CDC News Conference Transcript

Influenza Update

December 9, 2003

DR. GERBERDING: Good afternoon. Thank you for coming to attend this press briefing on the influenza epidemic this year. Let me first just start by saying that we know that some areas of the country are particularly hard-hit with influenza and it's been a very difficult and frightening thing for many people, particularly in the context of reports of vaccine shortages. We also know that many children have been affected. Some children and adults have already died this year, and that is of course something that we are very sad about at CDC, and our hearts go out to the families of those individuals.

Influenza typically kills more than 36,000 Americans each year, and some of those are children, some of those are seniors. It can affect people of all ages. And it's also important to recognize that, although there are people who suffer the severe consequences from influenza, most people who get influenza will have that typical mild illness. It will be annoying; they might miss a day of school or a day at work, but they will recover without incident. And so we're hoping that most of the people affected this year will fall into that category.

Now, let me say that what we know about the epidemic right now is that the flu is widespread in at least 13 areas of the country, 13 states. As of the end of last week, there were only two jurisdictions that had not reported any influenza. That was the Washington, D.C. area and the state of Massachusetts, although we wouldn't be surprised to see influenza there soon, if it hasn't arrived already.

We also recognize that the heaviest-hit states were mostly in the west, and that we are waiting to see whether or not some of the eastern states with large populations will see more widespread infection.

So the bottom line is that we have not peaked the flu season this year. We will expect more cases of flu. And we are watching very carefully to see where it's progressing and where the most cases are evolving so that steps can be taken to assure access to care, hospitalization, and so on and so forth.

The main concern that we're facing at CDC right now is, of course, the gap between the demand for flu vaccine in the context of the outbreak and the supply of the influenza vaccine. I'm going to say more about supply and demand and how those pan out in flu season, but I also wanted to address where we are right now with what's happened this year.

This year, manufacturers created about 83 million doses of influenza vaccine. About 4 to 5 million doses were in the formulation of FluMist, which is for healthy people between the ages of 5 and 49. Another 4 or 5 million doses was a pediatric formulation for children between the ages of 6 months and 23 months. Seventy-three million doses were the inactivated trivalent vaccine for adult immunization. That vaccine is something that has largely been distributed at this point in time. The manufacturers have very few doses of the killed virus. There are, however, almost 4 million doses of the FluMist, which is the intranasal vaccine, which can be available for healthy people, again between the ages of 5 and 49, who choose to receive that vaccine. Unfortunately, it's not licensed for children under 5 or for people older than 49 years of age this year, although possibly that would happen sometime in the future.

So one of the steps that we're taking at CDC in the context of manufacturers who don't have a flu supply when there's an ongoing demand is to look at how we can, first of all, purchase whatever doses are remaining. And Secretary Thompson has asked us to look into not only what we can purchase here in the United States, but also what might be available from a licensed vaccine in Europe. And we are doing that actively today, investigating what's out there and what's possible and available for purchase.

In addition, state and local health agencies are working on assessing the availability of vaccine in their jurisdictions and developing plan for redistribution, which we, of course, are helping to assist with. We have a number of data inputs and will be updating you with this information as we go forward, about the localized availability of vaccine.

We're working with the state health association, with local and county health departments, with the American Medical Association and the American College of Physicians, American Association of Health Plans, managed care organizations, and several other groups who are serving practitioners, serving hospitals, serving member facilities trying to ascertain where there is vaccine, where there's not vaccine, and what can be done to facilitate local redistribution.

All of that is ongoing in the majority of states right now. We are receiving some reports of shortages, but we are also receiving reports from many jurisdictions where there is no apparent shortage and people can still access vaccine.

Now, for people who are at highest risk of influenza complications--let me stress that those are people over age 65 years old who have the highest risk, as well as people with chronic medical conditions, and children between the ages of 6 months and 23 months. We are still encouraging people to be immunized and to be persistent about locating vaccine.

