C-SPAN/NEWSMAKERS

Host: Pedro Echevarria

Guest: Dr. Thomas Frieden, Director, Centers for Disease Control

Reporters: Maggie Fox, Lauren Neergaard

PEDRO ECHEVARRIA, NEWSMAKERS: You’re watching Newsmakers and our guest this week is Dr. Thomas Frieden, Director of the Centers for Disease Control. Dr. Frieden, thank you for your time today.

DR. THOMAS FRIEDEN, DIRECTOR, CENTERS FOR DISEASE CONTROL: Thank you. It’s good to be here.

ECHEVARRIA: Joining us in the studio to ask questions is Lauren Neergaard of the Associated Press, who serves as their Medical Reporter, and Maggie Fox of Thomason Reuters, serves as their Health & Science Editor. To both of you, thanks for coming in. Maggie Fox, you get the first question.

MAGGIE FOX, HEALTH & SCIENCE EDITOR & REPORTER, THOMSON REUTERS: Great. Dr. Frieden, I’m going to start off hard here. This week, the Presidential Council of Science Advisors issued a report on swine flu – H1N1 flu. It gave a pretty surprising estimate of what the impact on the United States would be. Can you tell us a little bit about how the CDC sees the various aspects of that report and whether you think some of the – some of the numbers might have been overblown or exaggerated? I think one of the numbers given was as many as 90,000 people could be expected to die from H1N1 flu this flu season.

FRIEDEN: Certainly. Everything we’ve seen in the U.S. and everything we’ve seen around the world today suggests that we won’t see that kind of number if the virus doesn’t change. But the Presidential Commission did a terrific job of giving an overview of what are the challenges in addressing H1N1 and what are some of the things that we need to do.

Many of those things are underway now. Many of them are difficult. Addressing influenza is hard. Influenza is one of the least predictable of all infectious diseases and that means that, among other things, we need to do lots to get ready. To get ready in terms of our healthcare system; what would we do if we needed more people on ventilators in intensive care units? How can we plan to surge up? And those plans are underway. What can we do to vaccinate people as quickly as possible when vaccine becomes available?

How can we make sure that people who have underlying health conditions, like asthma, diabetes, and who might get very sick from flu get rapidly treated if they get sick and flu is circulating, at the same time making sure that when flu comes this year we don’t overwhelm emergency departments with people who aren’t very sick and shouldn’t be in an emergency department?

The report I think, unfortunately, the media coverage of it, was not nearly as balanced as the report itself. The report was very helpful, thorough and an overview of the needs and what’s gotten all the play is one particular scenario that they outlined. And there are various scenarios you can come up with. Our approach is to say yes, flu is a very serious problem. We’re taking very intensive steps to respond to it and we will work to ensure that as – that as few people get very sick and die as possible. What the number will be, only time will tell.

We know that if we work well now, if we prepare to treat people promptly when they become ill if they have underlying conditions, can vaccinate people promptly when vaccine becomes available we’ll be much more likely to have as low a number as possible.

LAUREN NEERGAARD, MEDICAL REPORTER, ASSOCIATED PRESS: Dr. Frieden, when vaccine becomes available actually is one of the key questions. It doesn’t look like we’ll have significant supplies and the start of a campaign until the middle of October. That report actually urged you to get some out the door in September, partly because of all the concern about transmissibility with schools getting started. Is there any effort to actually do that and start some of the priority groups getting vaccinated in September?

FRIEDEN: We wish we had new vaccine technologies that would allow us to turn on a dime and make a new vaccine in a question of weeks or months. Despite over a billion dollars of research, we don’t have that yet. It’s not possible with today’s technologies to do that. What has happened is immediately, when the new – when the new virus began circulating, the CDC developed a seed strain to help develop a new vaccine.

HHS has been working with – Health and Human Services, a number of different entities have been working with vaccine manufacturer’s companies to rapidly make as much vaccine as can be made. We need to ensure that it’s made with full attention to all the safety guidelines and that’s being done. One of the decisions that had to be made was to go ahead with producing the vaccine; go ahead with preparing it to be used.

