and we’ll implement that. Another question from the phone?
>> Thank you. Elizabeth Weise, “USA Today,” please go ahead.
>> Thanks for taking my call. A quick follow-up on the vaccine production. Have you given some of that seed stock to vaccine companies at this point?
>> Let me get back to you tomorrow with more details on that. I think that the seed stock is still currently in our control. But I need to look and see more information on that. I know it’s being grown up, but I can get back to you in terms of where we are with that stock. Question here in the room.
>> Hi. Daniel Steinberger with CBS news. First question, school closings. Do you guys have numbers on that, and is that something you’re looking at or guarding against, you’re concerned about?
>> One of the recommendations we have on our website in terms of community mitigation, community control, is that if you have a case of swine flu in a school, that you dismiss the students until you have a better handle on transmission in that community and control efforts. I can’t tell you how many schools have been closed. That’s a fluid number. I can tell you that New York City undertook that with the cluster that they’re dealing with, and in Texas with the cluster they were dealing with, they closed schools as well. I’m not aware of which other areas have closed schools.
>> Also, you talk a lot about being concerned and acting aggressively and giving tips to people. At what point do you move beyond concern? What will it take for the CDC, for the World Health Organization, to move beyond concerned and be afraid or be, you know, very concerned or whatever word you would classify that?
>> I would say I’m very concerned. You know, we are — we are dealing with a new strain of influenza. We’re dealing with a strain of influenza that appears to be moving through our community. We have this documented in five states. We’re very concerned. And because of that, we’re acting very aggressively. And as we learn more, and if we determine that there are other steps that we could take to help further control that, we’re going to take those steps. With a new infectious agent, you don’t sit back and wait and hope for the best. You take bold steps, and then you pull back if you need to. We are in a pre-pandemic period. And, you know, that gets to the what do you call this? And that isn’t very relevant to us since we are an affected country. That terminology is much more relevant if you’re seeing a cluster of infection somewhere else in the world, and you’re wondering, is this something that’s going to spread from country to country? When I first started out at CDC as an epidemic intelligence service officer, it was during the cholera pandemic back in the early ’90s. And we were using the term “pandemic” very readily, and we were looking to see that that strain of bacteria was spreading from country to country. And it was a pandemic, but it wasn’t in the United States. And so our approach at that point was there’s a cholera pandemic going on. What can we do to control it at our border from coming in here? And I spent time on the border doing education around here’s what you look for for this. This is a very different situation. And it’s different because this virus is here in the United States. And so it changes our control strategies, and it changes our approach.
>> Hi, Beth Galvin with Fox 5 News. I was wondering worldwide, do we have an idea of the extent of this virus, and do we have a better idea of how it seems to be moving from person to person, not including people who were in Mexico, moving beyond that.
>> Right. You know, two questions. One, the global picture. I know that Canada is reporting cases. I’d refer you to the World Health Organization site to see which country, in particular, are reporting cases. But we’re hearing through the media of confirmed reports, and we are getting information from World Health Organization. But again, I’d rather not comment on the data coming from another country. It does appear that more and more countries are reporting suspect cases. And as they do that testing, I would expect that we’re going to see that this virus is in many different countries.
>> [ Inaudible ]
>> Right. What you do as part of a case investigation when you have a case of flu is you look for any signs of transmission within families or close contacts and circles. And the information that we’re seeing from the states and locals who are doing that is that this appears to be acting like a normal flu virus which has a fairly high rate of transmission in families. So they’re seeing people who have either colds or respiratory infections or flulike symptoms. But the only case in the United States where we have confirmed with virus, person-to-person transmission, was one situation in Kansas. But that’s not reassuring in my mind. That’s just a reflection of what testing has been done. I expect that we are seeing transmission within families, and that is consistent with why we put out the guidance we did about trying to limit transmission within a family to try and prevent that from going further in the community. More questions from the phone?
>> Thank you. Maggie Fox, Reuters. Please go ahead.
>> Hi, can you characterize how far back in the past we’re looking at when the latest onset was? And has there been in blips in pulse net giving us an idea of increased respiratory disease?