Our current recommendations for immunization this year included all people over age 50 in the recommended category. The main reason for that was because there's an enrichment of chronic diseases in people who are over age 50 years old. It was a simpler recommendation to simply say everyone over age 50, get vaccinated, than to try to hone in on the specific chronic illnesses that would be in that group. But we are recommending that the priority be given to people at the highest risk for complications.

And so we're certainly not restricting vaccine access to anyone at this point in time, but, like all situations, when there is a possible shortage, we want the people who need the vaccine the most to be the first in line to receive it. And I think we're getting good cooperation with that across the country at this point in time.

I would like to spend a little bit of time explaining why this situation evolved. Obviously, at CDC and elsewhere in the Department of Health and Human Services, we wish we had more vaccine. We wish the manufacturer had made more vaccine this year. And unfortunately, that isn't the case. So we're faced with a demand for the vaccine that exceeds the current supply, at least in some areas.

The manufacture of flu vaccine in this country is entirely in the private sector. When you have a measles vaccine development, you know exactly how many children are born every year and you can accurately predict exactly how many doses of measles vaccine you might need. And the manufacturer can make a good assessment of, okay, we'll make this many doses because we know we'll sell them.

Influenza doesn't work that way. Our best estimate is that there are probably about 185 million people who would be included in our recommended groups for receiving influenza vaccine. That would include the high-risk people as well as the contacts, the household contacts and the health care workers who take care of those people. But we don't have a completely accurate assessment of the number of people because those populations change and they're difficult to pin down and it's very tricky up front to know exactly how many people need it.

Having said that, no year have we ever vaccinated anywhere near that number of people. Generally, the top number of people who come forward for flu vaccine is somewhere around 70-75 million people. So each year, the manufacturer has to, really, look back on how many people got vaccinated the year before and make a guess about how many people will be vaccinated this year.

For the last five years we've thrown a lot of flu vaccine away. For example, last year, the manufacturer made 95 million doses of vaccine; we threw away 12 million doses. And that's how they arrived at the decision basically to make 83 million doses this year, because that was a pretty high-water mark and it made sense that the manufacturer would be likely to sell that many doses.

Unfortunately this year we're dealing with a situation where the flu season started early and, because the predominant flu strain circulating right now is the H3N2 strain, the Fujian strain, we are concerned, although we haven't proven this yet, that this could be an especially severe flu season. More people have stepped up to the plate to get their vaccines than they did last year, and probably more people have stepped up to the plate than they have in recent years. So the manufacturer's estimate of the appropriate amount of vaccine to make may have undershot the mark. And that's one of the consequences of having the vaccine manufacturing occur this way, in the private sector.

So we are in a situation where we want to do everything possible to redistribute, to identify the shortages, to communicate what we know about the evolving epidemic, and to help practitioners and health officials make locally prudent decisions. But at the same time, we're not able to manufacture more vaccine right now. It takes many weeks to develop new vaccine, and even if we started today, we wouldn't have new flu vaccine until the end of the flu season. And unfortunately, that would cut into the product of flu vaccine for next year's flu season. I'll explain why that is.

How we know what's in flu vaccine is to look at the flu strains that appear toward the end of the last flu season. And it's a race. We've got to find the strains, we've got to characterize those strains, they have to be grown in tissue culture and grown in eggs because the manufactured virus comes from egg cultures. And all of this has to happen very, very quickly because it takes awhile for the vaccine production to occur and for the many steps that have to deal with the purity, the concentration, and the overall product security of the vaccine that emerges. And that all has to happen in time for the product to be distributed and available for people before the beginning or at the beginning of flu season.

But we really need to know what's going to be in the next year's flu vaccine by somewhere around February if we're going to go through all those steps in time to make the vaccine available and distribute it. And that's really tough to do as the situation evolves. We can have a little more lead time in some years, but you've got to have a pretty good guess and get the ball rolling.

So that's part of the reason why this year's vaccine does not contain the Fujian strain, because it came up late in the season, we had trouble growing it in eggs, and so it couldn't be produced in time to make it into the vaccine that we're distributing right now.

