Director’s Update Brief
Tuesday
09 JUN 2009 1100 EDT
Day 52
The Week of Epidemiology, Budget, and
Communications Analyses in Support of
Vaccination Campaign Planning
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 2
Situation Awareness
09 JUN 2009
•
Severe Weather
– Missouri, Nebraska, Iowa, Kansas, Illinois
Source: FEMA National Sitrep for 9 June, 2009
•
Other Public Health Events
– Earthquake: Adak, AK (8 June 09); No reports of damage or
injuries; No tsunami generated
Source: FEMA National Sitrep for 9 June, 2009
•
International
– Vibrio cholerae (Cholera) - Zimbabwe: 98,441 cases; 4,277
deaths; overall CFP=4.3% (as of 2 June 09)
– Influenza H5N1 Humans - Egypt: 79
th
case NAMRU-3
confirmed
Source: GDD Ops Center Daily Report 8 June 2009
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 3
Key Events
Novel Influenza A (H1N1) 09 JUN 2009
•
Novel Influenza A (H1N1) Declarations
– WHO: Pandemic Phase 5 (29 Apr 1600 EDT)
– USG: Public Health Emergency declared (26 Apr 2009)
– HHS: Downgraded to Phase 1 – Awareness (9 May 2009)
•
International Cases: 25,288 confirmed cases in 73 countries*
•
US Cases: As of 05 JUN 2009 (all states reporting cases)
Cases
Hosp
Deaths
13,217
1,027
27
52
41
10
SLTTs AFFECTED
US TOTALS
CASES
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 4
Epidemiology/Surveillance
Novel Influenza A (H1N1) Case Counts by State
As of 05 JUN 2009 0100 EDT
(n=13,217)
•
Secondary attack rate
in household contacts:
• ARI—19%
• ILI—12%
•
Generation time
:
• ARI—2.0-3.1 days
• ILI—2.4-3.1 days
•
Hospitalizations
: 1,027 (7.8%) as of 05 JUN 2009
•
Deaths
: 27 (0.20%) in 10 states as of 05 JUN 2009
•
Change from daily to weekly reporting as of 03 JUN 2009
– next update 12 JUN 2009
*indicates sites reporting aggregate data to CDC
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 5
201-400
51-200
1-50
0
401-1000
>1000
Epidemiology/Surveillance
Novel Influenza A (H1N1) Cases Reported to CDC by State
As of 05 JUN 2009 0100 EDT
(n=13,217)
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 6
Epidemiology/Surveillance
Rate of Novel Influenza A (H1N1) Reported to CDC per 100,000 Population
As of 05 JUN 2009 0100 EDT
(n=13,217)
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 7
Epidemiology/Surveillance
Novel Influenza A (H1N1) Cases by Report Date
As of 05 JUN 2009 0100 EDT
(n=13,125*) (Weekly**)
*No Date available for 92 cases.
**Data for week ending 6 June 2009 include reports submitted between 8:00 AM EDT 5/31/2009 and 1:00 AM 6/3/2009.217
0
0
5
19
915
2,144
1,879
1,710
3,289
3,164
0
500
1000
1500
2000
2500
3000
3500
4000
28
-M
ar
4-
Ap
r
11
-A
pr
18
-A
pr
25
-A
pr
2-
M
ay
9-
M
ay
16
-M
ay
23
-M
ay
30
-M
ay
6-
Ju
n
Week Ending Date
C
a
se
s
(n
)
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 8
Epidemiology/Surveillance
Novel Influenza A (H1N1) Cases by Age
As of 05 JUN 2009 0100 EDT
(n=13,217)
1,265
7,502
2,327
98
2,025
0
1000
2000
3000
4000
5000
6000
7000
8000
C
o
n
fi
rm
e
d
a
n
d
P
ro
b
a
b
le
C
a
s
e
s
(n
)
0-4 Yrs
5-24 Yrs 25-64 Yrs
≥65 Yrs Unknown
Age Groups
10%
57%
18%
1%
15%
Percentages represent proportion of total cases
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 9
Epidemiology/Surveillance
Novel Influenza A (H1N1) Cases per 100,000 Population by Age
As of 05 JUN 2009 0100 EDT
(n=13,217)
6.0
9.1
1.4
0.3
0
1
2
3
4
5
6
7
8
9
10
0-4 Yrs
5-24 Yrs
25-64 Yrs
≥65 Yrs
Age Groups
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 10
Epidemiology/Surveillance
Novel Influenza A (H1N1) Hospitalizations by Age
As of 05 JUN 2009 0100 EDT
(n=1,027)
18%
184
421
353
39
30
0
50
100
150
200
250
300
350
400
450
H
o
s
p
it
a
li
z
a
ti
o
n
s
(
n
)
0-4 Yrs
5-24 Yrs
25-64 Yrs
≥65 Yrs
Unknown
