>>>Karen Marsh: Good afternoon, everyone. I hope you've enjoyed your lunch. We are going to start our luncheon presentation today and it is my distinct pleasure to introduce our next speaker to you, Dr. Richard Hatchett. Dr. Hatchett is the Director of Medical Preparedness Policy on the White House National Security Staff and he is here today to teach us more about the H1N virus, to provide some historical perspective, and to discuss what goes into community resilience. In addition to his role in the White House, he's also been the Associate Director for Radiation Countermeasure Research and Emergency Preparedness at the National Institute for Allergy and Infectious Disease, overseeing a program that develops drugs and devices to prevent or mitigate the effects of radiation exposure. In 2005/2006, he served as the Director for Bio-Defense Policy on the White House Homeland Security Council and was a principle author of the "National Strategy for Pandemic Influenza Implementation Plan." Dr. Hatchett previously served as Senior Medical Advisor in the U.S. Department of Health and Human Services, Office of Public Health Emergency Preparedness, where he worked on a wide range of bio-defense issues including the delivery of mass prophylaxis to urban populations, the development of disease contaminant strategies, and the role of modeling in the formulation of public health policy. Dr. Hatchett completed his undergraduate in medical education at Vanderbilt University, an internship and residency in internal medicine at New York Hospital, Cornell Medical Center, and a fellowship in medical oncology at the Duke University Medical Center. So, as you can see, we're in very good hands. We are extremely fortunate to have him with us here today. I give you Dr. Richard Hatchett. [APPLAUSE] >>>DR. RICHARD HATCHETT: Karen, thank you for that very kind introduction and thank you to FEMA and to Administrator Fugate and to Deputy Administrator Manning for inviting me to address all of you on this very important topic. Unfortunately, this is the only part of this conference that I have been able to attend. It looks like a fabulous conference. I've been to the Annual Conference for the Medical Reserve Corps on a couple of occasions in the past and I always found those to be terrifically inspiring, a great opportunity to learn, to hear from people working in local communities about what they were doing. I am-I am sure that this conference will fulfill that same function for all of you. I'm sorry that I have not been able to participate in it or will be able to participate in the sessions going forward. It's really terrifically inspiring. In thinking about the conference and in looking over the sessions, I was reminded of Justice Louis Brandeis's comment that the only title in our democracy superior to that of President is that of citizen. All of us are citizens and all of us contribute to the well-being of our communities and ultimately to our Nation, and that is what I'm gonna talk to you about today in the context of thinking about H1N1 influenza, the unfolding pandemic that we've been observing for several months now and that we anticipate will result in increased disease, illness, and unfortunately death in our communities in the months to come. At the National Security Staff, I belong to something called the "Resilience Directorate." It's a-it's a new directorate within the national security apparatus that focuses on preparedness and response to disasters and, in this case, the public health crises. Resiliency has been a buzz word in the preparedness and response community for several years now but it's not necessarily something that is easily defined. We talk about it a lot, we-we-we try to foster it, we hope to augment it, but we often don't have a terrifically clear idea or a terrifically fixed idea of what we're talking about. I wanna just start my remarks by referring to a-an attempt at a definition by a fellow named Michele Bernot (ph.). He's the Director of the Center for Earthquake Engineering Research at the State University of New York in Buffalo. He's devised a nice framework, which he calls the "Four R's" for talking about resiliency. He talks about "robustness" as the ability to withstand stress with minimum degradation or loss of function. He talks about "redundancy" as the availability of substitutes, things that can be switched in if a particular aspect or component of a-of a community or critical infrastructure fails. He underscores the importance of "resourcefulness, the capacity to identify problems and mobilize responses. And, finally, he talks about "rapidity, which is the ability to address priorities and accomplish goals in a timely fashion. I think we're going to have to draw on all four of these elements as we move into the fall, and I'm sure that all of you, your organizations, the constituencies you serve, your publics will contribute in their own unique way to enhancing our capabilities in this regard. Would you advance this slide, please? A little bit of technical difficulties. They advised me, they said that, you know, BlackBerries can interfere with your remote and I said, "There are probably 700 BlackBerries in the room and so that doesn't bode well." So please bear with me as we move through this. I'm gonna talk about four things basically. I'm gonna-I'm gonna give you an overview of the current situation. What I will not do is make predictions as anybody who is in the flu business knows that flu is inherently unpredictable. It is-it is a dangerous business to be in the business of flu predictions. So I will-I will talk about where we are now and I will look to some historical examples to tell you how these things have unfolded in the past in the hope that that will inform your understanding of what we might face or at least what we think we should be prepared to face potentially. I will spend some time talking about the vaccination program. It is-it is by no means the only part of our response but it is a very important part of our response. And it-and it-and it is likely to be a part of the response that many of you and your organizations may become involved in in a-in a volunteer capacity going forward. And then I'll-and then I'll just conclude with some overarching thoughts and comments. So the current situation... I'm gonna show you a couple of maps. I'll walk you through