Having said all that, the vaccine strain, the H3N2 Panama strain, is a very close match to the Fujian strain. This happens periodically, where there's a slight mismatch between what's in the community and what's in the vaccine. Our experience so far has been that the vaccine will still offer protection, although we won't know for several weeks or months exactly how close that cross protection is. We are initiating some studies to make sure that we'll have an answer to that question as we go forward.

So the situation, again, is that we have a flu season that's getting off to a rapid start. It has not reached what we call the epidemic threshold yet in terms of deaths from influenza-like illness, but we wouldn't be surprised to see that happen, given the pattern that's emerging right now. What we can say is the good news is we've probably vaccinated more people than we ever have before against influenza, and that means more people than ever are protected. But the unfortunate situation is that there are still localized shortages, and we've got to take steps to address those shortages.

We have been concerned about this happening in the past. There have been years when the vaccine manufacturer couldn't make enough influenza, and there were shortages. There are other mitigating circumstances that sometimes puts us in this situation. The Department of Health and Human Services and Secretary Thompson have developed a plan to try to address bad influenza, or pandemic influenza, and the administration has requested from Congress an appropriation of $100 million to address pandemic flu. Our budget is obviously not out of Congress yet, so we're not sure whether or not those resources, or what proportion of those resources might be made available in fiscal year '04.

But I think this is a problem that we've anticipated and we're taking the appropriate governmental steps as well as right now, in this kind of urgent situation, the appropriate public health steps to do everything we can to help people get through the flu season with the fewest complications possible.

So a lot of information is going to be coming forward. We'll have an MMWR report probably this week that will give you some updated information. And we'll just do the best we can to keep you apprised of the situation as it unfolds over the next several weeks.

Thank you, and I'll be ready to take some questions.

QUESTION FROM MIRIAM FALCO, CNN: A few quick questions. Number one, are we finding that the children--there's a lot of reports of children being ill and some of them dying. Are they having a particularly difficult time with the Fujian strain? And is there any way--you've detailed how the vaccine production is done. Is there any way to--have there been any new developments on how to even produce vaccine? It seems almost old-fashioned. Is there a way to do it quicker? We spoke to one of the manufacturers, and they're evidently already working on the next year's batch. So what can you tell us about those two topics?

DR. GERBERDING: Thank you. Yes, there are reports of children with serious influenza and deaths among children from influenza. And that is something that is very sad and also something that we're evaluating very carefully to determine whether or not there's anything about this particular flu strain that's preferentially affecting children or causing more severe disease in children. We don't know the answer to the question yet. It is common for children to develop severe influenza and for deaths to occur in every flu season, unfortunately, so it will take us some time to figure that out.

One thing that is important to appreciate, that when severe flu occurs, usually it causes pneumonia in those people who have to be hospitalized. But a common cause of more severe illness and death is the bacterial infection that can complicate the viral influenza illness. And some of the children who have died have had complicating bacterial infections.

So, again, that's not unusual, but it's something that is undergoing evaluation as we go forward into the flu season. And as we learn more about that, we'll be sure to let people know so the clinicians can anticipate any changes in practice.

There are other technologies available for making influenza vaccine, or at least theoretically available for making influenza vaccine that don't rely on egg culture. One of them is to use mammalian tissue cultures. Right now, the mammalian tissue culture system sometimes has difficulty in producing a large enough number of variants to make it feasible to create a widespread production of vaccine from that methodology. But part of what Secretary Thompson has requested in the pandemic plan is additional resources so that we can invest in the research necessary to improve that production mammalian cell line.

In addition, there's a methodology called reverse genetics, where the specific parts of the flu virus that change every year and initiate the immune response can be genetically inserted into a background organism that can be grown very easily and very quickly. That's not proven to be an effective strategy, but it's something that, again, investments in research as well as investments in the private sector could help make possible.

So in terms of our supply of vaccine, there are scientific issues around the methods for creating the vaccine and taking advantage of modern technology. But in addition, there are financial issues having to do with the fact that manufacturers don't want to throw away vaccine. Last year, for example, if the dose of vaccine sold for $10 and they threw away 12 million doses, that's $120 million of lost revenue to that corporation. And so the trick here is what can we do as a federal agency to assure that the manufacturer will make more doses than we need on average so that when we have a year of increased demand, we have the extra doses we need to avoid this kind of shortage. Those are exactly the kinds of things that Secretary Thompson has asked us to provide some recommendations to and the kinds of things that we included in the request for pandemic influenza support.