Age Groups
41%
34%
4%
3%
18%
Percentages represent proportion of total hospitalizations
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 11
Epidemiology/Surveillance
Novel Influenza A (H1N1) Hospitalizations / 100,000 Population by Age Group
As of 05 JUN 2009 0100 EDT
(n=1,027)
63%
22%
11%
0.9
0.5
0.2
0.1
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
H
o
s
p
it
a
liz
a
ti
o
n
s
p
e
r
1
0
0
,0
0
0
P
o
p
u
la
ti
o
n
s
(
n
)
0-4 Yrs
5-24 Yrs
25-64 Yrs
≥65 Yrs
Age Groups
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 12
Epidemiology/Surveillance
Novel Influenza A (H1N1) Deaths by Age Group
As of 05 JUN 2009 0100 EDT (n=27)
3
6
17
1
0
0
2
4
6
8
10
12
14
16
18
C
o
n
fi
rm
e
d
a
n
d
p
ro
b
a
b
le
c
a
s
e
s
(
n
)
0-4 Yrs
5-24 Yrs
25-64 Yrs
≥65 Yrs Unknown
Age Groups
States:
AZ - 4
CT - 1
IL - 5
MI - 1
MO - 1
NY- 8*
TX - 3
UT - 2
VA - 1
WA - 1
63%
22%
11%
*7 in NYC
Percentages represent proportion of total deaths
4%
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 13
Epidemiology/Surveillance
Novel Influenza A (H1N1) Hospitalizations Reported to CDC by States
As of 05 JUN 2009 0100 EDT
•
1,027 / 13,217 (7.8%) hospitalizations
•
Detailed clinical data available on 201 / 1,027 (19.6%) hospitalized
patients
– Median time from onset of illness to hospital admission
• 3 days (range 1-14 days)
– Median length of stay
• 3 days (range 1-53)
– Median days from admission to discharge or death
• 7 (range 2-65)
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 14
Epidemiology/Surveillance
Novel Influenza A (H1N1) Hospitalizations Reported to CDC
Clinical Characteristics
As of 05 JUN 2009 0100 EDT
(n=201)
30%
Sore throat
33%
Myalgias
35%
Chills
28%
Vomiting
33%
Rhinorrhea
42%
Fatigue/weakness
23%
Wheezing
29%
Headache
54%
Shortness of breath
21%
Diarrhea
84%
Cough
92%
Fever*
Percent
Symptom
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 15
Epidemiology/Surveillance
Novel Influenza A (H1N1) Hospitalizations Reported to CDC
Underlying Conditions As of 05 JUN 2009 0100 EDT (n=201)
71%
Any underlying condition
8%
Chronic Renal Disease
10%
Current Smoker
7%
Neuromuscular disorder
8%
Neurocognitive disorder
12%
Immunocompromised
11%
Chronic cardiovascular disease**
7%
Pregnant
16%
Diabetes
6%
Seizure disorder
3%
Cancer
32%
Asthma or COPD
Percent
Condition
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 16
Epidemiology/Surveillance
Novel Influenza A (H1N1) Hospitalizations Reported to CDC
Clinical Information As of 05 JUN 2009 0100 EDT (n=201)
(%)
Characteristic
36%
Treated with steroids
24%
Admitted to ICU
8%
Died
86%
Recovered
80%
Treated with antibiotics
72%
Treated with antivirals
9%
Dx with sepsis at admission
16%
Mechanical ventilation
9%
ARDS
41%
Chest radiograph with pneumonia at
admission
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 17
Epidemiology/Surveillance
Novel Influenza A (H1N1) - 05 JUN 2009
Surveillance Systems
•
WHO/NREVSS Collaborating Laboratories
– Seasonal influenza A (H1), A (H3), and B viruses co-circulated with
novel influenza A (H1N1) viruses
•
ILINet (week ending 30 May)
– % of ILI outpatient visits the national baseline
– Overall, the percentage of outpatient visits for ILI is decreasing
•
122 Cities Mortality Reporting System (graph)
– % pneumonia and influenza deaths not exceeding the epidemic
threshold
– % deaths due to pneumonia and influenza remains stable
•
Geographic Spread of Influenza as Assessed by State and Territorial
Epidemiologists – state reporting
:
Widespread: 4 states
Regional: 11 states
Local: 13 states + DC
Sporadic: 21 states
None: 1 state
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 18
Epidemiology/Surveillance
Novel Influenza A (H1N1) - U.S.