We anticipate that vaccine will be available in mid-October. It would be great if some were available sooner, but realistically, it doesn’t look like that will be possible, in large numbers. At the same time, what we’re talking about is potentially tens of millions of doses available in mid-October; then the next challenge is getting people vaccinated and that will be something that will have to be done on a state by state basis, working with doctors, healthcare – other healthcare providers, pharmacies, schools, workplaces, using all of the resources of different communities to get people vaccinated promptly.

NEERGAARD: Can you talk a little bit about who really ought to be first in line and what steps you’re taking to making sure that the people who are in those priority groups actually are first in line and the people who aren’t are not getting ahead of them?

FRIEDEN: The highest priority for flu vaccination are people who would become very sick or risk dying if they developed the flu. That means people with asthma, diabetes, heart disease, lung disease, immunosuppression, people with neuromuscular or neuro – or other neurological problems; children, for example, with severe developmental delays, who have difficulty coughing or breathing on their own, and pregnant women. These are all groups which were disproportionately affected by flu in this past year.

NEERGAARD: But how are you going to make sure that they’re first in line?

FRIEDEN: We’re working with a number of professional societies, the Obstetrics and Gynecology Society, for example, for pregnant women, specialty societies in other groups and we’ve worked with each state to identify, within their state, how are they going to reach these groups, whether it’s the endocrinology clinics for people with diabetes, primary care practitioners. One of the biggest challenges will be school-located vaccine clinics.

Kids don’t get vaccinated in large numbers against flu in a routine season, so vaccinating large numbers of kids will not be easy. To do that, it’ll be important to get consent forms back from parents, to work with schools, nursing staff in schools, administrators in schools, and we’ve had really wonderful collaboration with the Department of Education here in Washington, as well as at the state level, between state education departments and state health departments.

One of the key roles that CDC can play is to help states and localities to become better prepared, plan better. We’ve been providing funds; more than a half a million dollars worth of funds to the states and localities to prepare for vaccine programs, to prepare emergency departments to deal with large numbers of ill people, to prepare special societies. One of the things that we’ll be doing to get vaccine out is using the infrastructure of the Vaccines for Children’s program.

This is a very effective program that is responsible for many of our childhood vaccines and we have the way for doctors to sign up easily online and they can, by signing up with their state or locations, the Vaccines for Children’s program provider and system, they can then call down vaccine when it becomes available, if they’re approved by their state to receive it. So we need to use all resources of our healthcare system, all resources of our society.

Addressing H1N1 is a shared responsibility.

FOX : Dr. Frieden.

FRIEDEN: No one part of it – yes.

FOX: Sorry. Sorry to step on you, Dr. Frieden, but I want to ask you what kind of indication do you have of acceptance of the vaccine? As you know there’s controversy over vaccines and there seem to be some indications; for instance, in Britain, we hear that even healthcare professionals say that they’re very unlikely to get the vaccine. And we have a problem here, of course, with healthcare professionals. What kind of indication do you have that U.S. public’s going to be accepting of this vaccine and line up to get it?

FRIEDEN: In every vaccine campaign, anywhere in the world, there are people who are suspicious of it, people who are hesitant to get vaccine. I can tell you that when it comes time for my kids to get vaccinated with this vaccine, they will get vaccinated. If I’m in a group that needs to be vaccinated, I’ll be vaccinated. This is a vaccine, like each year’s flu vaccine, which I get every year. The flu vaccine protects against the flu.

There are lots of people who believe that it causes the flu. I think, first, it’s important to understand that the flu shot is a killed vaccine. It can’t possibly result in you getting the flu. It can get give you a sore arm; that’s common. But you can’t get the flu from the flu shot and each year you need this year’s flu shot to protect you against this year’s flu. And there’ll also be nasal spray for some groups of people who prefer not to get a shot. If you’re eligible for that, you can get that as well.

FOX: But, Dr. Frieden, do you – do you have an indication that people are actually signing onto this and making the leap from understanding that they should get the flu vaccine to actually going and getting it?