Let me take a question from the telephone, please.

OPERATOR: Thank you. Jeremy Manier with the Chicago Tribune.

QUESTION: Thanks, Doctor. I guess one of the things we were interested in is a little bit more on the blow-by-blow of how this year's formulation was arrived at. And exactly what was the issue with--difficulty with growing it in eggs? Was this just--I mean, this strain has appeared in this country before, right, and they've made vaccines for it? Or has it not been here before?

DR. GERBERDING: Let me just explain again how the situation works. When flu season is ongoing, the World Health Organization and multiple laboratories around the world sample patients with influenza and they collect the virus strains and characterize their strain type. Then they do the additional detailed molecular work to really determine whether it's the Fujian strain or Panama strain or any other specific strain of virus.

The viruses are usually grown in tissue cultures at that stage because they usually can readily infect tissue culture cell lines. But in order for a vaccine right now in our current approach to vaccine preparation, the only way to get a flu strain into production for vaccine is to grow it in eggs. And viruses are finicky. They don't always grow well in eggs. For example, some avian influenza viruses which, you know, are lethal in chickens have a terrible time growing in chicken eggs because they kill the cells that they're trying to grow in. So this is just a complication of this particular vaccine methodology.

And we were, obviously, able to grow the Fujian strain in eggs, but it just took longer than expected to get that production up and running. And so it was difficult to move into the production of that particular vaccine strain. And the decision makers, which include experts at the Food and Drug Administration and their advisory group experts from the AMA, from a variety of other organizations, including the World Health Organization, really kind of independently but simultaneously made the decision that it would not be prudent to try to race to get the Fujian strain in this year because it could jeopardize the whole vaccine production and we would end up starting the year with no vaccine at all.

I'll take another question from the telephone, please.

OPERATOR: Your next question comes from Daniel Denoon with Web M.D. You may ask your question.

QUESTION: Thank you, Dr. Gerberding. Is there--we've seen reports about unusual symptoms of the flu from stomach cramps, for example, in adults and also some mental status changes in children. Is there anything unusual about this appearing this year? And would you please comment on whether the multidrug-resistant staphylococcus-type infection is complicating flu this year in a way we haven't seen much of before.

DR. GERBERDING: Thank you. Influenza is a spectrum of illnesses. Sometimes people are asymptomatically infected or typically have a minor systemic illness, but the range of symptoms certainly does include gastrointestinal illness, sometimes diarrhea, cramping, abdominal pain, and other symptoms. So the abdominal symptoms are certainly not out of proportion with what one might see in a typical flu season.

In children who are severely ill or have fever, there are many things that may be related to influenza per se or to fever or to complicating infectious disease or other problems that might be present in a hospitalized patient that could cause mental status changes, so-- I don't know the specifics of the cases you're reporting, but if there is anything unusual, I'm sure the investigations we're doing of the children with the severe disease will be looking into that.

You also asked a question about drug-resistant staphylococcal infection complicating flu. Staphylococcal organisms in general are often seen in association with influenza. And when a Methicillin-resistant or a drug-resistant staph infection is common in the patient population or common in the community, it's not surprising that that would be the kind of staph that would complicate influenza.

And so there are some reports. I don't have documentation of that. I'm not aware that we have the organisms here at CDC. But it would not be at all surprising to see a drug-resistant staph infection complicate either a child or an adult with influenza. So not a surprise, but something that just adds an additional complexity to the treatment.

I'll take a question here.

QUESTION: Thank you, Dr. Gerberding. Betsy McKay of Wall Street Journal. You said earlier that one of the things you're doing is looking for additional vaccine supplies overseas, mainly Europe. Could you tell us a little bit more about that? What products might be able to be licensed in the U.S., if the rules about licensing might be changed for this year, and how much vaccine do you think you can get?