them individually. These are maps that have been prepared by WHO. They illustrate the remarkable speed in this case with which the virus is spread. The orange-ish colored countries are countries that have now officially confirmed cases of H1N1. The circles represent according to the legend in the-in the lower left, the number of deaths that have occurred in each country. What you can see is that to date the virus has spread globally. The blank spots in Africa are a little difficult to interpret. The-the... Africa is a very surveillance-deprived area so it-the fact that those countries have not been colored in doesn't necessarily mean that the disease is not there. But almost everywhere else in the world we have documented disease. The Western Hemisphere has been the most affected to date, not surprisingly because of the origins of the virus in Central America probably early in the spring. This is a chart that was prepared by WHO and I-and I draw your attention to the fact that the data is only from July 19th. Now ordinarily if I were standing up here and presenting data from July 19th, I would say that this is hot off the presses, this is very fresh data. In this case, this is almost an eon ago in terms of this pandemic, in terms of how fast it's changing and spreading. But what you can see is that there has been widespread disease particularly in the Western Hemisphere. Almost all of the Western Hemisphere has now experienced widespread disease. And, at the time, Australia and New Zealand were not colored. Apparently they were not reporting data but there is now widespread disease in Australia, New Zealand, Thailand, and certainly Great Britain. This is a slide that represents an effort by WHO to illustrate the in-the intensity of spread, meaning the burden of acute respiratory disease that has been observed in the affected countries. Lots of the countries are not reporting so this is a-sort of an incomplete map. And, again, this is data through July 19th. But what you can see is that actually the United States has been deemed by WHO to have a low or moderate intensity to date. We've had lots and lots of disease but we are a very big country. And except for a few local outbreaks like the outbreak in New York City, the outbreak in Milwaukee, the general intensity of transmission that we've seen has not been overwhelming yet. Canada's seen a little bit more. Mexico certainly had a-had a very large outbreak in the spring that has continued to percolate along and they are now seeing increasing disease transmission in the southeastern states down in the Yucatan Peninsula. In particular, the nations of the Southern Hemisphere have demonstrated very high intensity of transmission to date. That is not surprising. The flu seasons are reversed seasonally so they are in the middle of their high transmission flu season right now. We've been watching the nations of the Southern Hemisphere very closely, particularly nations like Australia, New Zealand, Argentina, Chile, Uruguay to some extent, that have similar social demographics, similar standards of living to the United States, trying to discern patterns there that may help inform our planning and preparedness for the fall. We've certainly been paying close attention to the disease domestically but we are also trying to learn what we can from the experience of other nations. Some of the nations in the Southern Hemisphere have undertaken quite aggressive responses and we are also striving to learn from their responses. Argentina, for example, most of the nations in the Southern Hemisphere I should say, have a winter break that would correspond more or less to our Christmas break. And most of the nations take that winter break at some point in July for a couple of weeks and people go skiing and do the sorts of things that you do in the winter. Argentina took a quite aggressive stance in terms of their winter break. They actually extended it. It would ordinarily have been about 2 weeks. They started it early on July 6th and they extended it through August 3rd. And so the schools were out for almost a month in Argentina and they have gone back into session and we continue to watch. They're still in their high transmission season. It'll be very interesting to see that-and they had quite intense disease. It'll be interesting to see what happens going forward and so we continue to observe that closely. I should warn you, actually, before we get too much further into this talk, I belong to the band of what we call "flu wonks" and flu wonks like to put up lots of curves of lines going up and coming down. And so you can see lots of curves of lines going up and coming down and I will try to explain what those mean. But it is-it is a unfortunate habit of people like me so you'll have to forgive me. This... There will be a wonkish element to this but I'll try to keep it at a high level. A little bit about what's going on in the United States. We have had disease transmitting in the United States really actually since early April. The first cases of H1N1 influenza, in fact, were diagnosed in the United States in California and Texas before the Mexico outbreak was recognized to be an influenza outbreak. And those samples were collected early in April so we have had several months of flu transmission. Flu transmits very rapidly. Typically, within 2, 3, 4 days of a person getting sick they have transmitted it on to others. At this point it is very difficult to know how many cases we have had in the United States. CDC some time ago publically estimated that there had been greater than a million cases. If you talk to people in the-in the flu modeling business, and there is actually a minor industry of flu modeling, you'll get various estimates as to the number of cases that we have probably seen to date. I have heard privately estimates ranging from 1.5 to 10 million cases in the U.S. to date. No one knows for sure but it's been a lot. We now have cases in every State, every jurisdiction. We have seen to date... as of August 6th... we have seen about 6,500 hospitalizes where H1N1 has been confirmed and we have also seen 436 deaths. That's suggests to us... Given the estimate of the cases, that suggests that the overall case fatality rate, the risk of any given individual actually perishing from flu is-is-is quite low, which is reassuring. But the aggregate numbers, as