Press Briefing Transcripts

CDC Briefing on Public Health Investigation of Human Cases of H1N1 Flu (Swine Flu)

May 1, 2009, 1:15 p.m. EST

• Audio recording (MPEG)

 

Glen Nowak:Thank you all for joining us today for an update on the H1N1 outbreak in the United States, and throughout the world.  Today we have Dr. Anne Schuchat, who is the director of CDC's National Center for Immunization and Respiratory Diseases.  Along with Dr. Nancy Cox, who is director of CDC's influenza division.  Dr. Cox will follow Dr. Schuchat with opening remarks.  And Dr. Cox will be talking about what we know about the virus.  I know there's a lot of interest in vaccine development.  First I will turn it over to Dr. Schuchat with where we stand for the number of cases and the actions taken in the last 24 hours.  So, Dr. Schuchat? 

Anne Schuchat: Good afternoon.  It’s a pleasure to see you all. I hope we can share some new information with you and help you see where we are.  I wanted to start by reminding folks that we are just one week into this.  To some extent it feels like it's been a lot longer than a week, but it really is just the first week.  And that's important as we get to the issues of what's going to happen in the future.  I also want to start recognizing that more and more communities are being affected, and more people are being directly impacted by the H1N1 novel virus that we're seeing this year.  And that can be certainly difficult for people.  And we hope with our information and answering any questions that you have, we can ease that challenge.  The latest cases that we release every day is 11.  Today's count is 141 confirmed cases.  And 19 states have confirmed this disease.  That's up eight states since yesterday's report.  And our website, www.CDC.gov lists the individual states and case counts that have been confirmed in all those individual states.  As we’ve been saying, we're trying not to pay too much attention to the numbers.  We're looking more at patterns, and at actions.  So the numbers we'll be giving you, but they'll have less and less meaning over the next several days, I think.  We do know the virus is in many parts of our country at this point. 

In terms of the cases that we have good information on, the median age is 17, with a range of 1 to 81 years.  The most recent onset of illness is April 28th.  So we think the cases do continue to occur.  And I think to look ahead a little bit, to give you some context, it's important to recognize that we do expect to see more cases.  We expect to see more states.  That won't be a surprise at all.  We're looking and we're finding where we look.  And we've increased the capacity that the states have to recognize this disease, by shipping those diagnostic kits that you heard about.  So we do think they'll be -- the counts are going to go up.  But there's several new actions I want to tell you about.  Because I think they show the aggressive response that we've been having to the situation, to make sure that we're prepared as things unfold.  We have, as you know, we previously made the decision to ship one-quarter of the antiviral assets in the Strategic National Stockpile to the states in project areas.  We have -- we are well on the way to getting those antivirals out to the affected and unaffected states.  And the Secretary of Health and Human Services, our new secretary, Sebelius, made the decision to purchase 13 million more courses of antiviral drugs.  Essentially to replenish our antiviral Strategic National Stockpile.  We don't know whether we'll need those or not, but we want to be ready.  Remembering that the antiviral stockpile assets are really to make sure we have enough medicine to treat a large number of people.  We also have, since the last 24 hours, have been able to ship antiviral drugs to Mexico through the request of the Mexican government and approval to help the Mexicans, we're shipping 400,000 regimens of antivirals to Mexico, to help them with the illness with many parts of that country. 

In the last 24 hours, we've issued two new MMWR reports.  One describes the story in a school in New York City.  And the other describes information from the Mexico outbreak itself.  It's really heartening to me that we've been able to get that kind of information out, with the partnership of the Mexican authorities and the New York City health department, to make sure that people can see the experiences in those two areas and learn from them as we go forward.  You may have seen that Harvard released a public opinion poll today.  If you didn't see that, I think we can probably point you to their press release information.  And there's some real interesting findings in what they reported, that I'll be mentioning.  And I want to say that I need to thank all of you about, but one of their findings is that apparently 75% of people report that they are following this.  They're paying attention.  And I think you're part of the reason for that, so thanks for all of the help you've been with that.  The other heartening news is that 59% of those polled say they're washing their hands more often, or using alcohol-based hand gels more often.  That's amazing, and that's great.  That will reduce other respiratory infections as well as reduce the transmission of this virus.  So we think this is a really good result of how the American people are reacting to this challenge. 