FRIEDEN: Vaccine is our strongest weapon against the flu. People want to know that flu vaccine is available and we’re working hard to have the flu vaccine available. We’re not talking about mandating it for anyone; making it required that people take it. It’s an option for people to take it. We encourage people to take it. We hope they’ll take it and realistically, I think what you’ll see in different parts of the country is that, as more people become sick or seriously ill or die from flu, we’ll get an increased demand for the flu vaccine and that’s one of the challenges that we have.

It’s likely that this flu vaccine will require two different doses, separated by about three weeks. So if you wait until people are already getting very sick from the flu that’s not quick enough to get vaccinated. When flu becomes available, we hope that people – particularly people at high risk will get vaccinated. We know that some of the most effective ways to do that are to work with healthcare professionals.

And you’re absolutely right; it’s very unfortunate that healthcare professionals don’t get vaccinated in as high a rate as we would like. But we do know that in the best performing healthcare systems in the U.S., you get 60, 70, 80, even 90 percent of healthcare workers vaccinated and that’s what we’d expect of all healthcare facilities.

NEERGAARD: Dr. Frieden, can you talk a little bit about what is going to really make this a very different flu season? I mean you did say that that 90,000 death figure is way overblown, but this is going to be a very different flu season because of who this particular strain seems to target. Can you talk about those age groups?

FRIEDEN: in the spring, I was Health Commissioner for New York City before taking this job, and we had lots of outbreaks in schools. That’s unusual for flu. We had schools with hundreds or even a thousand kids sick with the flu. The overwhelming majority of them had moderate or mild illness. Some people had it without knowing that they had the flu, even. But we didn’t see large outbreaks like that in most flu seasons and we saw them this past spring.

We expect that it is not unlikely that we will see outbreaks based in schools in the coming school year, in the fall or as the flu season progresses in winter. Exactly when, how large, where, only time will tell. One of the defining characteristics of influenza is that it’s very hard to predict what will happen. We have to be ready and one of the ways that we can be ready is understanding how to respond in schools. In most cases, we need to ensure that kids who are sick stay home. If you have a fever, stay home. You’ll get better quicker and you won’t make other people sick. Cover your cough and sneeze and wash your hands often.

Those three key measures can make a big difference in how fast and how widely flu spreads. This season is likely to be different because of outbreaks in places like schools, childcare settings and elsewhere and that’s why we’ve worked very closely with the education department to get guidance out to schools; what to tell kids, what to tell parents, what to tell teachers and administrators so that kids can keep learning, people can keep going to work, people can continue to go about their lives, even if we have a lot of people ill with the flu, and the healthcare system can be ready to deal with it.

NEERGAARD: What about the mortality? Who actually dies from this flu? Is it – are you still seeing that it’s the – people in their 20s, 30s and 40s who really die from this, which is completely different from a regular flu season?

FRIEDEN: Each year, tragically, we have dozens or even a hundred deaths from flu in children and this year we don’t expect to see fewer and, tragically, we may see more deaths. We will do everything in our power to reduce the number of people who die. That means taking those simple measures, like staying home if you’re sick, covering your cough, washing your hands, as well as making sure that people get prompt treatment if they’re very sick and getting the vaccine out as quickly as possible when it becomes available.

FOX: Dr. Frieden, can I ask you a little bit about surveillance? One of the problems that public health officials have, even with seasonal flu, is actually knowing who’s sick; what the so-called denominator is in this – in the figure of deaths to people who are only mildly ill. And the PCAST report – this Presidential report that was issued this week, urged CDC to do a little bit more about getting better surveillance.

What can you do to get a better idea and a better grip on who has flu? And please, can we have a little bit better number than the kind of general, more than a million people have been infected so far that’s been out there? Because it really is a bit unsettlingly vague, I think, for a lot of us.

FRIEDEN: In an average flu season, between five and 20 percent of the population are infected by flu. That’s a lot of people. In New York City, where we had a lot of H1N1 this past spring, the estimate is that about 800,000 people, about 10 percent of New York City residents got infected with the flu. That’s a lot of people, but the vast majority don’t get severely ill, don’t need to be hospitalized, and those who get severely ill, need to be hospitalized or may die tend to be, not always, but tend to be those with underlying health conditions.