the disease spreads through the community and spreads throughout the Nation, you know, will grow in a way that, you know, we, unfortunately, would not like to see. One of the defining characteristics of this virus is that it seems to be targeting our younger populations. The attack rates in younger populations... Or rather not the attack rates necessarily but the-but the percentage of total cases that are observed in younger populations is quite high. This is a chart showing some CDC data as of a couple of weeks ago, showing that about 60 percent of the cases have actually occurred in people younger than the age of 24. Influenza is a disease. It is more easily transmitted among younger populations for a variety of reasons. Even with seasonal flu we see more cases in younger people. We don't necessarily see more deaths or more hospitalizations because the people who tend to have a problem with influenza are people with other medical conditions, the aged whose immune systems may have declined, people with immunosuppression, and so on and so forth. And-and-and those people, there are greater concentrations of those people in older age groups. But this is-this is very, very striking, and what's particularly striking is the very low number of people, even after the virus has been transmitting efficiently in the United States for months, over the age of 50 who have actually been documented to have illness. And the informed scientific speculation... There is some data to support this, but the informed speculation is that people who were born before 1957 likely had exposure to previously circulating H1N1 viruses that circulated between 1918 and 1957, which appear to be a little bit more closely related to this particular virus than the H1N1 viruses that have been circulating since 1977. And so just to be very clear, H1N1 viruses have been circulating in the United States for 30 years but this is a very different H1N1. It is-it is genetically quite distinct from the H1N1 viruses that we've had circulating for the last 20 to 30 years. An immunity to the viruses that we've had circulating does not seem to provide a great deal of immunity to the current virus, but immun-but exposure to the viruses that circulated before 1957, the guess, or the informed guess as I was saying is, that they do provide some immunity, which may explain why the attack rates are so low in older populations. That same phenomenon might explain why we have seen a disproportionate number of hospitalizations in younger populations. As I said, with seasonal influenza the usual pattern that we see is that the burden of severe disease, the burden of mortality tends to cluster at the extremes of the age spectrum either in the very young, those younger than the age of about 4, and in those over the age of 65 both for hospitalizations and for deaths. What we are seeing with this virus is that among those hospitalized, the-the-the largest proportion, about 50 percent, are younger than the age of 24 and that there are a substantial proportion in the age range of 25 to 49 who are also being hospitalized. This does not necessarily mean that the absolute numbers of people in those age groups who are being hospitalized is greater than with seasonal influenza. We simply don't know yet because we don't know how many cases, you know, we're going to have. We-we... This is something that we'll figure out retrospectively, but there is a striking absence, or not complete absence but a striking reduction, in the number of hospitalizations and deaths occurring in the older populations. Just to give you a sense of the burden of disease that we have seen to date and that we may see in the fall, this is some data from New York State. What you can see here, the four-the four curves represent the number of hospitalizations by week. So week one is the first week of January, you know, so on and so forth. Week 52 is the last week of December. The number of hospitalizations by date in New York state with confirmed influenza over the last four influenza seasons, and what you can see is that-is that the 2008/2009 season up until the spring had, like 2005/2006 and 2006/2007, been a relatively mild year as far as influenza was concerned in New York State. 2007/2008 was a-was a bit more intense in New York State and you had more cases of influenza hospitalization mostly occurring in kind of the February/early March timeframe. This is what happened after H1N1 came out. As I said, New York City had a particularly large outbreak. The New York City Department of Health and Mental Hygiene, based on some subsequent surveys that they did, estimated that about 10 percent of the population of New York City actually fell ill with H1N1 during their spring outbreak. What you can see is the large outbreaks in the New York City area, and it spread into other parts of New York State, resulted in a striking increase in the number of people who were hospitalized. Just to reference point, to frame this up, we normally would expect somewhere in the order of 5 to 15 percent of the population to develop influenza during a typical seasonal flu year. They had about 10 percent roughly... Again, these numbers are not certain; these are best estimates at this point. But they estimated that about 10 percent of New York City's population developed influenza. So that was almost like a winter's worth of flu in the spring. Historically, when we look at previous pandemics, we have estimated that the overall attack rate, the overall percentage of the population that will become ill during the course of the pandemic, is somewhere on the order of 25 to 35 percent. So the outbreak in New York State, while it was a substantial outbreak, doesn't really compare in its-in its extent or intensity with what we have seen with previous pandemics. As I said, I'm not gonna hazard any predictions because influenza is inherently unpredictable. Come to the issue of the mortality patterns that we are seeing. Again, as with hospitalizations, we are seeing a unusual distribution of mortality. I wanna underscore that that is distribution of mortality. I don't want to-I don't-I don't want any of you to walk away saying that we know that we are having more deaths in aggregate than we would have in these age groups with seasonal influenza. But looking at the total number of deaths and which age groups they fall into, this