DR. GERBERDING: Well, first of all, the whole world is functioning pretty much in the same sort of time frame that we're functioning on here in the United States, at least in the Northern Hemisphere, because we are all in flu season and so this is not the time to begin production of a new flu vaccine without interfering with next year's production.

In the United States, vaccine manufacturer Aventis has a few doses of influenza left. I can't say how many right now, but we're looking into the possibility of securing those so that we can assist in redistribution to high-priority areas if necessary. There is a European manufacturer of influenza vaccine in the U.K. They do have less than a half-million doses that might be available. That product is licensed in the United States, but it's not cleared for use because it hasn't gone through all the stages of approval. So again, we're working with FDA and the company to see whether or not it would be safe to get that vaccine into the United States in time to have any impact on this year's flu season.

Other manufacturers have vaccine that is not licensed, and it would be impossible to get that vaccine to the United States--it might not be safe to get it to the United States--in time to make any difference in this season.

But remember, again, for healthy people between the ages of 5 and 49 who want to be vaccinated, there's also FluMist, the intranasal vaccine that still is available. And that's something that certainly an option for people who want to reduce their risk of illness but want to help us retain the injectable vaccine for those people who are at high risk from

flu complications.

Let me take a question from the phone, please.

OPERATOR: Robert Bazell with NBC News. Your line is now open.

QUESTION: Thank you. CDC issued a press release, Dr. Gerberding, on Friday afternoon, over your name, which said that--still said that people 50 and over should be getting the flu vaccine and that household contacts of people 50 and over, and the other usual list of people who have long been considered at high risk. Have you changed your policy in response to a shortage? Is there a new policy? Are you saying who should get vaccine and who shouldn't? And are, even with the list of people you now have, are you saying vaccine--what--do you have any idea how many of these people are going to be able to get vaccinations if they do go seek it, even with the amount of extra effort that you're suggesting?

DR. GERBERDING: Well, as I said, Bob, the number of people eligible to receive flu vaccine under our recommendations is about 185 million people. We know for sure that there are people out there who meet the criteria for our immunization who are not going to get vaccinated this year and who wouldn't normally have gotten vaccinated in any circumstances based on our past 10 years of vaccination. But whether or not there are people who want to be vaccinated or whose clinicians are encouraging them to be vaccinated, who can access the vaccine, is something that we're in the process of actively assessing.

The official recommendations for people who are recommended to receive vaccine is exactly as we stated in our press release. Those are people over age 50, people with chronic conditions, people between the ages of 6 months and 23 months, health care workers and other contacts of people in those high-risk groups. But given the fact that at the local level there are clinicians who have patients who need vaccination and they have access to limited supplies today, it only makes sense that they would put the emphasis on the people with the advanced age or the chronic medical conditions or the little children, because those really are the people most vulnerable.

Healthy people with no chronic medical conditions between the ages of 50 and 64 may be at a slight increase of influenza complications, but not nearly the risk that people with underlying diseases are. So we're certainly asking people to use some common sense and look at this as a supply and demand issue.

We wish we didn't have to have these caveats, but the reality is right now we have a gap between what we wish we had and what we have, and we're just doing the best we can to try to get the vaccine to the people who need it the most.

I'll take a question over here.

QUESTION: Hi. David Wahlbergfrom the Atlanta Journal-Constitution. Does the situation with you, with the vaccine shortage, suggest that the government should consider stockpiling some of the vaccine each year? And/or are there any other changes the government could make to alleviate this in the future?

DR. GERBERDING: Well, we are certainly looking at options that would help us have a surge capacity to add more vaccine to the system if we needed to. Obviously, the manufacturer is not eager to make more than they need if they have to throw it away and lose money on it. So one of the options is for the federal government to either purchase vaccine or to guarantee that if there's unsold vaccine, that we would pay a price for it to protect the manufacturer in the back.

And that's an option. It's not a decision at this point in time. We all have to recognize that it will be expensive, because most years we will throw away vaccine.

So our dilemma from a public health perspective, is how do we get all of those 185 million people vaccinated and at the same time how do we get the vaccine manufacturers to not put themselves at financial risk for making more vaccine than they're going to be able to sell?

We all recognize this is a dilemma, and we are exploring both the practical aspects of the solution, as well as the financial implications, and that's part of the reason why we have to work with the administration and work with Congress to see how we can prevent this from happening in the future.

Let me take another telephone question, please.

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

QUESTION: Thank you.

Dr. Gerberding, let's see, I have a couple of questions. One of them is about vaccine failure rates. Have you had any reports about how much that's occurring? And I also wanted to ask about the pandemic influenza plan that you mentioned, $100 million, if that goes through, would that then allow state health departments to better track annual flu or would it just kick in for pandemic?

And then I'll go off the line, but I do have one more question, but I'll try to come back later. Thanks.

DR. GERBERDING: Let me just address those two questions.

First of all, in terms of vaccine failures, every year there are vaccine failures, even if there's a perfect match between the vaccine and the strains of virus that are circulating in the community because the vaccine is not 100-percent efficacious. So we have situations this year where we are evaluating the possibility of vaccine failure, but that's not at all unusual. We won't be able to say anything concrete about the efficacy of this year's vaccine until we are much further into the flu season, and we have much more data than we have right now, but obviously it's an important question that we're working hard to evaluate.

The second question, I forgot. Can you come back on and ask me the second question?

QUESTION: Are you there? Can you hear me?

DR. GERBERDING: I can hear you.

QUESTION: It was about, I was wondering about the pandemic flu preparedness plan and whether or not that would allow states to better track annual flu or would it just be for pandemic, something kicking in?

DR. GERBERDING: We actually have a system for monitoring flu activity that has served us very well, and it was based on a set of sentinel areas in the country that we have assessment of influenza-like illness, and influenza [inaudible] and influenza-like illness. That system has, time and time again, been a reliable marker of flu activity and has been very useful to us in terms of planning and predicting where the disease is moving, and that system is in full force right now. So we already have I think a fairly robust surveillance system.

What we would like to have is of course an expanded network to do even more assessment of the strains of flu. We have had some preliminary discussions here about is there anything else that we could do earlier in the flu season that might help us know more about efficacy early on, but there are a lot of technical aspects, scientifically, methodologically challenging aspects of that question that we have not really resolved to see if we could do any better.

I think the pandemic, meaning a global outbreak of large-scale proportions such as we saw early last century, is what the pandemic flu plan is intending to address. But the same capabilities that we would need in the case of pandemic influenza would also serve us very well in years where we didn't reach that level, but where we had an especially severe flu season, and that would include rapid evaluation of the involved strain and capacity to enhance our vaccine production in real time so that if we saw that we were heading into a situation where supply could be exceeded by demand, we would be very quickly able to respond to that, and that's really what I think the ultimate goal here is and what we're requesting, at least the starting point, for the plan that is in--actually, the pandemic plan is still in draft form, but we all recognize there are certain elements, such as the research investment in new vaccines, methodologies, investments in surge capacity or surge protection that will be fairly generically relevant.

Is there a question here in the room? Over here?

QUESTION: Actually, I have two questions. Sabrina Gibbons with WSB Radio.

Is the flu vaccine that you are considering purchasing from Europe the same vaccine that we have here? And then I have questions about flu mist because that is a live virus. I know that health care professionals shouldn't get that, from what I understand. Is that safe, since it is a live virus, and should parents be concerned about giving it to children, say, over five? So what are the pros and cons of flu mist?

DR. GERBERDING: The European vaccine that we're looking at has the same strain protection as the vaccine that we're using here. So, while it's a different manufacturer, it was created using the same principles and decisions that were made to create the strain that we're using here.

The question about flu mist is a very good one. Flu mist is a live attenuated virus, unlike the vaccine shot, which is a killed influenza virus, and it's attenuated in more than one way, but one of the ways is that it doesn't grow very well at certain temperatures, and so it's very unlikely to cause severe disease, but because there is a concern that in an immuno-suppressed individual perhaps there could be greater potential for even an attenuated virus to cause severe disease or an influenza-like illness. It has not been recommended for people in those groups, but in addition, health care workers who take care of people in those groups, according to the package insert, should not have contact after they've received the intranasal vaccine.