What we have to do is prepare for it, understanding that it’ll be very different in different places. This past spring, the level of flu infection varied at least 20-fold between different parts of the country. No one knows exactly why that is, but we expect that some places will have more flu; some places will have less. Every place needs to be prepared and a lot of the data will come from the local area.

It’s – one of the things that we’re working on is helping laboratories be ready to diagnose when needed. Not every case needs to be diagnosed, but certainly anyone who’s hospitalized should have a test for flu. Doctors also need to understand that that test sometimes is falsely negative, so just because it’s negative doesn’t mean someone shouldn’t be treated.

We’ll track closely to see if the virus is becoming resistant to the drugs that we use to treat it. We’ll track closely to see if the virus is changing to be less effective or protected by the vaccine. Up till now, the vaccine looks to be a very good match with the strains of the virus that are circulating, but that needs to be checked week to week, month to month, to see if that changes.

And we’ll look very closely at emergency departments; how heavily are they being utilized. Are the people in emergency departments there because they’re very sick or because they’re very concerned about their health? Do they have fever? Are they being admitted? What’s going on with the intensive care units? Are they being overwhelmed or is there ample capacity, enough beds? Those are some of the things that the PCAST report quite appropriately highlights and which CDC is hard at work on enhancing and improving our systems to track.

ECHEVARRIA: You’re watching Newsmakers with Dr. Thomas Frieden of the Centers for Disease Control. He serves as their director. Joining us also is Maggie Fox of Thomson Reuters and Lauren Neergaard of the Associated Press.

NEERGAARD: Just to follow up on that; so would it be a fair assumption to say that over 2 million Americans, over 5 million Americans already have been infected with H1N1 flu?

FRIEDEN: One of the – one of the things that we will do in the fall is to track more closely than we have till (ph) date (ph), the number of people who have the infection based on telephone surveys. That will help us get a national number. Right now, we’re confident it’s more than a million. The fact is that what the number is isn’t so essential. What is essential is that we prepare well for having potentially quite a few cases in the fall and winter.

FOX: This is going to be hard for you to track, isn’t it? But can we talk about some of the challenges that face you in tracking it? I understand some of the reports indicate that people who are infected with H1N1 don’t have a fever sometimes; that their symptoms are a little bit different. People are asking questions like well; if I think I was infected this spring does it mean that I don’t need the vaccine in the fall? Isn’t this input a little bit important in judging how to react, besides just being prepared with lots of hospital beds?

FRIEDEN: Because lots of people have illness that they think might be the flu, but don’t necessarily have the flu, our general recommendation is that everyone should get a flu shot, particularly each year for seasonal flu and for H1N1, we’re prioritizing groups that would benefit the most. H1N1 has tended to spare the elderly, so relatively few people over the age 65.

Seasonal flu vaccine will become available in September and could start taking that. One of the things that will be very important as flu spreads is to track it community by community, to know when it’s present. In some communities, when you have a fever it’s likely that you’ll have H1N1. In other communities, with a fever, it’s less likely.

Fever is quite predictive of having flu and it’s quite predictive of potentially infecting others, so that’s the key symptom that people should watch for. There are always some people in each flu season who are infected with flu who get very mild illness and may not have fever. That’s much less of a concern because they’re much less likely to get severely ill; they’re much less likely to infect others.

NEERGAARD: There was a lot of confusion in the spring about people saying I want a test. I want to know if it’s swine flu or if it’s some other kind of flu. Don’t just tell me it’s flu. Given the – that the majority of the flu now circulating in the world in H1N1, is it going to be even worth it to have a test unless you are actually hospitalized this fall?

FRIEDEN: In the fall, it’ll be important to find out what’s happening initially; so find out if flu has arrived in a community, which flu it is, whether it’s resistant to antibiotics, whether it’s still protected by the vaccine that we have and so far that looks very promising. Everyone who’s hospitalized and may have flu should be tested. Doctors need to understand, of course, that sometimes that can be falsely negative. And anyone who’s very ill and you’re concerned that it might be flu, you might get a test. Certainly anyone in an intensive care unit; we’d like to know if people are in an intensive care unit with the flu.

By and large, testing is not necessary. Once flu is in a community, most people with flu don’t need to be treated. If you don’t need to treat, you certainly don’t need to know if you’ve got that particular strain of flu. And if it’s in a community and people have an underlying health condition and need to be treated, you also don’t necessarily need a flu diagnosis.