is not a pattern that we see with typical seasonal influenza. There is, as I said, a striking reduction in the elderly population. This is a slide from Mexico comparing H1N1 distribution of mortality-again, not absolute numbers but the distribution of mortality-with the last two seasonal flu years. The last two seasonal flu years are the black and the white bars and they show the very typical pattern of seasonal influenza mortality where roughly 90 percent of the mortality is observed in the people who are 65 and older and a large portion of the rest of the morality is observed in the population between the ages of 0 and 4. That is, as you can see with the orange bars which represent the distribution for H1N1, not what we are seeing with this virus. The last issue that I wanna touch on is certainly the issue that I think everyone is most sensitive to, which is that if this is a virus that is largely affecting young people, unfortunately it is also causing some deaths in the pediatric populations. Typically... And-and-and I show this slide to illustrate what we've seen to date with what we've seen for the last few years. This is CDC data. CDC has undertaken to-to-trying to keep track of pediatric influenza deaths. As a result of the 2003/2004 flu year where there was-there were... I don't know if any of you remember this but there were stories about an increased number of deaths in children from influenza that year. And the vaccine was late. There were some scarcity issues with the vaccine initially so it produced a lot of anxiety. In 2003/2004, we had 150 or so deaths in children that were directly attributed to influenza. And the average number of deaths that we see during a normal, typical seasonal flu year in the pediatric populations is somewhere on the order of 60 to a 100. It varies year to year. It depends on what the dominant strain that's circulating is, but it-but it is somewhere in that ballpark. The curves in purple and-and the-and the one yellow slot represent the pediatric deaths that have been reported to date for H1N1 virus. And so we have had roughly, I think, 29 or 30 pediatric deaths so far and we... Again, we don't know how large of an outbreak we've had, we don't know how large an outbreak is coming, but there is, you know, reason to be concerned that we will see substantially larger outbreaks in the future. So we don't know where this number will end up but it will certainly be... These are very poignant deaths. They attract a lot of attention. They typically report it certainly in local or regional newspapers. This is something we'll be keeping a very, very close eye on as we go forward. It certainly contributes to public perceptions of severity of the outbreak for obvious reasons. I'll talk very briefly about some of the social disruption that we saw in the spring. When the pandemic began, the reports that were emerging from Mexico initially were very concerning. We were hearing stories about hundreds or thousands of young people who were becoming seriously ill requiring hospitalization, many young people on ventilators, many young people dying. And at that point in late April, it was, I believe, April 23rd when we got confirmation back about the first Mexican isolates, it was not clear how large the outbreak in Mexico was. And so CDC took a-a-you know, they erred on the side of caution in terms of making recommendations about school closures, and they recommend that schools close at relatively low burdens of disease. And what you can see, the blue curve represents the number of schools that were closed on a day-by-day basis in late April and early May. It peaked at around 726 schools that were closed because of influenza, affecting almost 470,000 students. This was obviously quite disruptive. And I have to say that CDC is to be commended for working very, very rapidly to gain a better understanding of the virus and to understand that the disease was much more widespread than we had initially understood and that-and that the actual average case of in-of H1N1 disease was much less severe than we had initially feared might be the case. And so taking that context they adapted their guidance very, very rapidly and I believe on May 4th or May 5th released revised guidance saying that it was not actually necessary to close schools at the first sign of influenza. And you can see the sharp decline in the number of schools that were closed. That kind of contextual adaptation, I think is going to be very, very important as we go forward into the fall. I mean-I mean, we in the Government are bureaucrats and we don't typically work at lightning speed, but CDC worked very, very rapidly to sort out what was happening and to provide the best guidance and the best science-informed guidance that they could. And, as many of you have heard, they released their new school guidance on Friday where the goal will be to keep schools open but safe and to focus on ways to protect both the general student population, as well, particularly the vulnerable populations within schools. And we will continue to look at our guidance and revise our guidance as contexts change and we will continue to adapt. And you and your local communities will have to do the same thing. You'll have to look at the situation in your community and make adjustments as we go along, and you need to be ready to adapt in that-in that rapid fashion as circumstances dictate. I should point out the one other interesting thing about this chart is that even after the guidance to reopen the schools was released, it's-it was still necessary all the way through May to close some schools. There were reasons to close the schools. The number of students or teachers who were absent was simply too high to allow, you know, useful educational instruction to occur. And so school closures were observed throughout the rest of the spring but at a much reduced rate and, thus, with much less social disruption than we witnessed in the early part of May. I would anticipate that we are likely to see even though the guidance, you know, is to try to keep schools open and make sure that they're safe environments for our students, I would expect that we will see some school closures in the fall. And I think it's important for all communities to anticipate that that may occur and to work with students and families with the educational community to