There's been a lot of discussion in the past couple days about vaccines.  You may have known, I did a couple of hearings in Washington yesterday, and I think half of the questions were about vaccines.  This is the right time to be talking about vaccines.  As you know from our seasonal influenza experience, we have to plan for vaccine a long time before we intend to use it.  And so we're lucky today that Dr. Nancy Cox will be speaking with you in a little more technical detail about some of the virus characteristics and the vaccine issues.  But just in general, what I want to say is that our CDC experts are preparing this vaccine seed strain (Editor’s Note: This is a correction).  That's the first step. Trying to identify a strain that is going to be the right strain in terms of the immunologic characteristics, and also one that can grow well and the manufacturers can handle.  After that, there are steps involved with pilot lot production and clinical testing and dosage formulation and such, so if you were going to make one, how would you do it.  And then after that, there are additional steps in terms of making the vaccine.  There are also several steps in terms of decisions.  And I'm not sure if Dr. Cox is going to go into that.  But I want you to know that what we've done so far, is that aggressive, that make sure if we need to make a vaccine, that we can, and manufacture large numbers of doses of vaccines.  And we haven't made a decision yet if we make a vaccine, to produce a lot of it.  Those are decisions that need to be made in a deliberate, thoughtful, careful way.  They’re not CDC’s decision. There are a number of entities that contribute to that.  And it's really scientific expertise that helps with those types of decisions.  So when we talk about vaccine, it's the right time, because we won't have one if we're not talking about it now.  But there are a lot of things in the future that will be needed. 

Moving forward, I think we can expect to see more states, we can expect to see more communities affected.  We know that there are a number of schools that have been closed, and children that are staying home.  An important thing to remember is, the reason for those school closures was to keep kids away from a lot of other people.  So if kids are staying home, and then, you know, congregating elsewhere, that's probably not the best plan.  And it's also a time where decision-making is different, in different communities.  We think that's a good thing.  People are learning.  They're also adapting to the local circumstances with the ground troops.  In my city or town, is school closure an option, or will it affect how people will live around here. 

Very much, public health is trying to strike a balance.  We're trying to have, as far as we can, evidence-based interventions, and we're trying to have interventions that won't be more harmful than the virus itself.  It's a priority for us now to learn more about the severity of this virus.  It's been a topic in the media, so it's a great concern to us, to understand what this virus is going to do over time in our population.  And it's a priority to get good information out. 
I want to make sure that you know that in addition to our website, we actually have a hotline, 1-800-CDC-INFO.  And that's in English and Spanish.  At some of my hearings I learned some of our Spanish-speaking communities were not able to access some of our information. And that hotline's available 24/7.  So like all of us are, and all of you are, and we do hope you can let some of the readers know that that's an asset, not just the website. 

So I think in closing, before Nancy comes up, I just want to say, on behalf of CDC, how heartening it's been to see the response of the American public, to see people paying attention to this important situation, and to see people washing their hands more.  Starting to take action.  Taking the situation into their own control.  This is a shared responsibility we have.  Government is working hard.  But everyone has a role to play.  And I hope that we can keep you updated and work together in the weeks to come.  So I think I'm going to let Dr. Cox talk a little bit about what we've learned about the virus, and where we're going with this whole idea of vaccinations. 

Nancy Cox: Thank you, Dr. Schuchat.  We've actually learned a great deal about the viruses that are causing these infections.  And we're doing this with the international community.  So as you know, the virus has been detected, this new novel, this novel H1N1 virus has been detected in a number of countries internationally.  We're all working together to characterize the viruses that have been isolated from the individuals.  There are a number of countries that are sharing the sequence data, that is, the genetic sequence data that is derived from these viruses.  And we now have genetic information available from six countries, including the U.S., Mexico, New Zealand, Canada, Netherlands and Germany.  Now, the good news is that all of the genes of all of the viruses that we have examined to date are 99% to 100% identical.  What this means for us is that it will be somewhat easier to produce an influenza vaccine, because the viruses that are spreading are so similar to each other.  As Dr. Schuchat said, we are aggressively taking the very early steps that are necessary for vaccine manufacture, should a decision be made to go ahead and ramp up to full-scale production.  The first step in developing a vaccine is to derive what we call a vaccine virus that will grow well enough for vaccine manufacturers to produce large numbers of doses.  And we call this candidate vaccine virus a high growth virus, indicating that it will produce -- it will be able to be produced in large enough quantity.  So we are working with our partners around the world, as we do for seasonal influenza vaccine strain, to produce appropriate vaccines strains for this new virus.  Now, we have a variety of different techniques that can be used.  And I'll just give you a bird's-eye view of the various techniques.  We've already grown the viruses from patients in eggs, and we are distributing viruses to our global and domestic partners who use traditional methods called reassortment to make high yield candidate vaccine viruses.  Now, what reassortment means is that the new H1N1 virus is co-infected in eggs with the virus that grows well, already grows well in eggs.  And we use certain laboratory techniques to derive a virus that has the internal backbone genes from the laboratory strain that grows really well, and has the anti-Jens, the surface proteins from the new virus.  And this is what the vaccine manufacturers use to grow the vaccine.  We are also using more modern molecular genetic techniques called reverse genetics.  And if there are questions about these techniques, I can answer them during the question-and-answer session.  We believe it will take about three weeks to get the candidate virus.  We have already started that process in our laboratory.  If that process is going -- it's going quite well.  And so if the virus cooperates and grows well, we will soon be able to distribute a candidate vaccine virus to the manufacturers.  The companies then need about eight to ten weeks to make small lots of vaccine to test to see whether they can actually ramp up and produce large amounts of vaccine, to produce pilot lots, which then can be tested to see what actual doses of the vaccine will be required to induce good levels of antibody in humans.  I think I'll close there, and if there are any further questions on either the viruses or the vaccine, I'll be able to answer them later. 

