Directors Update Brief Wednesday

20 May 2009 1100 EDT

Day 32
Day of Supplemental

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Novel Influenza A (H1N1) Key Events 20 May 2009

Novel Influenza A (H1N1) Declarations WHO: Pandemic Phase 5 (29 Apr 1600 EDT) USG: Public Health Emergency declared (26 Apr 2009) SLTT Declarations: 11 CA, TX, WI, FL, NE, VA, MD, IA, OH, American Samoa, ME

US Cases:
US TOTAL Cases INCL DC US TOTAL States Affected INCL DC

Total Confimed and Probable Cases Hosp Deaths

5710 48

247 35

8 5

Deployments: 66 deployed, 5 pending, 207 potential New countries with confirmed cases: Greece Laboratory: 44 states validated: 9 states with multiple sites; 582 genes have been sequenced
2

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Epidemiology/Surveillance Confirmed and Probable Novel Influenza A (H1N1) Cases By Onset Date* and Report Date as of 20 May 2009 1100 EDT

500 400 No. of Cases 300 200 100 0

Onset Date (n=1,632) Report Date (n=5,605)

*Information on onset date no longer presented after May 12 due to change to aggregate reporting
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ay -M y 19 Ma - y 17 Ma - y 15 Ma - y 13 Ma 11 ay M 9- ay M 7- ay M 5- ay M 3- ay M r 1- A p - r 29 A p - r 27 A p - r 25 p -A r 23 p -A r 21 A p - r 19 A p - r 17 A p - r 15 A p - r 13 A p 11 p r A 9- p r A 7- p r A 5- p r A 3- p r A r 1- Ma - r 30 Ma 28

DDate of Illness onsetlness Onset

Epidemiology/Surveillance Novel Influenza A (H1N1) - 20 May 2009 1100 EDT Selected Underlying Conditions Persons Hospitalized with H1N1, 2009

66 (71%) of hospitalized patients had an underlying chronic condition

Condition Asthma or COPD Diabetes Immunocompromised Chronic cardiovascular disease Pregnant Obesity Chronic Renal Disease Cancer

No. (%) 37 (40%) 14 (15%) 11 (12%) 10 (11%) 7 (8%) 6 (6%) 4 (4%) 3 (3%)

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Epidemiology/Surveillance Number of cases of H1N1 reported to CDC by state as of 17:30 EDT on 19 May 2009 (n=5710)

0 1-50 51-200 200-400 >400

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Epidemiology/Surveillance Novel Influenza A (H1N1) - 20 May 2009 1100 EDT Age of Persons Hospitalized with H1N1, 2009 n=164

70 60 Number of Cases 50 40 30 20 10 0 0-23 mos. 2-4 Yrs 5-9 Yrs

61
Median Age = 19 years
37%

29 18
11%

16
10%

18
11%

18%

22
13%

10-18 Yrs 19-49 Yrs

50 Yrs

Age
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Epidemiology/Surveillance Novel Influenza A (H1N1) - 20 May 2009 1100 EDT Antiviral and Antimicrobial Usage Persons Hospitalized with H1N1, 2009

63/88 (60%) treated with antivirals Median time from illness onset to antiviral initiation 4 days (1-25 days) Median time from admission to antiviral initiation 1 day (6-13 days)

70 (75%) treated with antibiotics 100% initiated on day of admission

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Epidemiology/Surveillance Novel Influenza A (H1N1) - 20 May 2009 1100 EDT Indicators of Severity Persons Hospitalized with H1N1

26/118 (22%) were admitted to the ICU 13 (50%) required mechanical ventilation 9 had ARDS Median age of ICU patients (n=23) 23 years (1 month-86 yrs) Median length of ICU stay (n=14) 9 days (2-34 days) Time from onset to ICU admit (n=13) 6 days (2-14 days)

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Epidemiology/Surveillance Current Influenza Surveillance, 20 May 2009 1100 EDT

WHO/NREVSS Collaborating Laboratories (graph as of

5/19/2009)