I think that, given this is a relatively new product, that's a prudent recommendation right now, but I would also say that when someone has influenza, real influenza, we don't say go home for 21 days. We ask people to practice good respiratory hygiene, and good respiratory hygiene means staying home when you're sick. If you have a fever in a respiratory illness, you shouldn't go to work. You shouldn't go to school. Your kids shouldn't go to day care. They ought to be home so that they're not serving as a threat of transmission to others.

Good respiratory hygiene also includes washing your hands or cleaning your hands and covering your mouth and nose when you cough, the kinds of things you learn in kindergarten, but I think this flu season we all ought to be especially mindful of our responsibility to not only protect ourselves and our families, but also to avoid serving as sources of spread of respiratory illnesses to other people.

Do you have a question here?

QUESTION: I'm Beth Galvin with Fox 5 News. I just had a couple of questions.

One, from what you've seen so far, how worried are you that we could have a major epidemic this year?

And, secondly, for people trying to find the flu shot, what's your best advice for them for people that are having a tough time finding shots?

DR. GERBERDING: We're obviously still tracking the situation, and so this will evolve as we go forward, and I don't have that crystal ball that I always wish I had, so I can't really tell you where this is all going to go this year. But the fact that the flu was widespread in so many states this early in the year, and we've got a lot more states that are just coming into the transmission in that area, it's not going to surprise us if we see that we have more cases than average this year.

And because the strain is an H3N2 strain--at least the predominant strain right now is H3N2 strain--and historically that has sometimes been associated with more severe disease and more hospitalizations, it's not going to be surprising if that's the case, but we just don't have enough information to really say.

As I said at the beginning, because we have been monitoring influenza for so many years in the country, we've made some statistical decisions about what level we would say, okay, we're above epidemic threshold right now for influenza-like illness-associated deaths. And as of the end of last week, we hadn't reached that threshold. We'll be following that as we go forward.

What people can do is, first of all, obviously, contact your own clinician and determine whether or not you need flu vaccine or whether it's indicated. That's the first step. If the clinician doesn't have the vaccine, there are options for them to contact local health agencies and recognize that you have to be persistent, and that's something that, until we have more information from practitioners and we can provide a little bit better guidance about where the shortages really are, and we're not going to be able to give specific people specific information. But even if we're able to even out the supply across the country, we just need to be prepared for the fact that there may be shortages, and some people who would like to receive the flu vaccine this year may not be able to get it.

But there are other things people can do. As I said, there are things, you can protect yourself by avoiding situations where you would be exposed to ill people and by practicing good respiratory hygiene, and those things really do work. So it's not a hopeless case here, and I also think it's very important to, again, remember that the vast, vast, vast majority of people in this country who get influenza are going to be annoyed by it, but they're not going to suffer any of the serious consequences.

So one last very important thing is that there's treatment for influenza. We have four antiviral drugs that are effective against influenza, and so if people do get ill or require a visit to the physician or hospitalization, in particular, with a severe case of flu, treatments are available, and that can make a big difference. So it's not that it's only a vaccine-dependent intervention; there are other things that we can do as well.

Let me take a question here.

QUESTION: Don Dornberg with MetroSource News.

If we do move into a redistribution mode, presumably there might be health care providers that want to protect their supply, do you see it being done on a voluntary basis or is there an authority like CDC that's going to have to come in at some point and say this will be done, this one will be moved to--

DR. GERBERDING: You know, we've been in this situation several times in the past, and it generally operates sort of on the "good citizenship" level, where people who have extra flu vaccine and don't need it do willingly make it available, and the state health department is very key in helping to broker that because they can fairly easily figure out where there are areas of surplus and where the most, not just where the shortages are, but where the shortages are that have the most clinical relevance really are. So that's what we're relying on.

But at the moment, as of today, we don't have enough information to really know are there millions of doses out there that haven't been claimed or are there thousands of doses that haven't been claimed yet, and that's what we're working so hard with all of these different organizations to assess.