try to ensure that useful instruction can continue, that parents are able to adapt if and when they need to in the event that a school here, or a school there, or even perhaps a school district were to close. So being prepared for that doesn't mean having to implement it. It just means that it-you know, it is something that may happen. It may be forced upon us by circumstances. So just to summarize, that's kind of the end of the situation update. The good news, if there is some good news, is that the overall case fatality rate appears to be quite low. We can't really put a fix on that but it seems to be somewhere in aggregate in the-in the range of what we see with seasonal influenza. The challenge for us, obviously, going forward into the fall is that we may see a substantial increase in the burden of disease perhaps by as much as a factor of two or three. So it's not to say that we're totally out of the woods but we are certainly not dealing with, you know, the Andromeda strain or a 1918 virus. So what we also are seeing from our virologic surveillance, you know, both domestically and abroad, you know, sequencing new viral isolates and comparing them to the viral isolates that we've seen before, is that the virus is not mutating in any significant way that would either increase its severity or its transmissibility. The virus seems to be behaving in the Southern Hemisphere, to the best that we can tell, pretty much as it behaved here. It's transmitting, perhaps, more efficiently because they're in flu season, but the virus seems to be the same virus. And with the exception of a few isolated instances, the virus continues to be susceptible to Tamiflu and Relenza, our main antiviral drugs, which is good news. So I wanna talk about-a little bit about historical... Since I said I wouldn't make any predictions, I wanna talk about our historical experience. These charts, it's a little bit complicated. I hope everybody can see. I've got the arrow and we'll try to have the arrow to walk you through this. But they are basically illustrations of the epidemic curves of the last four pandemics in different locations. There was a pandemic in 1889, there was a pandemic... Obviously, all of you have heard about the 1918 pandemic. There was a pandemic in 1957, or that started in 1957 and one that started in 1968. The important-the reason I'm putting this slide up is to illustrate something that's very important to understand about pandemics. Pandemics are multiwave, multiyear events. We're heading into what will likely be the fall wave of the 2009 pandemic. But previous pandemics have returned over several years to cause enhanced mortality, higher rates of hospitalizations and death over several years. The 1957 pandemic, you can see that there was, in the lower left corner, in 1957, in the fall, there was a sharp spike and then a-and then a fairly dramatic decline in the number of deaths that were observed, and then it returned in the spring. So we need to mentally prepare ourselves for the duration of the campaign that we're about to face. We are racing against the fall wave in an effort to develop a vaccine that we hope that we can give to people to protect, you know, a large part of the population. But even if the fall wave beats the vaccine, it doesn't mean that, you know, we were too late because this is likely to be an event that will occur... We may see a spring wave, we may see a wave next fall, we may see a wave the following spring. We don't know. And so the effort to immunize the public will be critical even if the virus happens to get here before the vaccine does. We are moving as fast as we possibly can to make sure that we have the vaccine available, but it's not all about the fall. Just to illustrate another point about pandemics... This is deep into the wonky part of this talk so I'll try to get away from these curves that go up and go down. In previous pandemics, we-just so that you know, we have seen this same skewing of attack rates towards younger populations. It-it-it is very characteristic of influenza because of the social environments that we live in, because of the social environments that our children live in that attack rates are higher in children. There is nothing peculiar about this epidemic except, perhaps, the amplitude of the-of the more-of the case burden that we're seeing in younger populations. The reason I show this to you is the blue curve is-represents the age-specific clinical attack rates of the 1957 virus, which was actually different from the 1918 and the 1968 viruses, the red and the green curves, in the striking propensity for attacking younger populations. 1957, for the people who lived through it and experienced it, was a pandemic that was triggered by the opening of the schools in the fall. And a lot of us now are looking to the 1957 pandemic as a potential guide to what we might expect because of the way this virus seems to be behaving. So instead of looking to 1918, which is everybody's worst case scenario, a lot of us are now trying to learn more about the 1957 pandemic and trying to understand the dynamics of that event. And so a lot of the slides that I'm gonna show you actually relate to the 1957 pandemic, not to the 1918 pandemic. I'm sure all of you have seen lots of presentations about 1918 before. These are mortality curves. The dotted line represents the mortality in England, the solid line represents mortality in the United States. The only reason I show this is just to point out the fact that, again, as I said, you know, this is likely to be around... The 1957 pandemic was a pandemic, which caused, you know, higher rates of mortality for about 6 or 7 months once it-once it actually started. The... 1957 and 1918, actually, are important examples for us historically because they were the two pandemics where we knew that the pandemic virus was circulating in the United States in the spring and-late spring and early summer and sort of percolated through the summer. In 1957 there were-as this year, there were a number of outbreaks in camps, at Boy Scout Jamborees. There was a big outbreak at the Boy Scout Jamboree and that was observed all through the summer. I had the opportunity to spend a couple of hours with Dr. D.A. Henderson, who was most well known for leading the WHO Global Small Pox Eradication Program, but in 1957 was the Chief Operating