Seasonal influenza A (H1), A (H3), and B viruses cocirculated with novel influenza A (H1N1) viruses Influenza-associated Pediatric Deaths No new influenza-associated pediatric death were reported 2008-09 season total = 61 ILINet During week ending 5/16/2009, the percentage of ILI outpatient visits was below the national baseline Overall, the percentage of outpatient visits for ILI remains stable, based upon daily ILI reports from the US Outpatient Influenza-like Illness Surveillance Network (ILINet)

These data are considered provisional and preliminary and will not be officially released by the CDC until 1100 EDT. Internal Use Only (FIUO)---For Official Use Only (FOUO) NOT FOR FURTHER DISTRIBUTION -Sensitive But Unclassified (SBU) 9

Epidemiology/Surveillance Current Influenza Surveillance, 20 May 2009 1100 EDT

122 Cities Mortality Reporting System (graph as of 5/19/2009) As weekly mortality reports continue to be received at CDC for week ending 5/9/2009, the percentage of pneumonia and influenza deaths is not expected to be significantly elevated Percentage of deaths due to pneumonia and influenza remains stable, based upon daily mortality reports from the 122 Cities Mortality Reporting System Geographic Spread of Influenza as Assessed by State and Territorial Epidemiologists The influenza activity reported by state and territorial epidemiologists indicates geographic spread of both seasonal influenza and novel influenza A (H1N1) viruses and does not measure the severity of influenza activity. Eight states reported geographically widespread influenza activity, 14 states reported regional activity, the District of Columbia and 15 states reported local influenza activity; and 13 states reported sporadic influenza activity.

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Percent of Specimens Positive for Influenza Reported by WHO and NREVSS Labs: Novel Influenza A(H1N1) vs. Seasonal Influenza, by Week 20 May 2009 1100 EDT

30 25 Percent Positive 20 15 10 5 0
10 10 /4 /1 11 8 11 /1 / 11 1 5 / 12 2 9 / 12 1 3 /2 1/ 7 10 1/ 24 2/ 2/ 7 21 3/ 3/ 7 21 4/ 4/ 4 18 5/ 5/ 2 16 5/ 3 6/ 0 13 6/ 27 7/ 11 7/ 25 8/ 8/ 8 22
Influenza % Positive by Season (Week 18): 05-06: 8.70% 06-07: 6.75% 07-08: 4.38%

Week Ending Date

All Flu Seasonal Flu Novel Influenza A(H1N1)

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Epidemiology/Surveillance 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 20 May 2009 1100 EDT

5
% of Visits for ILI

0
/ 10 4 / 10 18 / 11 1 / 11 15 / 11 29 / 12 13 / 12 27 1 1/ 0 2 1/ 4 7 2/ 2 2/ 1 7 3/ 2 3/ 1 4 4/ 1 4/ 8 2 5/ 1 5/ 6

Week Ending Dates 2008-09 National Baseline

2006-07
NOTE: Week ending dates vary by influenza season

2007-08

*Preliminary ILI data for week 19, as of May 19, 2009 (n=667 weekly ILI reports received from 47 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.

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Epidemiology/Surveillance Current Influenza Surveillance ILINet Regions I-III

20 May 2009 1100 EDT
Region I - CT, ME, MA, NH, RI, VT
5

% of Visits for ILI

4/ 4

11 /2 9

11 /1 11 /1 5

12 /2 7

1/ 24

2/ 7 2/ 21

3/ 7 3/ 21

1/ 10

4/ 18

5/ 2

10 /4 10 /1 8

2006-07

2007-08

12 /1 3

Week Ending Dates

2008-09

5/ 16

Baseline

Region II - NJ, NY
6
8 7 6
% of Visits for ILI
% of Visits for ILI

Region III - DE, DC, MD, PA, VA, W V

5 4 3 2 1

0
4 1 4 1 0 1 8 6 18 13 15 29 27 2/ 7 3/ 7 4/ 4 5/ 2 10 / 11 / 1/ 2 1/ 1 2/ 2 3/ 2 4/ 1 5/ 1 11 / 12 / 10 / 11 / 12 /

0
4 1 0 4 1 1 8 18 15 29 13 27 2/ 7 3/ 7 1/ 1 1/ 2 2/ 2 4/ 1 3/ 2 5/ 2 4/ 4 11 / 10 / 11 / 12 / 12 / 5/ 1 11 / 10 / 6

Week Ending Dates

Week Ending Dates

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.