The reason we don't know this as rapidly as we'd like to is because think about you can go to some drug stores and get flu vaccine. So it's distributed so far out into the health care delivery system, it's very difficult to know where every vial of vaccine is, and it's just not something that we've invested in tracking because it's very, very difficult to do.

So we're relying on sort of a sentinel survey mechanism, and we're getting input from a lot of different sources that will help us I think very quickly over the next few days to know if we've got a lot or a little left.

I'll take another telephone question, please.

OPERATOR: Thank you. Seth Borenstein from Knight Ridder, your line is now open.

QUESTION: Thank you, Dr. Gerberding.

Two quick questions:

First, if you can talk about the supply and the possibilities of stockpiling the four antivirals because I guess they can be used as a--I know they can be used in prophylactic methods, and would you use that?

And the other is do you have the ability, if this "good citizenship" doesn't work, to say, okay, now, only the people who are recommended can get this? And have you considered using that ability?

DR. GERBERDING: The ability to ration a vaccine is one that is really left to the discretion of the health officials in the involved jurisdiction. The state health officials and the local health officials can help define that. We're not at a point today where we're refusing to vaccinate anyone, and that's something that's really, that's determined by a recognition of who's at high risk for complications, what the local supply issue is and what individual patient's risk characteristics really are.

I know you asked me a first question, and you'll have to refresh my memory on that as well.

QUESTION: Four antivirals that can be used for flu and what's the situation of their supplies, and since they can be used prophylactically, are you looking at using them prophylactically?

DR. GERBERDING: It's important to appreciate that these antivirals can be used prophylactically, but generally the way we use them prophylactically is to give them to people who are exposed, for example, in an institutional setting or at risk for complications and they've had close contact with someone who is known or likely to have flu. So use them for short periods of time; at the same time while we vaccinate the individual.

So it's not feasible to prophylax the large population of people continuously throughout the entire flu season with antivirals. That's not how they're recommended, and that would not really be a prudent use of that resource. But for short-term prevention or to cover somebody who's in a high-risk situation temporarily, we have a supply of antivirals that would meet those needs.

We have investigated the possibility of adding antiviral medications to our stockpile in the same way that we're talking about whether or not that's a good option for influenza vaccine, but no decisions have been reached on whether or not that would be helpful or not at this point in time.

A question here?

QUESTION: [Inaudible] with Fox News. Thank you, Dr. Gerberding.

You had mentioned earlier that we had not yet reached the level of epidemic and that there were specific thresholds. What are those thresholds? How close are we? If we were to reach them in this country, what are the next steps for the CDC? Where do you go from here?

DR. GERBERDING: The threshold depends a little bit on where we are in the flu season. Maybe I could get back to you after this is over and give you the map of how that really pans out. It's something that I think was referenced in last week's MMWR, if I'm not mistaken. So we can show you on a diagram, it's just, you know, there's an annual increase in flu that over time statistically creates a predicted number of influenza-like illness cases and deaths, and so from a statistical standpoint, if you're above a certain percentage at a particular time of year, then we say you meet the epidemic threshold, but it's sort of a statistical calculation and probably not very relevant since, in many parts of the country right now, we know there is a flu outbreak, and that's what people need most to be focused on.

DR. GERBERDING: I'll take a phone question--actually, one last phone question.

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

QUESTION: Hi, Dr. Gerberding. Thanks for doing this.

Just a quick question. The company in the U.K. that you're trying to buy vaccine from, what's the name of that company?

DR. GERBERDING: Chiron. And I did not state that we were trying to buy vaccine from them. I said that we're aware that they have vaccine, and we're exploring whether or not that's a sensible thing for us to do and whether or not we would be able to clear that vaccine for use in the United States in time to have any impact on this year's outbreak. That's something we're just taking the initial steps to explore with the FDA at this point in time.

Thank you very much for your attention. Obviously, this is a moving story here, and when we know more about supply, and we know more about demand, and we know more about the epidemic, we'll be sure to update you.

Thank you.

[Whereupon, the press briefing was concluded.]

Listen to the telebriefing

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