Officer for Alex Langmer (ph.) at CDC in performing epidemiology and surveillance related to the 1957 virus. And he gave a wonderful metaphor for what they experienced. He said, "We-we... It was like the virus laid down a bed of roots throughout the summer and then when conditions were right, in this case when schools reopened, the virus just came up like the grass in spring." It just came up everywhere at the same time and he said it was just almost overwhelming how quickly it happened. And that is a useful analogy, I think. It certainly is governing our efforts to prepare for what we might see in the fall. We can-we can't know anything for certain. This is a chart to illustrate how quickly the virus spread. It actual... This is how they tracked its spread in 1957 in real time. It was actually just counting the number of counties that were reporting outbreaks. And so this chart shows how the virus, over September and October, peaking around the week of October 19th, rapidly spread to hundreds and hundreds of counties. And each county would then have an outbreak that lasted 6 to 8 to 10 weeks, so that by the time you were at the peak you were probably looking at 1,500 or 1,800 counties that were having simultaneous outbreaks. That just absolute diffusion of disease, you know, would place insurmountable burdens on the Federal Government's ability to respond to all the communities at the same time. And this is the message that everyone has heard, is that, you know, the communities are going to have to draw deeply on their own resources if and when this actually occurs. Subsequently in 1957, they-through the use of survey tools they went back and tried to recreate the actual case curve, and they estimated that that week of October 19th, the week when the-when the epidemic peaked, about 12 million people actually became sick and had to stay home in bed for at least 1 day at-during the peak week of the 1957 pandemic. And that was over a denominator of a total population in the United States of about 170 million people. So that was, I don't know, 7, 8 percent of the population becoming sick in 1 week. This is a-kind of a complicated chart. It shows absenteeism in schools. I think this is an issue that people will be very concerned about this fall. In 1918... There were actually very few cities in 1918 that left their schools open. Only three that I'm aware of-New York, Chicago, and New Haven. And Chicago kept the best records and they looked at absenteeism in the different parts of the city over time and what you can see, looking at the chart, is that absenteeism in the Chicago schools peaked around 40 percent right at the peak of the epidemic. It actually peaked as the number of deaths were peaking. And because deaths are delayed, you know, by a week or more after cases... A lot of the absenteeism in Chicago schools was probably driven by parental fear and anxiety, not by student illness. Those anxieties and concerns were dramatically reduced in 1957 because the virus was much less lethal in its effects. And absenteeism in 1957 peaked in most schools around 20 to 30 percent in the schools that were studied. It was a little bit higher in high schools than it was in elementary schools. It wasn't... There weren't any absolutely clear patterns about which types of schools were affected first. There's a slight preponderance of high schools were affected before elementary schools, but there were some communities where the elementary schools were affected first. So it's likely to be a mix this fall. AT&T was one of the largest industrial concerns in the United States in 1957 and they actually went back and looked at the average absenteeism for AT&T across the Nation over the course of the 1957 pandemic. And the-and the average absenteeism spread out across the whole country. It actually peaked at around just 2 to 3 percent above baseline, but that was a-a-you know, averaging across the entire country. In specific locations they saw absenteeism that was up to maybe 8 or 10 percent above their baseline absenteeism. I'm gonna move quickly to talk about the vaccination programs or our vaccination program. We've got a couple of historical analogies to look at in terms of semi-emergency vaccination programs. I'll talk briefly about three of 'em. The... One of the most famous, many of you may have heard stories about this, was the 1947 Small Pox Vaccination Program in New York City. A traveler came back from Mexico, developed a hemorrhagic form of small pox. It was not as easy to diagnose as classical small pox. Moved around the city for several days, caused a few more cases of small pox. And so they implemented a crash program to vaccinate the entire city. New York City succeeded. Population then was probably about 8 million people. They claim to have vaccinated around 6 million people within about a month. There are others who have gone back... Concepkowitz (ph.), an Infectious Disease Specialist in New York City, has gone back and looked at it. He thinks they may have actually vaccinated only 3 or 4 million people. We don't know for sure but it-it-it's certainly part of our collective memory in the emergency preparedness and response community as to what can be achieved when the population is with you and, you know, has an incentive to be vaccinated. Another example that bears scrutiny is the 1954 polio vaccine field trials. This was the largest clinical trial ever conducted in the United States. It involved about 1.3 million students in the spring of 1954. David Oshinsky wrote a book called Polio: An American Story that won the Pulitzer Prize for history in 2006, all about how this field trial was stood up. It's a very interesting study. It's not a-it's not a perfect example and... Of course, it was a successful campaign. It was not a perfect example because it was a-it was a clinical trial, so there was lots of additional recordkeeping. But I should say that the-in standing up a vaccination program where you were targeting 1.3 million students, they had to get the assistance of something like 50,000 physicians, almost 200,000 volunteers to stand that trial up. That is just to give you a sense of the magnitude of what we might be facing going forward as we talk about trying to vaccinate 100, 150, even 200 million people, or as many people as wanna be vaccinated actually. The last example that we have looked at, and many of you have heard or remember the swine flu fiasco as it's-as it's known popularly... In 1976, there was an H1N1 outbreak at Fort Dix. A young soldier, 22-year-old young man, died. This was the first time that H1N1 had been seen in the population since the late '50s. It was thought that the virus that broke out at Fort Dix was closely related to the 1918 virus. There was a tremendous amount of anxiety that we might be facing a recurrence of the 1918 virus with the terrible mortality that we saw in 1918. And there were some questionable decisions that were made and it's not my intention to review the decisionmaking process. We've studied it. Harvey Feinberg, the President of the Institute of Medicine, and Richard Noystada (ph.), an Historian at Harvard, actually wrote a very, very interesting study in 1978 about the decisionmaking process, and it's extremely interesting reading for some of us. But that's not why I'm bringing the example up. I wanna bring the example up because it was perceived to be an emergency and there was a-a effort to rapidly vaccinate the America population. And the effort in 1976 focused on older populations and we succeeded in-actually, in vaccinating 40 million people in about two and a half months. That was a remarkable accomplishment but it was... If you dig down into that accomplishment, what you can see is that the vaccination rates were quite variable. Some cities vaccinated 60 percent of the target population, some cities vaccinated 15 or 20 percent. It depended a lot on the efforts of people in the local communities and on the commitment of local public health officials. The other thing about 1976 that's important to bear in mind, is about 85 percent of the vaccinations were done through public health clinics and only about 15 percent through private providers. And we, I think, envision a different mix in terms of our-in terms of our vaccination strategy for the fall. Fortunately... Our-our-the only example that we have to turn to that even approaches in scope what we're attempting, fortunately, is what we do every year, which is-which is our Seasonal Flu Vaccination Program. We tend to vaccinate around 100 to 120 million people a year. Most of those vaccinations take place in high-risk individuals, in the elderly, increasing numbers in the children, fortunately. Most of it goes through the private health system. Most of the vaccination actually occurs before influenza really begins to circulate, and with seasonal flu, because of prior immunity and prior exposure to vaccine, most people only need one shot. So there are-there are actually some striking differences with what we're looking in the fall. We are likely to be in the middle of a vaccination program while a lot of influenza is circulating. This may be an incentive to people to come in and get vaccinated. It may put a real strain on our delivery systems. We are... The Advisory Committee on Immunization Practices has issued its high-priority recommendations, which actually cover 159 million Americans. So we are aspiring to vaccinate a much higher number of people than we normally vaccinate with seasonal flu. And it is-remains to be seen. We're in the middle of the clinical trials and studies but it-the-because people have never been exposed to this virus before it may actually require two shots. And so that's going to impose additional logistical burdens. There are many elements to our program; I won't belabor this. Delivering the vaccine is only part of it. We need to track the vaccine, how much we have, how much we're using. We need to make sure that we track the safety of the vaccine. That was one of the unfortunate outcomes in 1976 was an unexpected side effect. And after vaccinating millions and millions of people, we had several hundred people who came down with a rare neurological disorder called Yim (ph.) Beret (ph.) Syndrome and about 30 people actually died as a result of the vaccination program unfortunately. So tracking vaccine safety going forward is going to be a critical effort. And then-and then the largest challenge will be coordinating the delivery. And I think that's where a lot of your organizations may, you know, play a very important role in helping us at the local level actually deliver vaccine to the people who need it and to reach out to high-risk groups and to hard-to-reach groups. I was having a very interesting discussion at lunch with Michael Sweeney about the challenges that they face in reaching, you know, groups that, you know, predominately live in another language. That will be a terrific challenge. We need to be mindful of everyone in our community as we try to move forward. This is a slide just showing that people get vaccinated in a bunch of different places. We will hope to utilize and leverage all of these locations as we-as we move forward. We are still working on this. We, you know, certainly welcome the input and assistance of people at the local level in terms of helping us figure out how to deliver vaccine most efficiently to those who need it. And, finally, these are the high-priority groups that I mentioned the Advisory Committee provided. There's been a lot of press and play about this. Pregnant women certainly are at high risk. Health care workers will be, you know, on the front lines. Children younger than 6 months of age, actually, are... The vaccine is not licensed for children younger than 6 months of age, which is why we wanna vaccinate the people taking care of infants. Because of the disproportionate burden of disease in young people, they are a high risk-or a high-priority group. And then people who have, you know, the documented high risk conditions-pregnancy, neurological disorders, asthmas, chronic obstructive pulmonary disease-will be in the population that we target. And this is a chart showing our coverage rates for seasonal flu. In normal risk populations, the coverage rates by different age groups are actually not as high as we'd like them to be. They are higher in groups that are identified as being at high risk, but we certainly want to aim to achieve higher rates of coverage even than we've achieved here. This is gonna be one of the big challenges for the fall. I just wanna conclude briefly by going back to some of the thoughts that I had brought up earlier about adaptation and social resiliency. This is a chart that we have