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Epidemiology/Surveillance Current Influenza Surveillance ILINet Regions IV-VI 20 May 2009 1100 EDT
Region IV - AL, FL, GA, KY, MS, NC, SC, TN
6 5 4

% of Visits for ILI

3 2 1 0
27 1/ 10 4 1 4 1 18 15 29 13 2/ 7 3/ 7 1 4/ 4 8 11 / 10 / 1/ 2 2/ 2 5/ 2 12 / 11 / 12 / 10 / 11 / 5/ 1 4/ 1 3/ 2 6

Week Ending Dates

2006-07

2007-08

2008-09

Baseline

Region V - IL, IN, MI, MN, OH, WI

6 12 10 4 8

Region VI - AR, LA, NM, OK, TX

% of Visits for ILI

% of Visits for ILI

6 4 2

0
4 0 4 1 1 1 8 6 18 15 29 13 27 2/ 7 3/ 7 4/ 4 10 / 5/ 2 11 / 1/ 1 1/ 2 2/ 2 3/ 2 4/ 1 5/ 1 10 / 11 / 11 / 12 / 12 /

0
4 1 0 4 1 1 8 15 18 29 13 27 2/ 7 3/ 7 4/ 4 10 / 11 / 1/ 1 1/ 2 2/ 2 3/ 2 4/ 1 5/ 2 11 / 11 / 12 / 12 / 10 / 5/ 1 6

Week Ending Dates

Week Ending Dates

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.

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Epidemiology/Surveillance Current Influenza Surveillance ILINet Regions VII-X 20 May 2009 1100 EDT
Region VII - IA, KS, MO, NE
8 5

Region VIII - CO, MT, ND, SD, UT, WY

4 6
% of Visits for ILI % of Visits for ILI

2 1

0
1 0 4 1 1 8 6 4 15 18 29 13 27 2/ 7 5/ 2 3/ 7 4/ 4 10 / 11 / 1/ 1 3/ 2 2/ 2 4/ 1 1/ 2 5/ 1 10 / 11 / 12 / 11 / 12 /

0
4 1 0 1 1 8 4 18 15 13 29 27 2/ 7 3/ 7 10 / 11 / 1/ 1 1/ 2 3/ 2 2/ 2 4/ 1 5/ 2 5/ 2 4/ 4 10 / 12 / 11 / 11 / 12 / 5/ 1 5/ 1 6 6

Week Ending Dates

Week Ending Dates

2006-07

2007-08

2008-09

Baseline

Region IX - AZ, CA, HI, NV

8 10

Region X - AK, ID, OR, WA

8 6
% of Visits for ILI % of Visits for ILI

2 2

0
1 4 1 1 0 4 8 18 6 15 29 13 27 2/ 7 3/ 7 5/ 2 4/ 4 10 / 11 / 3/ 2 1/ 1 2/ 2 4/ 1 1/ 2 10 / 11 / 12 / 5/ 1 11 / 12 /

0
1 0 4 4 1 1 18 29 15 13 27 2/ 7 3/ 7 10 / 11 / 1/ 1 2/ 2 1/ 2 3/ 2 4/ 4 10 / 11 / 11 / 12 / 12 / 4/ 1 8

Week Ending Dates

Week Ending Dates

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.