Glen Nowak: Thank you.  Operator, we'll start by taking a couple of questions from the floor.  

Reporter: We live and work here in Georgia.  And we know there have been a number of suspected cases, a number of confirmed cases. 

Anne Schuchat: We're going to need to refer you to the Georgia health department about that.  We're really trying to make sure that the local authorities who know what's going on in realtime are the spokespeople.  What I can say is that many states are having cases.  They're investigating a lot more than they've actually confirmed.  And they're really the most knowledgeable.  We're in a supportive role, making sure they have the information they need, and recently as we've said, we got the test kits out so their state labs could do the confirmation.  We do expect now that much more of the confirmation is going to occur right there in the states without the requirement to forward strains on here to CDC.  And we think it's really good that there's going to be local and state ability to interpret the situation, and that they'll be able to guide intervention.  The interventions that are going on are complex, and usually the local authorities know the communities the best.  So we really want to be supportive and respect their ability to make good decisions. 

Reporter: Two questions.  First, could you talk about your investigation into the attack rate?  Could you tell us what the attack rate is, and how you've been looking at that in Mexico and the United States?  And I also have a question about in the genetic analysis, have you ascertained what this virus has in common with or doesn't have in common with the 1918 virus? 

Glen Nowak:  Do you want to take those questions? 

Anne Schuchat: Yes.  Okay.  Let me give you attack rate.  I think Nancy can characterize the virus a lot better than I can.  There are many ways that we can look at attack rates.  And it's one of those tools that epidemiologists use to try to understand the situation.  One way is looking in households and families, trying to understand if you have -- when you have a virus in a family, you sort of expect it to go through the family.  The proportion of family members that are infected is a good way to come up with an attack rate.  So we're looking at lots of families, and aggregating the information to estimate an attack rate.  At this point I would say that we're estimating an attack rate that's fairly high.  You know, in the 25% to 30% range.  But that's not a final attack rate.  And it's consistent with what we see with seasonal influenza.  There's a lot of what we're seeing that isn't surprising.  Because of what we know about seasonal influenza that is easily spread, person-to-person, that family members are at higher risk and further out there.  In Mexico, there are some other ways that it's being looked at.  But our best data would be from sort of the information we have here.  You know, there are also ways, when you have a cohort, a school or a tour group or something that you can estimate an attack rate.  So we do think that this virus is easily transmitted, similar to seasonal influenza.  This isn't one that -- it is easily transmitted.  I'll let Nancy talk about what we know about 12918 -- 1918. 

Nancy Cox: Thank you.  That is a question that, of course, many people are interested in.  What we have found by looking very carefully at the sequences of the new H1N1 virus is that we do not see the markers for virulence that we're seeing in the 1918 virus.  However, we know that there's a great deal that we do not yet understand about the virulence of the 1918 virus or other influenza viruses that have a more severe clinical picture in humans.  So we're continuing to learn.  We're continuing to look for markers.  And the other thing is that we have entered the sequence data into data bases that are publicly accessible in the public domain, so that a lot of researchers around the world can begin to look those gene sequences as well in case they see something that we haven't already seen.  Thank you. 

Glen Nowak: Operator, I'll take a question from the phone right now. 