shown frequently. Many of you may have heard the story comparing Philadelphia and St. Louis in 1918. Philadelphia was one of the cities on the east coast that was hit quite early. They actually allowed a large city parade to take place. They resisted implementing any measures to really try to control the spread of disease in 1918. They had a terrible outbreak and you can see the death rates that were observed. Philadelphia's the blue curve. St. Louis, on the other hand, had a couple of weeks lead time. They were observing what went on on the east coast and they acted very aggressively. The health commissioner in St. Louis was sort of arm in arm with the mayor and with other public officials in voluntary organizations actually, and they implemented a broad array of community mitigation measures-closing schools, theaters, banning public gatherings-and they kept them in place for about 6 weeks. And you can see that the death rates in St. Louis were dramatically lower as a result. I bring this up not to talk about the virtues of community mitigation measures but to talk about the adaptability of an entire community. That with a little bit of lead time and effective communication from its-from its elected leaders, its leaders of its voluntary organizations, was able to adapt to a very challenging circumstance. And, you know, St. Louis saw its first cases only about 2 weeks after Philadelphia did but, yet, they were able to act very, very quickly. It's not just on a city-by-city basis. In 1995, Chicago had a-had a terrible heat wave in the middle of July and you can see the mortality peak over a few days in the middle of July when temperatures spiked up to around 95, there were high rates of humidity. Almost 700 people died in this heat wave. What is most important about this curve is not what it shows but what it doesn't show. There was another heat wave at the end of the month with almost the same duration, almost the same temperatures, and you can see what happened in the city. The city, having lived through the terrible heat wave in the middle of the month, reacted very, very quickly. They sent people around knocking on doors, and particularly in poor communities where the death rates had been very high, and they actually prevented a recurrence of the high rates of mortality that were seen just a couple of weeks before. I think-I think this kind of adaptation-rapid adaptation, rapid response to what's happening in your community is what we're going to be looking for from you all in the fall. Human communities are not just built environments; they are composed of people, social/political institutions, economic activities, and infrastructure. I think getting a handle on this contextualized adaptation, this ability of individuals and groups to draw on available resources and their own ingenuity to solve problems, is, you know, our biggest challenge, what we will be tested on in the fall. I would say that-I would offer to you that our capacities in this regard to adapt-to adapt quickly should not be underestimated. Such adaptation is much easier when a community is magnetized by an external threat. External threats are wonderfully effective at promoting cooperation, breaking down barriers, removing bureaucratic obstacles, and I think that we should all go into the fall realizing that we can draw on this. I actually, if I can offer something to the general discussion, would like to call this the "Dunkirk Effect, and I'll finish up by talking about the Dunkirk Effect briefly. All of you know the story. The British Expeditionary Force was on the European mainland. It was essentially the entire British Army in 1940, 200,000 men. They ended up being trapped when the King of Belgium surrendered his army and the Germans were sort of coming in from both sides at 'em. They retreat to the beaches of Dunkirk and when the evacuation started on May 26th, Churchill thought that they would be lucky if they could get 50,000 men out. And the problem was that the British destroyers, you can see in this picture, they-they-they-their drafts were too deep. They couldn't come into the shore so men were having to wade out to the destroyers to board and they were having to stand neck deep in water for hours at a time. And so a couple of days later, on May 28th, the British Ministry of Shipping actually put out a call for all boats with shallow draft-pleasure crafts, private yachts, fishing boats, Merchant Marine vessels, more than 700 all told, none of them with arms, all piloted by civilians-and asked for assistance. And with the help of the small boats, in a week, actually, all of the British Expeditionary Force and about 140,000 men from the French Army were evacuated successfully. And it was quite interesting. After things got organized this is a wonderful example of what I would call "contextualized adaptation." Churchill called the evacuation "a miracle of deliverance achieved by valor, by perseverance, by perfect discipline, by faultless service, by resource, by skill, and by unconquerable fidelity" in his sort of wonderful way. He also, incidentally, reminded his colleagues in Parliament that wars are not won by evacuations. But I wanna-I wanna just conclude there. I wanna finally just draw on a personal experience. I was a civilian up until 2002 and I had the privilege of responding to Ground Zero after the attacks of September 11th. It was a utterly life-changing experience. It-it... Seeing the volunteers who responded to provide support to the search and rescue workers changed the direction of my career. That's actually why I'm standing in front of you today. It instilled in me a terrific confidence in our public's-in our ability to respond. I am confident going forward looking towards the fall, towards whatever we encounter, that those same resources will be drawn on by you, by your organizations, and you will draw on the public in your communities to meet the challenges that we have ahead of us. And so with that I'd like to thank you for your service and thank you for inviting me to speak to you. [APPLAUSE] >>>Karen Marsh: I wanna thank Dr. Hatchett for presenting such a wealth of information in a clear and only slightly wonky way. I know that all of you agree with me that we're awfully glad that he holds the position that he does. So please join me in thanking him once again for being here today. [APPLAUSE]