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BioSense % Patients Presenting With ILI as a Chief Complaint by Age April 18-May 16, 2009

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BioSense % Patients Presenting With ILI as a Chief Complaint by Age April 18-May 16, 2009

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BioSense % Patients Presenting With ILI as a Chief Complaint by Age April 18-May 16, 2009

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Epidemiology/Surveillance - Percentage of Visits for ILI NYC ED and Other ILINet Providers, 2008-09 and Previous Two Seasons 20 May 2009 1100 EDT

6 % of Visits for ILI

0
20 06 4 20 0 06 4 20 4 06 4 20 8 06 5 20 2 07 0 20 4 07 0 20 8 07 1 20 2 07 1 20 6 07 2 20 0 07 2 20 4 07 2 20 8 07 3 20 2 07 3 20 6 07 4 20 0 07 4 20 4 07 4 20 8 07 5 20 2 08 0 20 4 08 0 20 8 08 1 20 2 08 1 20 6 08 2 20 0 08 2 20 4 08 2 20 8 08 3 20 2 08 3 20 6 08 4 20 0 08 4 20 4 08 4 20 8 08 5 20 2 09 0 20 3 09 0 20 7 09 1 20 1 09 1 20 5 09 19

Week NYC ED Sites* Other NYC Sites

*Consists of 50 ED sites across NYC; An average of 19 sites reporting each week from across NYC of various practice types (Family Practice, Pediatrics, Internal Medicine, and Student Health)

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# ILI
1000 1500 2000 2500 500 0 10/4/2008 10/11/2008 10/18/2008 10/25/2008 11/1/2008 11/8/2008 11/15/2008 11/22/2008 11/29/2008 12/6/2008 12/13/2008 12/20/2008 12/27/2008 1/3/2009 1/10/2009 1/17/2009 1/24/2009 1/31/2009 2/7/2009 2/14/2009 2/21/2009

Age 0-4 Age 5-24

Epidemiology/Surveillance NYC ED ILI Counts by Age Group Oct 2008 - May 16, 2009 20 May 2009 1100 EDT

week

Age 25-64 Age 65 and older

2/28/2009 3/7/2009 3/14/2009 3/21/2009 3/28/2009 4/4/2009 4/11/2009 4/18/2009 4/25/2009 5/2/2009 5/9/2009 5/16/2009

International Novel Influenza A (H1N1) - 20 May 2009 1100 EDT

WHO global case count: 10,243 confirmed cases in 41 countries* New countries with confirmed cases: Greece Countries with highest confirmed case count after the US and Mexico: Canada: 496 (=) Spain: 107 ( 4) Japan: 210 ( 51) UK: 102 ( 1)

Increases in case counts expected in countries receiving CDC PCR kits as testing capabilities are improved

*Note: WHO case counts are current as of 05/20/09, 9:00 am EDT

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Division of Global Migration and Quarantine Novel Influenza A (H1N1) Students Dismissed by Date (ED as of 1400 EDT 19 May 2009)

500,000
468,282

Number of Students

400,000
369,237 329,834

300,000
245,449

19 May 2009: 24 schools closed due to H1N1 in 5 states NH, NY (n=18), PA, TX, and WI.

200,000
169,000

197,985 118,033 55,765 61,697 0 11,794 17,663 4,838

100,000 0
4/29 4/30 5/1 5/4 5/5 5/6 5/7

5/8 5/11 5/12 5/15 5/18 5/19

Date
Source: ED and CDC Confirmed School Closing Reports released each weekday at 2:00pm.

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Communications Summary Novel Influenza A (H1N1) - 20 May 2009 1100 EDT

Channel Traffic Public Inquiries News Stories Print/Internet Web Themes 2 deaths linked to H1N1: St. Louis man and 16-month old boy in NYC School closings in NYC WHO meeting vaccine development proving much tougher than expected; taking longer than expected; now delayed Nations urge WHO to change criteria, consider severity not just spread Emerging Themes Controversy over change in school closing guidelines, NYC: Guidelines did not call for that school to be closed and public is upsetschool should have been closed sooner Schools across the country continue to close Strong local reaction to deaths in the community: NYC hospitals -- seeing hundreds more people than usual
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5/16 Sat 380 109 927,305

5/17 Sun 188 114 512,254

5/18 Mon 178 212 547,371

5/19 Tue 510 189 1,216,785