We also know that many of those tests have a lot of false negatives; so on the one hand, if you test positive you’re not going to do anything different than you would otherwise. And on the other hand, if you test negative you’re also possibly not going to do anything different. In most cases then, it won’t be necessary to test and in many cases, it’ll be very important to act without having a test if you want to treat promptly and make sure that you’re treating even for someone who might have a falsely negative test.

NEERGAARD: If we could switch gears a little bit now; this is not the only thing on your plate. You’re brand new at CDC. What are your other priorities, other than dealing with H1N1 flu? I know in New York City, you tackled smoking; you tackled Trans fat in restaurants. What’s up first on your plate now?

FRIEDEN: Well really, H1N1 is the top priority for the agency right now. The potential for flu to cause widespread illness, deaths and economic and social disruption to people’s jobs, to kids learning is huge and we’re doing everything we can. We’ve mobilized, literally, more than a thousand staff at CDC to work on H1N1 and we’ll continue to do that for as long as is necessary. That’s our top priority.

There are other things that we’re doing to try to make sure that CDC does the best job it can to protect the American people and to support states and localities to do that as well. CDC is a wonderful institution. There are the world’s experts in many or most public health problems here at CDC and it’s been a delight to get to know people here and learn what people are doing.

Some of the directions that we’re going are, first, to strengthen the science; to make sure that we’ve got the best possible information to address whatever the problem is, whether it’s new manufacturing technologies and making sure that workers are safe or H1N1 or smoking or obesity, to make sure that whatever we’re proposing, whatever we’re studying is based on what’s actually happening and what’s likely to help people the most.

A second key priority is strengthening state and local health departments. State and local health departments are where the action is at. That’s where prevention happens. That’s where response happens. CDC exists to help state and local health departments do a better job of protecting the people in their areas and I want to make sure that everything we do as an agency is practical, is helpful and focused. As a City Health Commissioner for seven-and-a-half years in New York City, I saw many ways in which CDC was terrific in helping local areas respond; other areas where there could be some improvement and we’re working on that.

The third big area is global. Globally, CDC does a lot around the world to help other countries track health problems and that’s in our own interest as well. In fact, in H1N1, it’s the CDC staff around the world and CDC trained lab experts and epidemiologists who have been able to tell us what’s going on and track the virus to a large extent in some of the lower income countries, so strengthening our work there. Those are three key priorities for us.

FOX: Now those are the sexy areas; fighting H1N1, sending the epidemiology teams abroad to fight scary viruses like Ebola, but as you said, there are a lot of other things on CDC’s plate and a lot of improvements to be made. Can you talk about some of those areas? Because we’ve understood for years that there are people at CDC who feel neglected, who feel unhappy, who feel unmotivated. What are you going to do to reenergize the people who are working in some of the other areas?

FRIEDEN: CDC handles a very broad range of health problems. We have to continue to address the communicable diseases, the infectious diseases, like H1N1, HIV, sexually transmitted diseases and many more. At the same time, we need to strengthen our work in the non-communicable diseases. I’ve said before that public health does a great job monitoring and controlling diseases and conditions that killed people a hundred years ago, but not such a great job monitoring and controlling the leading causes of death today.

That includes smoking, obesity, high blood pressure, heart disease, stroke, alcohol abuse. These are problems that are the leading causes of illness and death today and there are things that we can do to understand them better and to help control them better.

NEERGAARD: Are you going to try to carry some of the – same kind of a big stick that you did in New York City, where you know you talked about maybe taxing junk food? Is that something that CDC can get into?

FRIEDEN: We have to look at what are the leading causes of illness and death and what can be done about them. A lot of those things are going to be done at the state and local level. If you look at what happened with tobacco control; we have much farther to go with tobacco control. There are still about 45 million smokers in the U.S. Today, a thousand people will be killed by cigarettes in the U.S., but we’ve had some real success; number of male smokers to proportion of men who smoke has been cut by two-thirds over the past few decades.

