immunization in the time of h1n1 anne schuchat, md rear admiral, us public health service director,...
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Immunization in the Immunization in the Time of H1N1Time of H1N1
Anne Schuchat, MDAnne Schuchat, MDRear Admiral, US Public Health ServiceRear Admiral, US Public Health Service
Director, National Center for Immunization Director, National Center for Immunization and Respiratory Diseases and Respiratory Diseases
Centers for Disease Control and PreventionCenters for Disease Control and PreventionAtlanta, GAAtlanta, GA
Immunization Program Managers MeetingAtlanta, GA—January 20, 2010
ResponsibilityResponsibility
Responsibilities GaloreResponsibilities Galore
Presidential, State, CDC TransitionsPresidential, State, CDC Transitions American Recovery and Reinvestment American Recovery and Reinvestment
Act (ARRA)Act (ARRA) Vaccine Management and Business Vaccine Management and Business
Improvement Project (VMBIP)Improvement Project (VMBIP) Health Reform deliberationsHealth Reform deliberations
April 23, 20091st press
conference(N=7 cases)
CDC Emergency Operations CenterCDC Emergency Operations Center
UncertainUncertaintyty
Decision-Making in Decision-Making in Setting of UncertaintySetting of Uncertainty
Severity in Mexico vs. USSeverity in Mexico vs. US– Trinational team deploys to MexicoTrinational team deploys to Mexico– Field teams assist affected areas in USField teams assist affected areas in US
Frequent public and media Frequent public and media communicationcommunication– Risk communication principlesRisk communication principles– Acknowledge uncertaintyAcknowledge uncertainty
Immunization Planning in Setting of Uncertainty
Would there be vaccine?
Would it work?
One dose or two?
Would it arrive ‘in time’?
Would there be enough?
Would anybody want it?
Would it be safe?
Would people come to public venues?
Would providers be too busy caring for the ill to vaccinate the well?
Would the H1N1 vaccination program affect future seasonal vaccine use?
Anxiety
Guiding PrinciplesGuiding Principles
Minimize illness and deathMinimize illness and death Limit societal disruptionLimit societal disruption Direct greatest effort in ways that will Direct greatest effort in ways that will
have most impacthave most impact
SeveriSeverityty
60 Minutes Episode on H1N1 High School Athlete Luke Deval: H1N1 complicated by MRSA pneumonia
Teens and young adults Teens and young adults disproportionately affecteddisproportionately affectedFew cases among elderlyFew cases among elderly
2009 H1N1 (April - Jun)Seasonal 2007-08
*April 12-June 30
0-4 yrs5-9 yrs10-17 yrs18-49 yrs50-64 yrs65+ yrs
N=312N=3,930
0-4 yrs5-9 yrs10-17 yrs18-49 yrs50-64 yrs65+ yrs
Proportionality
Source: ED and CDC Confirmed School Closing Reports
0
100000
200000
300000
400000
500000
600000
700000
27-A
pr
28-A
pr
29-A
pr
30-A
pr
1-M
ay
4-M
ay
5-M
ay
6-M
ay
7-M
ay
8-M
ay
11-M
ay
12-M
ay
13-M
ay
14-M
ay
15-M
ay
18-M
ay
19-M
ay
20-M
ay
21-M
ay
22-M
ay
26-M
ay
27-M
ay
28-M
ay
29-M
ay
1-J
un
2-J
un
3-J
un
4-J
un
5-J
un
8-J
un
9-J
un
10-J
un
11-J
un
12-J
un
Date
Stu
den
ts D
ism
issed
(Y
ell
ow
)
0
200
400
600
800
1000
1200
Sch
oo
ls D
ism
issed
Students Affected Schools Closed
School and student dismissals related to 2009-H1N1, US, 2009
Updated school recs
1st school recs1st school recs
Toolkits: K-12, Higher Education, Toolkits: K-12, Higher Education, Childcare InstitutionsChildcare Institutions
CapaciCapacityty
Preparing for FallPreparing for Fall Strengthen monitoring systems Strengthen monitoring systems
– EDs, ICUs, Labs, schools, Southern Hemisphere EDs, ICUs, Labs, schools, Southern Hemisphere
Prepare for medical care surgePrepare for medical care surge– Self-triage, protect EDs, prepare ICUs Self-triage, protect EDs, prepare ICUs
Plan for multiple scenarios (severity, supply)Plan for multiple scenarios (severity, supply)
Communication & mediaCommunication & media
Preparing for Voluntary H1N1 Preparing for Voluntary H1N1 Vaccination Program Vaccination Program
ProductionProduction Clinical trialsClinical trials Planning Planning (enrolling (enrolling
providers, organizing providers, organizing mass & school clinics)mass & school clinics)
Vaccine distribution and Vaccine distribution and administrationadministration
Strengthening safety, Strengthening safety, efficacy monitoringefficacy monitoring
Communication planningCommunication planning
Cumulative Number of Provider Agreements, H1N1 Vaccine Program,
Sept 2009-Jan 2010
22
Pre-launch
Predictability
ScarciScarcityty
FlexibiliFlexibilityty
Place of VaccinationNHFS, Interviews Conducted November 2009
0
5
10
15
20
25
30
35
40
45
50
Doctor'sOffice
Clinic orHealthCenter
Hospital OtherMedically-
RelatedPlace
HealthDepartment
Pharmacyor Drug
Store
Workplace School OtherNon-
MedicalPlace
Medical LocationSeasonal 61%, H1N1 65%
Non-Medical LocationSeasonal 39%, H1N1 35%
H1N1
Seasonal
• Est. 61 million vaccinated in first three months• Highest coverage in children, pregnant women• Most doses went to target populations
HumiliHumilityty
Learning from the 1976 Experience
Pandemic
H1N1 Influenza Disease Burden H1N1 Influenza Disease Burden Estimates for Apr -Dec 18, 2009 Estimates for Apr -Dec 18, 2009
2009 H1N12009 H1N1 Mid-Level Mid-Level Estimated RangeEstimated Range
CasesCases ~55 million~55 million ~39 M to ~80 M~39 M to ~80 M
HospitalizationsHospitalizations ~246,000~246,000 ~173,000 to ~362,000~173,000 to ~362,000
DeathsDeaths ~ 11,160~ 11,160 ~7,880 to ~16,460~7,880 to ~16,460
Bumps in the RoadBumps in the Road
Vaccine strains grew slowly in eggs Vaccine strains grew slowly in eggs Messaging about vaccine supplyMessaging about vaccine supply Supply/demand imbalancesSupply/demand imbalances Perceived equity of allocations Perceived equity of allocations Potency declines Potency declines 2 product recalls 2 product recalls Others to come…? ? Others to come…? ?
Pandemic H1N1 Influenza Status• H1N1 decreased but not disappeared• Immunization coordinated at state and local levels
– Mix of private and public venues– Preparedness and immunization leadership– School-located and other mass vaccination,
also traditional medical and pharmacy settings– Evaluation for best practices critical
• Vaccination and surveillance continue this winter…
Pneumonia and Influenza Deaths, United States,108 Cities: 1957-58
Where Will Immunization and Where Will Immunization and Pandemic Preparedness Go Pandemic Preparedness Go
From Here? From Here?
Build on school- assoc vaccinationBuild on school- assoc vaccination New norms for pregnant & other adultsNew norms for pregnant & other adults Altered communication environmentAltered communication environment Sustain stronger links w/ health careSustain stronger links w/ health care Investments in vaccine development, Investments in vaccine development,
public health infrastructure? public health infrastructure?
Thank you!