>> Maggie, you’re going to have to hit me with that once more. Are you looking for when was the first case?
>> No, when’s the last case. I’m trying to get a grip on how far back in the past. I don’t think you guys have any indication of whether it’s actively spreading still, right? These are past cases that are being investigated. When was the last onset of illness that you’ve got, and has there been any blip in the surveillance for new hospitalizations for respiratory disease?
>> Yeah, I’ll need to get back to you with onset dates. You know, we are seeing active investigations going on in states that are not all retrospective investigations. What we’re hearing about from state and locals is ongoing respiratory illness that is consistent with swine flu. And so it’s very important that people understand the signs and symptoms of swine flu. And if they have those, if they have fever, if they have respiratory symptoms and muscle aches, some may have diarrhea or nausea, that they contact their doctors and be properly evaluated. In particular, if they’re either connected to a group of other cases or if they’ve traveled to an affected area, in particular, Mexico. Another question from the phone?
>> Thank you. Steven Smith, “Boston Globe.” Please go ahead.
>> Hi, Dr. Besser, thanks for taking the questions. A quick point regarding flu or flu vaccine against the swine flu. Are you thinking in terms when you talk about revving up production that this would be a vaccine specifically for this strain of H1 or N1, or would there be some way to combine protection against this strain in the seasonal flu that’s already under production in the strains that were selected in February? And a second question. When you were talking about some of the major questions still hanging on transmissibility, virulence, can you describe how CDC is going about its hunt for answers to those questions, those in the United States and abroad?
>> Sure. Your first question had to do with vaccine and vaccine strategies. And there are a couple different approaches. One would be to look to see, can you add another strain of flu to the seasonal flu vaccine? And that’s an attractive approach in that you would have one vaccine that is covering not just seasonal flu but this new strain that’s circulating. If that’s possible, that would be great. We do know, though, that seasonal flu vaccine production is moving forward. And we don’t want to do anything that would delay production of vaccine for that season. But that is something under consideration. We’re also looking at the production of what we would call a monoval, or single vaccine, against in particular strain. And that would not impact on the current production activity around seasonal flu, but at some point, we would need to rev up that production. And we’re laying out those time lines to see when would we need to make that decision, get that into production to have it here for next flu season. There are a number of different courses that we could see with this outbreak. As many have reported in some situations where there has been a pandemic, they’ve seen an early way that was not very — was not very aggressive. You’ve seen that go away, and then the next flu season, they’ve seen it come back. And so that’s something we are keeping in mind. And that will factor into our decisions as to whether to manufacture a vaccine for controlling this outbreak. Your question about studies, there are long lists of studies. And scientists around the country and around the globe are determining what are the most relevant and appropriate studies. There’s an incredible amount of collaboration in terms of sharing of the strain of flu and sharing ideas around investigations. We are participating as part of a tri-national team, looking at disease, looking at transmission in Mexico. We’re also very engaged with state and local public health here in defining what particular studies could we do, should we be doing in these early cases and early clusters to help inform our future decisions? You know, we’ll be looking very closely to see how effective is school dismissal in halting transmission? Is that an effective strategy? Each of the things that we’re doing, we’re trying to evaluate as we go so that when other communities are faced with the same situation, they’ll have more information on which to make their decision. Another question from the phone?
>> Thank you. Yuki Noguchi, National Public Radio, please go ahead.
>> Yeah, I wanted to ask you about the outreach efforts. It seems like the social media, your social media has really taken off. And I’m wondering what kind of response you’re getting from that and what you’re learning from that experience.
>> That’s a great question, and I hope to be able to give you a little more on that tomorrow. Communication around this, this outbreak, is so important. It’s important that people have information. They know where to turn for information. Our CDC website, www.cdc.gov/swineflu has current information on the outbreak. It has case counts. It has links to World Health Organization, all of our guidance information, information for the public. We have a Spanish language website. We are putting up and have put up podcasts so that that’s another way to get information on this outbreak. But use of the blogosphere and the rest of the new media is also a very important part of communicating nowadays. And I want to get back to you tomorrow with more information on what we’re doing in that domain.