Operator: Thank you.  Robert Bazell, NBC news, your line is open. 

Robert Bazell: Thank you.  As both of you well know, this is about nomenclature.  The term H1N1 applies to a lot of viruses.  And two in particular.  One of them is the seasonal influenza that is now circulating in the United States and we knew about all summer.  And then this new virus that's come along.  And they differ in two critical ways.  One is the seasonal influenza is resistant to antivirals, the new one is susceptible to antivirals.  And there's Novak seen for the new one.  In your technical public indications, MMWR, you refer to it as swine associated H1N1.  In the same Harvard poll that you just talked about, it found that only 20% of the American public had any idea that H1N1 and the swine flu were the same thing.  So how can you justify using the term swine associated in your own publications when you're trying to get away from the term swine flu and trying to be as clear as possible to the American people during health emergency? 

Anne Schuchat:Our communication is extremely high priority for us at CDC and across the globe.  We want to make sure that the way we communicate leads to health improvements.  And we understand the confusion that has been going on in the past several days about the nomenclature.  Much of our work is very technical, very scientific and not very easy for the public to understand.  And sometimes we use terms that have unintended consequences.  So I would say that we're in a transition state where we're trying to get away from the word swine, because we know that isn't -- it's not exposure to swine that is the way that people in the United States are getting this infection.  And that that has caused some confusion.  We're also really trying to make sure that we get new guidance and new information out quickly.  And so we're working on transitioning some of the materials that we have, the website and so forth, so that we don't leave -- so we don't lead to miscommunication.  And it's helpful for us to hear the problems that are occurring.  I was also heartened by the Harvard poll that it was a relatively small number of people that thought that they could get this influenza from eating pork.  So I think we have a ways to go.  We're trying to be sensitive to those clear communication, and unintended cultural or social impacts of our words. 

Glen Nowak: Another question from the phone?

Operator: Maggie Fox, Reuters, please go ahead. 

Maggie Fox: Thanks.  The MMWR that went out suggested that there might be a higher prevalence in Mexico that we might have thought, and could explain why there's so many fatalities because there's more cases overall.  Can you explain how strong a possibility that is? 

Anne Schuchat: Yes.  I think before I answer that directly, I want to give you some sense of what we're dealing with.  We're trying to understand the severity of this virus, or estimate it at a pretty early stage.  You might think about a baseball player trying to estimate a baseball player's batting average one week into the season.  I think that's about what we are trying to cope with here in the U.S.  The situation in Mexico is a little bit -- you know, emerged awhile ago, but we're only really getting data now for the past several days.  And so in Mexico, their first attention was to more severe illness, and we learned about those cases earlier, as they have continued to look.  I understand they are finding a milder case of it.  And, of course, the MMWR talks about the cases we know, and lab confirmed and some of the trends there.  Here in the U.S., we have seen a different story.  Many of our early cases came from that New York City outbreak that also was reported in today's MMWR, and that was generally a mild outbreak, or mild illness presentation in those young school children.  Seasonal influenza has a spectrum of illness.  Millions of people get influenza each year.  Most of the time it's mild.  But 200,000 people are hospitalized for influenza in America every year, and 20,000 children are hospitalized for influenza every year.  So while most people have a mild illness, some have a much more severe spectrum.  We're at the stage now of trying to not be so certain that we know about the severity.  There may be a spectrum, and we're trying to learn from Mexico, and learn from our U.S. experience, what we're seeing isn't surprising in terms of what we know from seasonal influenza. 

Glen Nowak: A question from the floor? 

Cece Connolly: Cece Connelly from the "Washington Post."  As best you know, the very first onset in the United States was march 28th, the young girl in imperial county.  There's a lot of discussion in California help circles right now that perhaps this outbreak actually began there, in the United States.  And I'm wondering if either of you could speak to that question a little bit.  And also, just why it's important from a public health perspective to try to identify and learn from the very earliest cases. 

Glen Nowak: We'll turn it over to Nancy. 

Nancy: Cox:You know, I do think that trying to go backwards and understanding how this began is important.  And valuable.  Our focus right now is on the response, on learning what we need to know about how to reduce the health impact of the virus.  So our attentions are pretty intensely focused in that way.  We appreciate others are looking back and researching.  And I would say that as we do our investigations here in the U.S., we may find that there were cases earlier.  You know, we have a very good seasonal influenza surveillance data, and we didn't find the one before the march 28th one, it was actually through the systems that we detected the unusual atypical virus.  I think you've all heard since December of 2005 through January 2009, there were 12 non-typable, or atypical strains tested here that turned out to have the swine association, or nomenclature at that time.  So I don't think we know for sure that was the first one in the U.S.  But I think it's important in going backwards to understand.  But in going forward, we're focusing on the response. 

