1. Immunization in the Time of H1N1 Anne Schuchat, MD Rear Admiral, US Public Health Service Director, National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention Atlanta, GA Immunization Program Managers Meeting Atlanta, GA—January 20, 2010

2. Responsibility

3. Responsibilities Galore  Presidential, State, CDC Transitions  American Recovery and Reinvestment Act (ARRA)  Vaccine Management and Business Improvement Project (VMBIP)  Health Reform deliberations

4. April 23, 2009 1 st press conference (N=7 cases)

5. CDC Emergency Operations Center

7. Uncertain ty

8. Decision-Making in Setting of Uncertainty  Severity in Mexico vs. US –Trinational team deploys to Mexico –Field teams assist affected areas in US  Frequent public and media communication –Risk communication principles –Acknowledge uncertainty

9. 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?

10. Anxiety

12. Guiding Principles  Minimize illness and death  Limit societal disruption  Direct greatest effort in ways that will have most impact

13. Severity

14. 60 Minutes Episode on H1N1 High School Athlete Luke Deval: H1N1 complicated by MRSA pneumonia

15. Teens and young adults disproportionately affected Few cases among elderly 2009 H1N1 (April - Jun) Seasonal 2007-08 *April 12-June 30 0-4 yrs 5-9 yrs 10-17 yrs 18-49 yrs 50-64 yrs 65+ yrs N=312 N=3,930 0-4 yrs 5-9 yrs 10-17 yrs 18-49 yrs 50-64 yrs 65+ yrs

16. Proportionality

17. Source: ED and CDC Confirmed School Closing Reports School and student dismissals related to 2009- H1N1, US, 2009 Updated school recs 1st school recs

18. Toolkits: K-12, Higher Education, Childcare Institutions

19. Capacity

20. Preparing for Fall  Strengthen monitoring systems –EDs, ICUs, Labs, schools, Southern Hemisphere  Prepare for medical care surge –Self-triage, protect EDs, prepare ICUs  Plan for multiple scenarios (severity, supply)  Communication & media

21. Preparing for Voluntary H1N1 Vaccination Program  Production  Clinical trials  Planning (enrolling providers, organizing mass & school clinics)  Vaccine distribution and administration  Strengthening safety, efficacy monitoring  Communication planning

22. Cumulative Number of Provider Agreements, H1N1 Vaccine Program, Sept 2009-Jan 2010 22 Pre- launch

23. Predictability

25. Scarcity

29. Flexibility

32. Est. 61 million vaccinated in first three months Highest coverage in children, pregnant women Most doses went to target populations

33. Humility

34. Learning from the 1976 Experience

35. Pandemic

38. H1N1 Influenza Disease Burden Estimates for Apr -Dec 18, 2009 2009 H1N1 Mid-Level Estimated Range Cases ~55 million ~39 M to ~80 M Hospitalizations~246,000 ~173,000 to ~362,000 Deaths ~ 11,160 ~7,880 to ~16,460

39. Bumps in the Road  Vaccine strains grew slowly in eggs  Messaging about vaccine supply  Supply/demand imbalances  Perceived equity of allocations  Potency declines  2 product recalls  Others to come…? ?

40. 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…

41. Pneumonia and Influenza Deaths, United States, 108 Cities: 1957-58

42. Where Will Immunization and Pandemic Preparedness Go From Here?  Build on school- assoc vaccination  New norms for pregnant & other adults  Altered communication environment  Sustain stronger links w/ health care  Investments in vaccine development, public health infrastructure?

43. Thank you!