>> Hi, Diana Davis from WSB here in Atlanta. Other than the signs and symptoms that you gave a few moments ago, is there any one thing at this early stage that stands out that can help either adults or parents of young children differentiate whether or not they need to see a physician? Fever? Onset? Degree of fever? Anything at this early stage?
>> One — one positive aspect in terms of timing is that we are — we are at the end stages of our seasonal flu period. If this outbreak had occurred in January or February, it would have been very difficult to detect because of all of the flu activity that’s normally going on. And so to say to every single person who had flu, they should see their doctor, would mean that a lot of people who have seasonal flu would be flooding doctors’ offices and other points of care. There isn’t anything that we’ve identified that distinguishes this type of flu from seasonal flu. And so those signs and symptoms, in particular, in individuals who have traveled since we do have an association with the outbreak in Mexico, that can be helpful. But I wouldn’t limit it to that because it’s really a minority of cases to date that we’ve been able to identify that travel history. And that, again, is information that makes us think that this is traveling from person to person and not just everyone that’s gone to a spot where this is taking place.Two more questions from the phone?
>> Thank you. Rob Stein, “The Washington Post,” please go ahead.
>> Thank you for taking my question. Yesterday the WHO was talking about mitigation. I was wondering if you could explain a little bit about what’s meant by that, and what exactly are you doing or would you do to mitigate the impact of this virus?
>> Thank you. When we look at global pandemic planning — and again, we’re in pre-pandemic phase four — in global pandemic planning, the initial concept is if you could identify an outbreak in its first spot, where it was first kicking off, you could send in teams and try and quench it, try and contain it, try and knock it out. And that’s been a lot of our strategy around avian influenza, with surveillance, trying to look and investigate every cluster that’s been taking place around the globe. That is not a feasible strategy here. And it’s not a feasible strategy because by the time this is identified, we’re already seeing this in a very diffuse, very wide geographic area. We’re hearing of cases from many different parts of Mexico. We have five states with confirmed cases here. And we’re hearing of many countries around the globe that have suspect cases. And so the idea of containment, meaning keeping it to one little place, is not feasible. This is a virus that spreads easily, person to person. Influenza viruses, in general, again, we’re learning more about this virus, but they spread easily from person to person. And in general, they can spread before a person is symptomatic. Again, here we need to look at the transmission with this particular virus. I wanted to give answers to two questions that I received earlier. The earliest onset date for a case here was March 28th. The latest onset date for a confirmed case in the United States is April 24th. But, again, there’s ongoing work, and we don’t have any evidence that there’s not been transmission since April 24th. If we’re looking at an incubation period of about two days, there’s a lag time before cases will present. And then the question about vaccine feed, it has not gone to the manufacturers at this point.
>> One more question.
>> One more question from the phone, and then the last question here in the room.
>> Thank you. Lauren Neergard of the Associated Press, please go ahead.
>> Yes, can I ask if you are abandoning the term “swine flu”?
>> You know, there’s a lot of discussion around what to call this. In the public, we’ve been seeing a fair amount of misconception, that by calling it swine flu, there could be transmission from pork products. And that’s not helpful. That’s not helpful to pork producers. That’s not helpful to people who eat pork. It’s not helpful to people who are wondering, how can they get this infection? When they hear that term, some people think this is transmitted that way. And so we’re discussing, is there a better way to describe this that would not lead to inappropriate actions on people’s part? So I don’t know what decision will be made on that. But any information you can share that this — when it’s described as swine flu, that’s the origin of the strain or one of the components of the strain. And not a reflection on how the disease is spread currently. Last question here in the room?
>> I understand that President Obama has requested $1.5 billion in emergency supplemental funding for swine flu. Do you know if that’s all destined for CDC? Did you make that request up the food chain? Do you know what it’s for?
>> I hadn’t heard that, but whenever there’s a public health emergency, there are requests in terms of emergency supplemental funding to support all the activities that are going on. And so each of the departments will look to see what activities are they undertaking? What will they need and put in requests. So I hadn’t heard that. Thank you very much.
>> Thank you. And this does conclude today’s conference call. We thank you for your participation. You may now disconnect your lines.