Glen Nowak: We'll take another question from the room. 

Betsy McKay:Thanks.  Betsy McKay from the "Wall Street Journal."  Actually, I have a question for Dr. Cox, which is looking forward, what you know, you know, understand about this new strain right now, what are you going to be looking for in terms of changes if it spreads in the population, and what could happen?  What could change if it's any different from seasonal flu in that respect? 

Nancy Cox: As all of you know, and we've said many, many times before, influenza is an unpredictable virus.  So the influenza virus is unpredictable.  It constantly surprises us.  So we will be watching very closely to monitor all of the properties of the virus.  So we'll be looking for the possible introduction of antiviral resistant mutations.  So we'll look at the possibility that the virus may become resistant to antivirals.  Hopefully we hope that will not be the case.  We will be looking for changes in the genetic makeup of the viruses.  We'll be looking for changes in the way that antibodies bind to the viruses.  So we'll be looking, really, at what we call the evolution, the molecular evolution of the viruses.  And identifying at a very, very minute level what changes are occurring, and then developing hypotheses about what these changes might mean, and then testing those hypotheses in the laboratory.  So our view will be very expansive in terms of what we're doing, and we'll be doing that internationally, not just in the United States.  We'll be working with all of our global partners through the world health organization, global influenzas network.  We have many, many solid relationships with our partners around the world. 

Glen Nowak: Thank you.  Operator, we'll take a question from the phone.

Operator: Thank you.  Tom Randall, "Bloomberg News," your line is open. 

Tom Randall:My question is about the intense media coverage and the sort of viral social networking and exchange of information that we live with today that didn't exist in previous global outbreaks.  And I'm wondering what have been some of the benefits and the obstacles that this creates. 

Anne Schuchat: You know, actually, just a couple days ago in speaking with Congress, I included the media and the information technology that we have today as one of our major tools against influenza that we really didn't have in 1918.  I think there are tremendous benefits that are connectedness can lead to in addressing this.  We probably have learned about this much quicker than we could have if we didn't have such a connected world.  We have certainly, through your help, and through the new forms of social media been able to get the word out to many, many more people than we would have, knowing what to do, what to look for, how to stay informed.  There are, of course, down sides to being so connected in terms of information.  Misinformation can flourish, and scams can occur.  And I think it's very important, really, that we make sure there is credible information circulating virally to help us with this kind of public health challenge. 

Glen Nowak: Thank you.  We'll take another question from the phone. 

Operator: John Cohen, "Science Magazine," go ahead. 

John Cohen: Thank you for taking my call.  The MMWR about Mexico reports a confirmed case that had an onset of march 17th.  That's earlier than the onset reported for the report from Perote.  What is that case?  And if you could clarify that specifically, I would appreciate it.  Thank you. 

Anne Schuchat: Let me clarify that.  The march 28th case we were talking about earlier was here in the United States, in California.  The Mexican illness probably did begin earlier.  And the details on that particular case in Mexico I don't have.  We do have CDC staff as part of a W.H.O. team and part of a tri-national team, Canada, U.S. and Mexico, investigating and responding in Mexico.  So I think there will be lots more data forthcoming.  But we don't -- you know, basically the first reported case with the sequence, et cetera, was from California. 

Glen Nowak:Question in the room?  A question from the phone? 

Operator: Denise Grady, "New York Times," please go ahead. 

Denise Grady: Thank you.  This morning, at the press briefing that was given by the W.H.O., they -- there was a strong impression that vaccine production, it sounded very, very likely to go ahead.  More likely than I'm getting the impression from you.  And so I wonder if you can give us some sense of how and when that decision really will be made about whether or not to go ahead and make the vaccine. 

Glen Nowak: We'll have Nancy Cox answer that question. 