WHO/NREVSS Collaborating Laboratories Summary, 2008-09
0
500
1000
1500
2000
2500
3000
3500
1
0
/4
1
0
/1
8
1
1
/1
1
1
/1
5
1
1
/2
9
1
2
/1
3
1
2
/2
7
1
/1
0
1
/2
4
2
/7
2
/2
1
3
/7
3
/2
1
4
/4
4
/1
8
5
/2
5
/1
6
5
/3
0
6
/1
3
6
/2
7
7
/1
1
7
/2
5
8
/8
8
/2
2
Week ending
N
u
m
b
e
r
o
f
P
o
s
it
iv
e
S
p
e
c
im
e
n
s
-2
2
6
10
14
18
22
26
30
34
38
42
46
50
54
58
62
66
70
Pe
rc
e
n
t Po
s
iti
v
e
A(H1N1-Sw ine)
A(Could not be subtyped)
A(H3)
A(H1)
A(Unknow n)
B
Percent Positive
* Percentage of all positive
influenza specimens that are
Novel Influenza A(H1N1) or
Influenza A (unable to subtype)
for the week indicated
33%*
44%*
61%*
82%*
83%*
96%*
21 labs reporting
for current week
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NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 19
Epidemiology/Surveillance
Novel Influenza A (H1N1) – 05 JUN 2009
Percentage of Visits for Influenza-like Illness (ILI) Reported by
the US Outpatient Influenza-like Illness Surveillance Network (ILINet),
National Summary 2008-09 and Previous Two Seasons
NOTE: Week ending dates vary by influenza season
*Preliminary ILI data for week 21, as of June 5, 2009 (n=934 weekly ILI reports received from 48 states)
†
There was no week 53 during the 2006-07 and 2007-08 seasons, therefore the week 53 data point for those seasons is an average of weeks 52 and 1.
0
1
2
3
4
5
6
7
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
2006-07†
2007-08†
2008-09
National Baseline
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 20
Epidemiology/Surveillance
Novel Influenza A (H1N1) – 05 JUN 2009
Current Influenza Surveillance – ILINet Regions I-III
Region II - NJ, NY
0
2
4
6
8
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region III - DE, DC, MD, PA, VA, W V
0
1
2
3
4
5
6
7
8
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region I - CT, ME, MA, NH, RI, VT
0
1
2
3
4
5
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
2006-07
2007-08
2008-09
Baseline
NOTE: Scales differ between regions
NOTE: There was no week 53 during the 2006-07 and 2007-08 seasons, therefore the week 53 data point for those seasons is an average of weeks 52 and 1.
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 21
Epidemiology/Surveillance
Novel Influenza A (H1N1) – 05 JUN 2009
Current Influenza Surveillance – ILINet Regions IV-VI
Region IV - AL, FL, GA, KY, MS, NC, SC, TN
0
1
2
3
4
5
6
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region V - IL, IN, MI, MN, OH, WI
0
2
4
6
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region VI - AR, LA, NM, OK, TX
0
2
4
6
8
10
12
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
2006-07
2007-08
2008-09
Baseline
NOTE: Scales differ between regions
NOTE: There was no week 53 during the 2006-07 and 2007-08 seasons, therefore the week 53 data point for those seasons is an average of weeks 52 and 1.
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 22
Epidemiology/Surveillance
Novel Influenza A (H1N1) – 05 JUN 2009
Current Influenza Surveillance – ILINet Regions VII-X
Region X - AK, ID, OR, W A
0
2
4
6
8
10
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region IX - AZ, CA, HI, NV
0
2
4
6
8
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region VIII - CO, MT, ND, SD, UT, WY
0
1
2
3
4
5
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
Region VII - IA, KS, MO, NE
0
2
4
6
8
10
/4
10
/1
8
11
/1
11
/1
5
11
/2
9
12
/1
3
12
/2
7
1/
10
1/
24
2/
7
2/
21
3/
7
3/
21
4/
4
4/
18
5/
2
5/
16
5/
30
Week Ending Dates
%
o
f
V
is
it
s
f
o
r
IL
I
2006-07
2007-08
2008-09
Baseline
NOTE: Scales differ between regions
NOTE: There was no week 53 during the 2006-07 and 2007-08 seasons, therefore the week 53 data point for those seasons is an average of weeks 52 and 1.
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 23
Epidemiology/Surveillance
Novel Influenza A (H1N1)
Pneumonia and Influenza Mortality for 122 U.S. Cities
Week Ending 05/30/2009
4
6
8
10
12
21 30
40
50
10
20
30
40
50
10
20
30
40
50
10
20
30
40
50
10
20
Weeks
Epidemic Threshold
Seasonal
Baseline
2007
2008
2006
2005
2009
%
o
f
Al
l
D
e
a
th
s
D
u
e
t
o
P
&
I
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 24
Weekly Influenza Activity Estimates Reported
by State and Territorial Epidemiologists
Week ending May 30, 2009 – Week 21
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 25
Epidemiology/Surveillance - BioSense
Location of BioSense Emergency Departments (ED) Reporting Chief
Complaint and Final Diagnosis Data.
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 26
Epidemiology/Surveillance - BioSense
Percentage of Visits for ILI Reported by Emergency Departments
04/01/2009 to 06/03/2009: U.S.
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 27
International
Novel Influenza A (H1N1) 09 JUN 2009
New Countries with Confirmed Cases & Other Major Developments
•
New countries with confirmed cases (last 4 days):
Caribbean:
Cayman Islands, Dominica, Trinidad & Tobago, Barbados
Middle East:
United Arab Emirates, Saudi Arabia
Europe:
Luxembourg
•
Other major developments:
–
First death in the Caribbean:
Dominican Republic
• Pregnant 17 year old female with underlying disease
– India reporting first two cases of human-to-human transmission
• Both family members of individuals with foreign travel history (one to
NY, other unknown)
– ECDC reporting first case in South Pacific (French Polynesia) identified
in woman arriving from Los Angeles
– China CDC investigating possible transmission on 5/26 Cathay Pacific
flight from JFK to Hong Kong
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 28
International Case Count Map
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 29
Division of Global Migration and Quarantine
Novel Influenza A (H1N1) - 09 JUN 2009
Community Mitigation and Ports of Entry
•
Community Mitigation
–
CDC strategy for fall under development
–
Guidance documents for summer camp (in clearance) and
child care (in progress)
•
Ports of Entry
–
MMWR draft in development, on experience at POEs, April
– May, 2009
Internal Use Only (FIUO)---For Official Use Only (FOUO)
NOT FOR FURTHER DISTRIBUTION
-Sensitive But Unclassified (SBU) 30
Joint Information Center (JIC) Summary
Communication Surveillance
09 Jun 2009 0100 EDT
•
Channel Traffic 6/7-6/8
–
Web Page Views: 233,304 (-54%)
-Public Inquiries (CDC INFO): 89 (-67%)
–
Clinician Inq (CDC INFO): 8 (-64%)
-Print/Internet News: 108 (+47%)
–
Television Stories: 78 (-72%)
-Twitter: “Swine Flu”: 9.0/min (+257%)
•
Major News Media Themes
–
Quarantine: N.O. mayor in China, Student dorm, Ruby players in Australia
–
Local case counts and confirmed deaths
–
Information Gaps:
•
Scant information on public health guidance or health protection (despite
coverage of quarantine)
•
Public Inquiries (CDC INFO)
–
Symptoms of H1N1? (22%)
- Testing? (15%)
-Prevention (9%)
•
Twitter Topics
–
Quarantine
-Worry about new cases
–
-Difference between swine and bird flu?
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