Our recent progress in tobacco control has stalled and we need to do more. But you’ve seen lots of local creativity, local innovation in tobacco control. We need to see that same type of local leadership and creativity on issues like obesity, physical activity, things that we really can make a difference with. No one could have predicted a couple of decades ago that the obesity epidemic would have gotten as bad as it has as quickly as it has.

The number or the proportion of Americans who are obese has doubled in just a couple of decades. That’s not because our genes have changed; they haven’t. That’s not because our tastes have changed; they haven’t. We’re hardwired to like sweet, salty foods. It’s because our environment has changed. There’s more unhealthy food around. It’s more accessible; it’s cheaper. There’s less healthy food around. It’s harder to get to; it’s more expensive.

Until we change that environment, we’re not going to change or tip the scales on the obesity epidemic that we’re living through. And not only does obesity cause lots of health problems, but it is driving, to a large extent, the increase in healthcare costs in this country.

ECHEVARRIA: Dr. Frieden, we are out of time, but we want to thank you for being on Newsmakers.

FRIEDEN: Thank you very much.

ECHEVARRIA: We have a few minutes left, but let’s start with swine flu. What did you learn from what he said and compared to what the President’s team also said about it?

FOX: It’s very interesting. The CDC, in the past couple of days, and Dr. Frieden just now have distanced themselves from some of the press coverage of what came out of that report. The report itself was a fairly balanced report, written by scientists who aren’t normally involved in medical issues, with the exception of Dr. Varmus – Dr. Harold Varmus, who used to head the NIH and was on that panel that wrote the report.

People tend to jump on big, scary numbers and the 90,000 number became a huge issue in the media and some of us who have been writing about flu for a long time were somewhat surprised at the play that that got. And Dr. Frieden reflected that. That’s the – that really is a bit exaggerated. We have known that flu can cause a huge number of deaths very quickly if it takes off badly. This flu doesn’t look like it’s going to do that so far and the preparations have been based on a worst case scenario anyway and he reflected that opinion; don’t you think?

NEERGAARD: Yes, he did. And he showed really what kind of a balancing act that public health officials are facing this fall. You want people to sit up and pay attention. You want people to be concerned; concerned enough that if their child shows symptoms they don’t just send them to school and then to go off to work like usually we all do. And so – but they also don’t want people to panic and so that’s going to be a fine line, I think, this fall.

ECHEVARRIA: What about vaccine availability?

NEERGAARD: He was not very optimistic that it’s going to be much earlier than mid-October and that’s what a lot of the concern is. The kids are already back in school. There are already some schools that are experiencing clusters of illnesses and so the question is how rapidly will flu season start. It usually doesn’t start till late October or early November, but this one looks a little different, so we don’t really know.

ECHEVARRIA: And he also mentioned a billion dollars has been invested in trying to come up with vaccine and yet we still have concerns about the availability of vaccine.

FOX: Well that’s the problem. Making flu vaccines is a really slow process. We rely on 40-year-old technology to make flu vaccines. Now there are companies that are trying to come up with quicker ways to do that, but the testing and the licensing process is very slow. It also doesn’t help; there was an incident with swine flu in 1976 when a whole lot of people were vaccinated. Surveillance showed a lot of side effects. It was never clear that those side effects were actually caused by the vaccine, but it caused a great deal of doubt about the safety of vaccines.

People don’t like getting shots and they’ll look for any excuse not to and people glommed onto the idea that this shot was dangerous. The upshot is a lot of companies got out of the business of making vaccines and not much was invested in making the flu vaccine technology better. We’re now stuck with that, and CDC’s stuck with that. They have nothing to do with the process of making them, but now we’re facing what could be a crisis, and we’re paying the price for our slow investment in that kind of technology.

ECHEVARRIA: Final thoughts.

NEERGAARD: Stay tuned. We have clinical trials that are underway right now that are going to answer the number one question: Do you get one shot or do you get two shots? And if you need two, how are you going to make sure you line up and get both of them?

ECHEVARRIA: Lauren Neergaard writes on medical issues for the Associated Press. Maggie Fox is with Thomson Reuters as their Health & Science Editor. To both of you, thanks for being on Newsmakers.

NEERGAARD: Thank you .

FOX: Thank you.

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