Nancy Cox: There is a very coordinated global response whenever there's an influenza outbreak, or potential influenza outbreak, whether it's a seasonal outbreak or whether it's a potential outbreak as we were looking at the bird flu outbreak in recent years.  And so the W.H.O. actually has four W.H.O. collaborating centers, along with essential regulatory laboratories such as the FDA included in that group.  Experts from the W.H.O. collaborating center, essential regulatory laboratories, work with the W.H.O. to make recommendations for what strains should be included in seasonal vaccines as well as in pilot lot vaccines for h5, or for other influenza viruses.  In the United States, the FDA's vaccines and related biological products advisory group takes the responsibility for determining the formulation of influenza vaccines used in the United States.  So there is a coordinated process that takes place within the global community, and within the United States.  And it's a very stepwide process, so we can continually evaluate what is going on, what we need to be doing at that point in time, and make sure that everything is coordinated so that the vaccine manufacturers will be able to make vaccines and test the potency of the vaccines, and go forward as seamlessly as possible should we decide to scale up.  Thank you. 

Glen Nowak: One more question from the floor, then one from the phone. 

Reporter: I think my question is for Dr. Cox again.  What is the likelihood that we might, if we decide to go ahead with the vaccine, have to sort of scrap the seasonal flu vaccine and kick in the manufacturing in H1N1 vaccine? 
Glen Nowak: Dr. Cox? 

Nancy Cox: Thank you.  That's a question that's been on the minds of many.  The seasonal vaccine, as you know, is an extremely important tool that we have for preventing and controlling influenza during our influenza season in the winter.  The vaccine manufacturers have produced a great deal of the vaccine for the next influenza season.  Some of the vaccine manufacturers are actually farther ahead than others.  Some of them, I believe, have had some difficulty in growing the influenza b strain, which was updated.  But if a vaccine for this new virus is prepared, it would be prepared either in parallel with or after the seasonal vaccine is already produced.  So that we would be able to have the seasonal vaccine, and then if necessary, a supplemental vaccine with this new H1N1 virus. 

Glen Nowak: We'll take one last question from the phone. 

Operator: Thank you.  Craig Schneider, the Atlanta Journal-Constitution, please go ahead. 

Craig Schneider: Hi.  Thank you for taking my question.  I want to get a better sense as to the process that leads a sample, a specimen to go from a hospital to a state lab to the CDC for final confirmation of -- that it is indeed this swine flu.  Can you help me understand a little bit about the decisions and testing along the way there? 

Glen Nowak: Sure.  Dr. Schuchat can answer that question. 

Anne Schuchat: Yeah, I'd like to begin recognizing that the decision-making is one that will be dynamic.  There may be ways that those steps occur at different periods.  Early on, we're very interested in knowing whether this particular new strain is in a community, or a state.  And we may have heightened attention to diagnostic testing from a lot of people.  Once we know the strain is present, the indications for confirming that it is due to this particular strain may change.  But I can tell you generally what steps occur, as a person is evaluated for care, even without a novel influenza strain, they are often tested with either a rapid test, or a specimen collected for culture that can tell you whether there's influenza there or not, and sometimes whether it's "A" or "B."  We have special surveillance systems to try to increase the testing, and the specificity of the testing.  But in general clinical care, some of those samples will then be forwarded on to the state, or big city public health lab where additional testing is done.  Through the investments in the epidemic preparedness, the public health laboratory community, the laboratory response network, and additional labs were equipped and trained to actually do additional testing with a PCR test that CDC developed, that was licensed just this past year, that looks for that H1N1 bird flu strain and also looks for the regular seasonal strain.  And with that testing kit, they could figure out if influenza "A," but it doesn't type.  So early on in this response, using that five-target PCR test kit, and finding out that it's "A" and it doesn't type, meant that they would forward the specimen on to CDC, where our much more specific testing would confirm whether it was actually due to this novel H1N1 reassortment strain that we've been dealing with.  Right now, because of the emergency use authorization that was approved on Monday, and shipments that started at that point, we have got state public health labs doing that specific testing.  It's truly remarkable this has occurred in such a short period of time.  And every day now states are recognizing this novel influenza strain themselves.  It may be at a certain point the triggers for sending specimens in for this kind of confirmation and will change.  Early on, in the seasonal influenza, and early on in this kind of novel outbreak, we really want to know when the virus has arrived.  Later on, we want to know is it changing, is it resistant, are different types dominating, for instance.  And so we certainly don't test every isolate or specimen in the seasonal influenza period.  And for this kind of outbreak, we don't expect to be diagnosing every individual case specifically.

Glen Nowak: Thank you.  And just for the media, we will be doing another press briefing tomorrow, probably about 12:00 noon, it will be penciled in.  And probably another one on Sunday.  We haven't made a decision whether we'll do that by phone only or in this room.  But we will be reconvening tomorrow, right now, probably at noon.  Thank you. 

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES