 to welcome back Dr. Maquot into his old stomping grounds in Southern California before we lost him to the state, but we didn't lose him really. He's working for the health of all of Californians. In this context of national health care debate and uncertainty about where we're going, I also heard the governor say something about the opinion of the health care. So there are lots of issues that I'm sure he grapples with on a daily basis. He's agreed to talk to us from the length of the pandemic, the H1N1, to capture all of the things that the State Department of Public Health does to protect our health. He got his MD from St. Louis University and his Master of Science in Public Health from UNC, I believe, by Chapel Hill. He's one of the best public health programs in the country. But I got to know him when we were planning the MPH program for UC Irvine and this was before he went to Sacramento and he came to all our meetings and was very much an inspiration to all of us who are trying to decide how best to develop an innovative program. So I'm delighted that he made time to be here this past year of the MPH. Some of the students, some of them will come later on today, but just to squeeze two or three hours out of your day, I'm sure it's difficult but it's a pleasure making so welcome and look forward to the talk. Thanks. I really appreciate the invitation. It's always a pleasure to get back here at Orange County. I don't get back enough and I'm really glad to see a lot of the students, but to touch base with some of my old friends and colleagues in the Department of Health Care Agency, I guess. So what I hope to do today in the time we have together... I thought it would be a good sort of public health practice approach to sort of talk about H1N1, but really the point is to try to give you some sense of what a state health department is all about and what various capacities and resources we had to draw upon across the department to really deal with H1N1. We tend to think that you know public health responses to certain kinds of challenges are really unidirectional or you know there's part of public health that's involved with that and all the rest of it sort of sits and watches, whereas in H1N1 it's really just an all-hands-on-deck type approach. So it's not so much... it's as much as giving an update on H1N1 here in California, but it's more an idea sort of walking through all what we consider to be the major challenges and how we approach those from the state health department standpoint. I should... when I say state health department, certainly here in California, we consider that we have a fairly well integrated public health system. We have 58 counties of course and three additional cities that have local health departments and we can think about the public health response as a system with fairly clearly delineated responsibilities on the quota of local health departments and state health departments. So hopefully my remarks will acknowledge that and yet focus on what the state health department's responsibilities are and activities that help us move things along. Just to give you a little bit of sense of the scope of the state health department, I don't think it took me a while to relearn what the full scope of things are. We really are organized around five major centers and a couple of other key offices that really capture all the programmatic focus areas. Just to walk through those real briefly, the Center for Chronic Disease Prevention and Health Promotion has two major divisions. One is chronic disease and injury control, which houses most of our programs that deal with social and behavioral change as it relates to dealing with public health challenges. So like our tobacco program, some cancer screening programs like our every woman counts program of breast and cervical cancer screening program, most of our other efforts that are disease specific, so stroke and diabetes and arthritis, et cetera, how the department of the Division of Environmental and Occupational Disease Control is primarily deals with the center around our capacities at doing environmental investigations of potential health impacts from environmental exposure. So Environmental Health Investigation Branch does a lot of that work, investigates cancer clusters and stuff like that. So a lot of our public health activities, Dean, how are you? Good to see you, right? The Center for Infectious Disease has two major areas. One is our Office of Tays. Probably the biggest single expenditures of general fund in the state goes to our AIDS program, which includes programs if they pay for drugs for individuals living with AIDS, but also a lot of prevention activities and surveillance activities around HIV and AIDS. And then the other division is Communicable Disease Control, which is all the other infectious disease programs. So it's TB, sexually transmitted diseases, hepatitis and numerous other infectious disease issues that we deal with on a regular basis. Our Center for Family Health is what a lot of folks have been used to calling maternal and child health includes our WIC program, the Women Infants and Children's program. And in fact, we can really characterize ourselves as a nutrition agency because over a third of our budget is in fact the WIC program, well over a billion dollars. And we work, of course, very closely with local jurisdictions, a lot of local providers to provide work services throughout the state. But the Family Health also includes our Family Planning program, our genetic disease screening program, our birth defects monitoring program, and other programs that come to us as beneficiaries of the Title V internal and child health block grant activities are all housed in Family Health. Our Center for Environmental Health has a number of key environmental programs. You may be aware that there's also a California Environmental Protection Agency that deals mostly with industrial pollutants, et cetera. Our environmental health and public health is privately focused on food safety, working very closely with local jurisdictions for inspection of the full range of restaurants, wholesale and retail outlets for food. A second major focus is drinking water. We oversee the thousands of drinking water systems throughout the state ensuring that they are regularly testing water for the contaminants required by the US EPA. And our third major program there is radiological health. We are responsible for the licensure of the use of all nuclear radioactive materials throughout the state. Our Healthcare Quality Center has two primary responsibilities. First and foremost is we are the agency that licenses all healthcare facilities in the state. So all hospitals, all nursing homes, all ambulatory surgical centers are all licensed by the California Department of Public Health. And similarly, we have a landfill services division that is responsible for the licensure and certification of all clinical laboratories throughout the state. So we have a huge responsibility there. Our health information and strategic planning has a lot of core resources in helping us think about performance management throughout the organization and strategic planning moving forward. But its main focus is archiving all vital records throughout the state. So we are the vital statistics entity for the state working very closely with local jurisdictions. So all birth and death records, all marriage and divorce records are housed with the Department of Public Health through our health information and strategic planning. And finally, we have an emergency preparedness office that's primary responsibility is reception, planning for and distribution of major resources we get from the federal government to help us plan for responding to bioterrorism and other emergency threats to the to the country. So that, you know, we have a lot of other sort of coordinated and coordinated activities that surround and provide administrative support. But this is really the core of our activities and almost every one of these entities were involved in one way or another in the age of one in one response. Here's a very dense looking environment, excuse me, organizational map. Here are the five centers here in their various subdivisions. And there's the Office of Emergency Repairness Office of Health Information Strategic Planning. We also have a Division of External Affairs, which includes our legislative and governmental affairs and public affairs office. And of course, over here are all the administrative functions of support, so information, technology, human resources. So this gives you an idea of what a state health department organizational chart looks like. This is the director's office. We have two chief deputies working out of that office to help help direct activities in the department. So we had already talked about health information, strategic planning and the environmental, excuse me, the emergency preparedness office. What I wanted to do in the short time we have together, and I hope I don't start talking too fast because I've got a lot of stuff to cover, but I think I'll try to take my time and get done what we can get done and open up for questions and, you know, see where we go from there. But I wanted to kind of lay out what I consider to be the major chunks of work or the initiatives that we needed to mount efforts behind at the state health department level to really deal with the H1N1 epidemic, or pandemic. Epidemiology and surveillance, of course, was front row center, was out front in making the diagnosis and quickly getting a sense of the spread of the disease throughout California. The vaccination program certainly in the second phase has become the major single activity that we did is mounting a major mass vaccination campaign. We'll talk a little more about that. Community mitigation, I kind of cluster in that energy, all the other advice and guidance that we had to give, that we needed to give to communities about how best to manage the pandemic. So it ranged everything from individual use, for example, of infection control procedures and uses of certain types of respirators to protect healthcare workers all the way to the opposite extreme of giving guidance on when schools should close, under what circumstances. So it's that whole bulk of guidance given to the community to assist with community guidance in dealing with the with the pandemic. Communication was an overarching challenge of ours and it involved, you know, when you're dealing with an emergency threat just like down in Haiti, it's a matter of the communication is really too problem. It has to do with communication between the various partners and key stakeholders and dealing with the response itself. And then there's the broader issue of communication to the public, keeping them up to date on what's going on and reinforcing the specific steps they can take to protect themselves and their families. So we'll talk a little bit about that communication effort. Somewhat belatedly, we got involved in monitoring healthcare surge. In other words, this has to do with the whole impact of the pandemic on our healthcare system and looking at what ways we could both monitor the impact both from an infectious disease standpoint, healthcare worker protection standpoint, as well as what's happening in the emergency rooms, the hospital beds, the ICUs, etc. and ensuring that we have a data source where we could talk about the impact and regionalize that. And then finally, if we have time to talk a little bit about the organization of these activities in a state health department working through our joint emergency operations center and how that, how we set ourselves up as an incident command center as a department and help coordinate and integrate the activities going on. So if we don't get through all of this, you'll at least have some sense of what the big chunks of responsibilities were at the state health department continue to be in dealing with the pandemic. The epidemiology and surveillance component, the first big chunk of work I was talking about was primarily housed and responsible in our Center for Infectious Diseases and more specifically in our infectious disease branch and our immunization branch have been most of the work of epidemiology and surveillance. I just throw this up here to remind us of how probably we were in California to have set up a system that was, we in fact in Southern California here detected the very two first cases of H1N1 in the United States. There was a program called the Bi-National Infectious Disease Surveillance Program and it was through that the networks that had been set up working with both Mexican and United States positions to routinely monitor for certain diseases that this virus was first identified and finally confirmed by the Centers for Disease Control. We've continued a lot of our activities and this is just one of multiple reports that have come out of the state health department that have been provided further epidemiological specification of the extent of the illness. For example, this report here reported on the first cases in conjunction with Texas and was one of the first articles that spelled out the degree of severity of the illness, how likely a person was to get infected, how likely it was an infected person to get hospitalized, how likely it was a hospitalized person to get after required infections or excuse me intensive care and so it was a clinical epidemiological survey of the earliest cases and our organization working through a lot of local jurisdiction partnerships have been able to maintain our cutting edge contribution to knowledge about H1N1. So to date, according to the the World Health Organization, there are more than 208 countries and territories that have reported laboratory confirmed cases. Until I saw this, I wasn't aware that we actually there were 208 countries in the world but I don't know how many there are totally. This has got to be the majority of them and there have been, as of January, the 10th of 13,000 deaths and world wide distribution of viruses and of course, you know, the fact of the matter is 13 sounds like a lot but when compared to, for example, with with annual influenza, this is really a small number, frankly, compared with what we've seen in the past. In looking at overall, overall, as of the 18th week of aggregate reporting, week one refers to the Centers for Disease Control starts all over every year and so the first week in January is week one of reporting and as of that, there were had been 38,989 hospitalizations and 1,800 deaths here in the United States. This gives you an idea of what I, what I, in this survey of epidemiology, what I'm trying to get you a feel for are the number of parameters that we're using to monitor the kinds of things we look at on a regular basis, daily and weekly basis to kind of help us get an idea of what's happening with the illness and probably one of the most valuable resources we have is a network of physicians throughout the state, we call them sentinel physicians and they have on agreement with us, agreed to report to us on a weekly basis what percentage of the patients that they see in their offices present with influenza like illness and that's a very, very sensitive indicator of the activity of disease throughout the population is probably as close to real time as we get in terms of saying what's really going on and in addition to that, just to put an extra word, is that in addition to them reporting to us on a weekly basis, they also submit specimens from those individuals who have been identified as having influenza like illness and through local and state laboratories we then analyze that specimen to see if in fact they do have influenza and if they do have influenza, if in fact it's H1N1, so we've been able to, it's a very robust epidemiological tool that we use that gives us a lot of information on a daily and weekly basis about what's going on. This gives you an idea of what's happened over the past several years in terms of influenza like illness from week to week and you can see numerous peaks that have been associated with 2007, 2008, 2009 and most recently up to the 2010 and you'll notice very, very unusually here that you'll see that in terms of where we are and at week two for example where we were at week two in 2007, eight and nine relative to where we are here and see where that point is relative to where the spike is. The point is during regular sous-seasonal influenza we typically see the greatest burden of disease following week two whereas here in now in 2010 we've seen the huge increase in activity and we're now at a very low point with infectious disease, excuse me, influenza like illness being reported but the big question is now will there be another spike that corresponds with the spike that we've seen in previous years during regular seasonal influenza or will this fade out? My personal gut and my guess is most, I'm not an infectious disease expert but I'm sure most infectious disease experts would be very reticent to predict that we're out of the, out of the, that we are not going to see further activity yet this year. Certainly a lot of the same factors that are responsible for why this tends to peak late in January, February or March are still with us and are likely to influence the course of disease as we go forward. This is another collective, collective influenza like illness visits throughout western part of the United States, these particular four states in this region are showing the similar variety of influenza like illness from reported from week to week and up through the last part of last year. So you can see what's, you can see the significant decrease and you have a great question right as to what's happening from this point on. This is another way we look at the burden of disease in the population. These are hospitalizations and the dark of blue are the deaths. So it gives you an idea of the U-shaped curve versus, you know spelling out the number of hospitalizations per week over a time period and what percentage of those have ended up in fatalities. Another way of indicating here a significant decrease. This is actually, this graph has not been updated and only goes through I think July of last year. So this gives you an idea of as of this date, the number of counties or the extent of disease throughout the state. Another way that we characterize ourselves and in assistance in telling what's happening here in California is by Centers for Disease Control guidelines. We characterize ourselves as either having a widespread regional, local or sporadic disease throughout California during most of the time so far between the end of May or April and May and until just recently we have been describing ourselves as having widespread diseases. And that's defined by the number of jurisdictions in the state over half of them continuing to have active outbreaks of disease in schools, etc. Right now we're describing ourselves as having sporadic indicating that there's not sustained transmission in any community and we're back to seeing the sporadic cases all over the state. So things have changed dramatically over the last two to three weeks but this shows that there actually are a few counties here in California that are still yet to report cases of H1N1 but it's certainly very, very prominent throughout the state. This is another way we've looked at severity of the illness. This is the number of individuals that have been hospitalized and this is the percentage of those hospitalizations that have ended up in deaths. And you can see that early on when fewer cases were actually being reported hospitalizations that the percentage of them were that actually ended up as fatalities was much higher whereas as the number of hospitalizations increased significantly the percentage of those that died as a result of that went down significantly. My guess is that this is an artifact that that's the appropriate term for this indicating that there was a much greater sensitivity about the potential danger of H1N1 leading to greater a lower threshold for actually hospitalizing an individual for care in the hospital. But once again another epidemiological tool that we follow to monitor things. This is another way of looking at once again influenza like illness but to give you an idea of where we were in terms of once again we're talking here about the second week in January and we're seeing here this is the percentage of influenza like illness being seen in doctors' offices and all these other colored lines are in previous years over the same time period so we can see at this particular point in time we're at a barely low level compared to other years in terms of the influenza like illness percentage that we're seeing in an office so very it's just another indication that this pandemic is affecting our population is totally bizarre it's totally very very different from anything that we've seen before in terms of its epidemiological pattern and relationship to seasonality. This is another thing that we use that's very very helpful is once again I mentioned the influenza like illness the sentinel physicians they send in data on a weekly basis and they also send in specimens and we continue to monitor what percentage of the specimens that are sent in in individuals that have a syndrome of influenza like illness what percentage of those are actually influenza and what percentage of the influenza are actually age one during the height of this a month or six weeks ago we were seeing 35, 40 even 50 percent of the specimens sent in by gosh they did have influenza and the vast majority of them over 95 percent had age one and one now we're seeing something quite different that we're seeing a very low percentage I think the low back down here is somewhere around 3 percent in other words of those individuals described as physicians as having influenza like illness we're only seeing 3 percent of them that actually have influenza what that really means is the vast burden of influenza like illness is now being caused by viruses other than influenza at least at this particular time right now there's an annual epidemic of respiratory sensational virus and we're seeing that as primarily the greatest burden of communicable disease respiratory communicable disease in the population at this particular point in time so we also then look at as I said we take these specimens and say what percentage of or influenza and then further specify how much percentage of those are h1n1 and even at this very low number we're still seeing we're still seeing very little if any seasonal influenza in that mix right now so even the small numbers we're seeing here of influenza documented by laboratory the vast majority of those are still h1n1 this is another tool we use this is a surveillance system that's been set up by the Centers for Disease Control to specifically look at a pediatric influenza impact and this has been this is something that's been going on for several years what I really wanted to point out here is this is these are the influenza illnesses and confirmed test testing these are pediatric cases that were quote-unquote severe meaning they required intensive care or it ended up in fatalities and you can see during the first part of 2009 what the number of pediatric influenza severe pediatric influenza cases that were reported a moderate number here throughout the season when seasonal flu was peaking in the early part of 2009 compared with what started here in April and May and you can see just a huge differential impact on the pediatric population both in terms of severe cases and deaths so one of the things that characterizes continue to call this influenza pandemic quote-unquote moderate but from a pediatric standpoint we have seen two, three, four times as many pediatric severe cases during this particular outbreak of age one and one pandemic and we have ever seen before since this this system was inaugurated and Bill, do you remember when we first started the pediatric? I'd like very severe year probably around 2005 yeah so it's been the last even the last five or six years that we've had this this system but this one once again I'm trying to give you an idea of the various factors and aspects we look at to try to look at and this finally I wanted to show you this is our monitoring of outbreaks in other words we keep very much in touch with local jurisdictions and they report to us on a regular basis for their on a weekly basis whether they're experiencing outbreaks so it's another way this is probably the main way that we use to determine whether we have quote unquote widespread disease so when I go to the press and say we're still widespread I'm saying that over half the jurisdictions are reporting outbreaks this is what we're talking about here and what we've done here you can't see this down here but we've categorized outbreaks as to the the venue or the location of them and this this hatched a mark in between is guess what what's the what do you think is the main venue where these outbreaks are occurring? schools? schools exactly so that's you can see that the vast majority of the outbreaks through this this blip here let me say a couple other things I just wanted to point out is here this number we've circled here what this what this chart is showing is the hospitalization rates per per population base in various age categories and you can see that the number of hospitalization rates for children under one year of age was much more significant and yet look over here over here is the fatality cases in other words this is the fatality ratios in other words of those that were hospitalized what percentage of them died and you can see here that the 36 to 64 year age group actually had a more severe outcome in that in terms of in terms of outcomes so more many more kids hospitalized under one year of age but in terms of of severity and fatality outcomes greater impact from the 36 49 and 50 to 64 what's really unusual about this in terms of comparing it with the seasonal influenza is this the 65 year age group in other words the low percentage of hospitalizations usually I think I have another chart to chart to chart to demonstrate this and usually this is just exactly the opposite well we still see hospitalizations in the at the extreme ages but usually the group over 65 is way ahead of the charts as is the the fatality ratio over here I think I have another chart oh yeah here it shows in the light blue we have the typical pattern on number of hospitalizations per age group and you can see here at 65 just the the predominant of the illness in fact this is the impact is in the individuals over 65 you can see with the dark blue of H1N1 you can see that it's much more almost inverted U U shaped curve here and much less impact on the individuals over 65 I'm not doing here oh yes I just wanted to give you an idea here of risk factors for fatal for a fatal illness obviously the things I wanted to point out here is if you look in this probably can't see these numbers so what we're talking about here is the number of symptoms and their likelihood to lead to a fatal outcome we can see that both you know the shortness of breath is responsible for influenza admissions to intensive care units that were non-fatal but they were also 72% of the ones that were fatal also had shortness of breath so shortness of breath was a very high predictor among the symptoms of needing intensive care unit hospitalization as well as a fatal outcome the other remarkable thing here is the existence of a chronic cord morbid illness cardiac disease metabolic disease immunosuppression overall 81% of the individuals admitted to intensive care unit had one or other a co-morbid condition and that included children as well as adults and we can see that that that pertains also for those that died I think that's 86% so the vast majority of individuals who are admitted and had required either hospitalization or ended up dying had a co-morbid condition which is consistent with what we usually see with seasonal influenza obviously the fact that they had an infiltrate on their x-ray both in terms of requiring admission to ICU and fatal outcomes was also significantly increased in both groups here's though here's the one factor here that is very different between these two groups that those that had to go in the intensive care unit and who require mechanical ventilation almost 90% of the individuals that ended up being fatalities required mechanical ventilation so we're seeing the obvious you know re-clarification here is it's the impact on the pulmonary system specifically developing pneumonia overwhelming pneumonia and death despite mechanical ventilation that was a major factor here so oh wait and another thing we do here as part of the epidemiology is we play a major part in the national effort to identify growing antiviral or resistance to antiviral medications that's another thing so once again of the samples that are sent to the state one of the things that we do is take a sub-sample of those and consistently we have been doing it now since May looking at a percentage of those to see if any of them are identifying or are are demonstrating antiviral resistance and we have shown very very little antiviral resistance since we started doing it I think we we have very little resistance to also Tamavir which is Tamaflu the major antiviral medication that's been used and a stockpile for you so we can see of the almost 2000 cases we've looked at that there's only been a couple hands full of cases that have shown antiviral resistance very important in demonstrating the stability of the virus for a number of reasons including its stability to the effectiveness of the vaccine so all of that was primarily just to give you an idea of the variety variety of parameters that we're using you can see that we don't have just one or two single things but we put together a cluster of indicators and those that are you are that are getting into epidemiology realize that this is more the more the the rule than the exception in terms of how we monitor the impact of disease to populations but I hope this gives you a an idea of all the things that we're monitoring and there's no way we could do this without a very intense and close and cooperative relationship with local jurisdictions Jenna do you have a question? Yeah I want to get back to that pattern you were showing with age related to case fatality rates and hospitalizations and like you're saying for ILI normally you see an increase in case of case fatality rates with age or we have a positive matter not seeing that pattern so what do you attribute that difference in those two patterns to be caused by? Well you know I that's that's totally speculative I I might might be hard Hildi I don't have any thoughts or comments about that you've seen a lot here in Orange County there are all serologic studies showing that people over Oh of course taking care of the age about ascertaining them and have antivirus and we have with this and then there's probably other parts of your immune system that are not measured by so they probably have exposure to something very similar very early in life right yeah so for example I'm one of these guys I'm 63 to almost 64 years of age so I've been through you know pandemics that have occurred in the 50s mid 50s and in the early 70s and I may have that may have conferred some immunity on me and a lot of other folks my age and older to have some impact on that mentality so those over the age of 60 would they be a lower priority group for immunization? Yeah absolutely yeah absolutely in fact if I can answer that you'd be very early on particularly in laying out the vaccination program and I'll mention this I was going to mention this in the next segment that priority groups were were laid out based on the epidemiology that has to have been gained that's another thing just to just to point out the obvious that this heavy intense you know public health work on the part of epi and surveillance is a lot of times taken for granted but it develops absolutely critical information that helps us and it was very critical in this respect because it identified just exactly that when they first laid out about the priorities for vaccination it did not include individuals over 65 at all it certainly included individuals you know children up through 18 years of age in fact you have younger adults through 24 because we were seeing extremely high comparatively with the seasonal flu hospitalizations but also included pregnant women you know healthcare workers parents of children under six months of age because they were not eligible for the vaccine so parents and caregivers and individuals between 25 and 64 who had underlined medical conditions so individuals over 65 I'm glad you brought out that point because without you know robust epidemiological information early on in the disease we wouldn't have been able to specify and lay out those priority groups as we move forward that was I think quite confusing the public too because normally the high risk group would be the elderly absolutely in this case even though it's an infectious disease flu flu like symptoms you're proposing different criteria for immunization sure sure and we'll talk a little bit about too it really went operationally but further than that because when we started working with local jurisdictions in deciding who should be early what providers out there should be getting vaccine we tried you know usually it's nursing homes and you know uh uh in in in excuse me um uh interior excuse me um uh internist and uh et cetera dealing with the elderly now we were focusing on you know uh obstetricians gynecologist pediatricians family physicians a whole group a different group of individuals so really had some operational uh translations that were were extremely helpful to us um so the vaccination program as I've mentioned after this huge an ongoing responsibility working with local jurisdictions to continue to monitor the burden of disease and the population monitor that uh uh mobilizing the mass vaccination campaign has and continues to be probably our major effort at this particular point in time and I just wanted to point out the number of centers in the in the the department of public health that have been involved in that obviously the center for infectious disease and it's specifically our communication branch but the emergency preparedness office the center for family health was extremely important primarily because of the outlets that we had available to us working through for example the WIC program and coordinating communication distribution through WIC offices both of the local and supported by the but and the office of public affairs of course about about communications so um we experience a number of challenges and here's how we organize them don't here's how we hope to organize them but so the distribution policy for H1N1 vaccine first of all it's early on the federal government decided to take full responsibility for the development and distribution of the vaccine so the federal government is still in fact working with the manufacturers to put out a total of somewhere in the neighborhood of 200 million doses of vaccine and have decided to make that free of charge the population this is a very a completely different tack than the federal government has taken in the past usually they have provided vaccine to us at the state level for a small percentage of the population given most of that vaccine to local jurisdictions to set up three clinics but the vast majority of the vaccine has been delivered through the private sector and at a charge for both the vaccine and the administration to be it's still true that the mass vast majority of the vaccine for each one in one has been distributed to the private system but even the privates are no longer allowed to charge for the vaccine although they do charge an administration fee so the way this was done was that the centers for disease controls shows a single distributor versus excuse me specifically McKesson and McKesson it is the major distributor so all the manufacturers and I forget there's five or six major manufacturers here in the United States all send their vaccine to this single distributor and then the McKesson distributes it all to either directly to private providers or to state health departments for distribution to local health departments and we we first identify each state was allowed to identify a proportionate number of vaccinators across the state and here in California we were approved to identify over 16,000 individual vaccinators that could apply to receive vaccine I think we actually have over 14,000 active vaccinators in this state what we did was we set up a cell excuse me a website we got the word out that anybody who wanted to receive vaccine could register at this website and could indicate the number of vaccine doses they wish to receive and we quickly became that became very very busy and then what we did was this was activated on September the 1st they registered that they would order that vaccine they were required to order at least 100 doses of vaccine at a time and then they would receive information training and updates on how to for example the requirements for preserving the vaccine in their offices etc and then they were required to actually report the doses of vaccine administered through that program this is the the website was set up that we that they would come to register and indicate the number of doses that they wanted ordered the allocation of the vaccine was through a variety of mechanisms vaccines registered after outreach from state local health and to partners so so we we we worked very closely with local jurisdictions to once we the state collected all of the the potential vaccinators we then determined what county they were from sent that list back to the county and the county helped prioritize which of those vaccinators should first receive vaccine and of course the whole principle that was being used was which of these vaccinators could could ensure early delivery of the vaccine to the high priority group so that's where the choice was made that will some of it would be set aside for public clinics some of it would go to obstetricians and pediatricians versus gerontologists for example now there was a couple of phases to this you may I'm sure you're aware early on there was a significant manufacturing delays of delivery of the vaccine and so there was a scarcity and so each one of the each county was given a certain allotment so that for example every time the Centers for Disease Control told California you've got another two million doses available we would then allocate those doses on a population basis to each one of the counties and then would together look at the list of vaccinators that had registered for vaccine within those counties and determine which of those orders should be filled then we would recollect that data send it to McKesson then McKesson would deliver that vaccine directly to the vacciner and vaccinator so the vaccinators would be a whole number of private providers including physicians including chain pharmacies and retail pharmacies and retail chains including local health departments that would work through a number of partners as they do every year to deliver free clinics throughout the state but now at the present time we've completely shifted because now there's much more supply than there is demand and so we've gone away from the individual allocations of a certain amount to each county and we are honoring orders from any any ongoing entities vaccinators that are continuing to need vaccine we are ordering that on a flow basis as we go forward just to briefly review that process I think I kind of go over this but the first 15 million doses of vaccine or so in California so each local health department receives an allocation each local health department receives a list of literature vaccinators and their respective orders from us they review those vaccinators and adjust their orders and then we receive their list and orders for vaccine distribution and their orders are filled as vaccine is released from McKesson so that's a I guess the point I'm going through all this is this is a very different process that has been used on an annual basis to get seasonal influenza vaccine that gives you an idea of the complexity of the process in mobilizing this max vaccination max vaccination process so we've got so far and we're recently vaccine is an ample supply and orders are being filled on a first come first serve basis we have California has done an outstanding job of ensuring that the vast majority of the vaccine that's been allocated to us has in fact been ordered on a timely basis we are beginning to fall back now simply because we're not getting as many orders but when orders were intense and supply was limited at any given point in time we could demonstrate that we had ordered over 99% of the vaccine that was made available to us so we were way ahead of every other state in terms of the total number of doses that was delivered to California so we feel that's a that's a great great success we the stuff that we've actually received here in California represents a larger share than would be proportional and given to us as part of the population indicating the success of our efforts to bring bring vaccine into the state we did I just wanted to point out that in addition to the process set up for the Centers for Disease Control using McKesson but restricted vaccinators to vaccinators who wanted more than 100 we realized that there's a whole lot of other providers out there so Cal that might not need that much vaccine so we set up a second you know we independently established relationship with the second distributor that would and we collected names of individuals who wanted vaccine but didn't want 100 so they weren't part of the national program but we set a separate process set up to to augment the number of vaccinators including those that wanted less than 100 doses of vaccine oh yeah just just to point out that obviously the local health departments so we provided or provided data to them on a regular basis about the entire profile of their shipping box so they have an idea of exactly what's been distributed to the to their county we've gotten over 16 million doses here in California obviously we've got a population of over 38 million people so that's a lot of vaccine and in fact it's certainly more than we have typically received during the regular influenza season but it still falls more short of our expectations in terms of the total number of individuals we'd like to see vaccinated we were pleased to find out that they're able to assess that we were successful in directing a lot of that vaccine so that the at least by surveys that have been done the number of individuals that are in one or other of the priority groups in fact did get proportionally high percentage of vaccine so we were somewhat successful in making sure that vaccine was directed to priority groups before it was made available to the general population just to kind of delineate some of the huge challenges we got in the vaccine program perhaps the biggest challenge early on was the manufacturing delays even though on the one hand the program actually got started a couple of weeks earlier that the federal government had initially anticipated I think we were thinking first about the middle of October and our first vaccine actually she started showing up I think the first week in October but in terms of how much we were expecting to see on a week by week basis very early on in the program there were deficiencies or a slow movement of vaccine into the state which was one of the major concerns and causes caused a lot of consternation early on in terms of who was getting the vaccine you know when there's a tight lot of demand any perception that somebody was getting the denying you know that though raised of considerable concerns and there were definite inequities and distribution in the early system because we hadn't anticipated the shortage backman is the name of the information technology process that's used to collect information and transfer that to the Centers for Disease Control it's a system that's probably 15 years old and has never been used on a project this big our folks as I'm sure the local folks were were very much challenged by using this information technology system so it's it's a testimonial to how important it is to think about infrastructure information technology systems and the critical nature of the quality of those systems in helping us orchestrate and manage a process like this shipping information format reconciling orders this kind of stuff comes up all the time this was a totally new distribution system that was very challenging and obviously adjusting supply demand you know but within a very a manner of a few weeks we went from a situation of of demand us can significantly outstrip in supply to just to the exactly the opposite and making adjustments to the distribution system to accommodate but that was was very challenging just remind everybody that while early on we continued to emphasize the importance of those priority groups getting vaccinated now we have ample supply and are encouraging everybody and we're basing that continued urging because of number one even if you took all the individuals that we think have gotten ill from influenza here H1N1 during this particular last wave and you add to those the individuals we think have gotten vaccinated we're still estimating that a majority of people here in california are still susceptible so we've still got the reservoir of susceptible individuals out there including myself I just got my vaccine yesterday so I've got to get to develop full immunity but that's combined with the fact that once again we're still you know in the middle of january or to latter later january during most influenza seasons the burden of disease is still in front of us at this particular point in time so we're still emphasizing that this is a significant threat to california and we we need to get everybody protected I think I we've gone over this before about the priority groups for for immunization and and this just tells you who I don't think we need to get into that and in fact you know I've got I've got another whole hour presentation here I did want to kind of show a little bit of our communications things you know this this is what our our communication program has been something that's been under development for considerable time and we've been tried very hard at the state level to make sure that it is coordinated and complementary to a wonderful work that's coming out of the Centers for Disease Control but an awful lot of wonderful works that's being done by local jurisdictions and getting the word out both about the importance of immunization and to continue to reemphasize the number of steps that individuals can take to protect themselves so this gives you a little idea of the kinds of things that we've been put together and resources we've the way we've used our resources to try to get the word out to the population radio sponsorships are these really quick little things you heard on radio this was brought to you by the Center the California Public Health Department that emphasizes the importance of getting immunized blank it's just that kind of a quick message a whole series of outward things hopefully you've begun to see some of these in some of your neighborhoods billboards bus shelters bus tail lights etc to try to get the word out in that in that venue the PSA contest was a contest we put together to invite people to develop either 30 or 60 seconds excuse me 15 or 30 second public service announcements we actually had a statewide competition and we announced winners and these were the nice thing about it it was free to us and we were able to make that available with cooperative efforts to the California Broadcasting Association to make that those PSAs available and they're being used extensively throughout the state at this time and in addition we have developed and we have a contract to develop pay for PSAs so we in addition to relying on public service announcement time which is typically three o'clock in the morning we're also actually purchasing time on major broadcast media throughout the California and you'll be seeing this is this is still ramping up and we think this is the right thing to do at this particular time once again to try to try to create demand more demand for the vaccine so the website we've included a huge amount of information on our website both for our partners out there in the communities our local health departments and the health care providers but also information valuable to to the the general public and we have a very busy hotline once again complimentary to a lot of work that the local jurisdictions are communicating I just want to here's our website has a a lot of information on it very once again complimentary to what almost every local health department is very successfully done we've implemented a full locator system where actually we've even using put a to a texting process you can put in a a number and put in your your zip code and it'll immediately show on your cell phone a number of places where you can get vaccine in your community and of course this is critical that we need to work with local jurisdictions to ensure that that information is continues to be up to date this these are some of the billboards or signs that you're likely to be seen around the around the state poster messages getting vaccinated washing your hands covering your cough and staying over your sick so I think I'm going to end with that we've got five more minutes I already go over my time but I thought just once again go back to the beginning to show you that the things that I haven't talked about is the huge amount of work we've done at working with hospitals and healthcare providers to monitor the quality of the infection controls procedures that they're using how they're using N95 respirators to protect healthcare workers but also how how the what impact it's having so we're monitoring on a regular basis hospitals in terms of what's happening in their emergency rooms what's happened with their hospital bed availability what's happening with the number of individuals that are going into their intensive care units and of those how many are or what's the ventilator availability throughout the state the machines necessary who aren't officially agreed for individuals that are severely compromised so we're very proud of that activity and that we'll we'll consider that going on what the how up in there in see if we have time for a few questions right thank you very much this is to sort of summarize I mean the whole idea I've tried to give you here is is not I mean you've gotten a lot about age one end one but I hope to give you some idea of the scope of of resources and capacities we've had to draw on at the state level and this is exactly the same thing that's happening in the local level that it's not just their infectious disease or immunization program almost everybody in the department is have something to do so this gives you an idea of what capacities are there and how we've used them so questions or thoughts or comments yes yeah I'm curious if this seasonal flu actually kills more people what made at age one in one sort of a physician or a pharmacist so much more attention than the seasonal flu or other that's that's a good question so the question was why why you know if at this point in time we're showing that it's caused a lot less you know death and hospitalization what was the big deal you know I think it started out you remember by by being categorized as a novel virus and a novel virus basically means that it's a new when they looked at the genetic makeup of the virus it's never been seen quite never been seen before so the idea is that virtually the entire population is is is susceptible to infection with the virus this is absolutely unique because in dealing with seasonal influenza we're always counting on the fact that at least a certain percentage of the population is carrying forward some degree of immunity to the new viruses that are come along when we see a novel virus like this this is the setup this is exactly what has happened in the past that has caused major epidemics or pandemics in the past the other the other factor is what's characteristic of all influenza viruses and that is that are extreme of immutability and they're not just it's not just that it changes from season to season but even within a given season we've actually seen situations where at the beginning of the season an influenza virus is completely susceptible to all the known antivirus and by the end of the season virtually all of it is resistant it can happen in that period of time so when we talk about you know the degree of susceptibility of the population and the immutability of the virus we we thought this was a and this was a perfect setup for a very severe pandemic the X factor was the severity of the illness and you'll remember the third factor that probably factored in here and I think somebody had asked maybe it was you about Mexico you know that you'll remember that after we first identified a couple of cases in the United States Mexico had a huge impact to the virus much earlier than in the United States and at least the early information we were getting was that this was an extremely severe epidemic or pandemic and in Mexico so I think it was those factors you know the the perception of the early impact on Mexico the novel virus factor and the immutability of the virus which was we thought very appropriately characterized this as a major consideration folks will always be able to do the Monday morning quarterback thing and say here's public health again you know exaggerating the you know you're going way overboard you know we think that everything we did in terms of communications you know the mass vaccination program the intensification of our epidemiology and surveillance was exactly what needed to be done and we'd like to think that those factors could actually if not completely eliminate certainly mitigate a possible third wave of this virus coming forward quick question Hildi I'll just add to that that you know the virus was introduced in the United States in certain populations right and initially those were likely to be healthier populations so young people who had traveled to Mexico on spring break you know people who were mobile and so especially early on there was a concern that when this gets to higher risk populations it may have a more severe profile and then the absence of vaccine you know most thank you cleanses just as we go into it give a vaccine that hopefully will be a good match so that's that's an excellent point and I just would I'd be emphasize you know we forget about the normal sequence of events here the iterative process we have developed in dealing with with influenza you know we have 4,000 deaths here from seasonal influenza here in California alone this is this is even given despite the fact that we you know six or nine months prior to that we identify the viruses that are likely to cause it we develop a vaccine to make the vaccine available in October so now of November well before the vaccine or the illness usually starts up and in spite of all that with even with a moderate disease we see this much what Bill Hilde's pointed out is that we're we're we were moving into this obviously a major impact of influenza and we knew that the vaccine was not going to be available to really to really impact the first major wave of this disease so that's an excellent excellent point that needed be taken into consideration yes a couple of questions to kind of different one is do you have a program to monitor the effectiveness of your public information in other words that whole list of PSAs and advertisements and stuff do you try and find out how that's an excellent question question number one anyway is do we have a way of monitoring the impact of our public awareness campaigns and frankly we don't have we have we have rough indicators you know for example now as we start distributing more PSAs and more you know paid television advertising we will be looking very much to see if that impacts the the number of individuals that are seeking vaccination but I think we need to do a better job of having you know because you know in the business community they're very good on this they know exactly how much money they're spending on advertising and by God they know you know the cost benefit of it we need to better do a better job of public health right now I don't know if anything's being done at the local level here you know in in Orange County to monitor the impact of your public awareness stuff efforts but at the state we we don't have an organized way of assessing that Do you have another question? The other question is is there a an estimate of what would be a sufficient level of vaccination in order to have effective herd immunity here? Is that a good excellent question this the second question was do we have an estimate of what percentage of the population would have to be vaccinated or infected to provide what's called herd immunity in other words you get a certain percentage of the population protected and it virtually stifles all further communication or excuse me transmission of the virus I was amazed when recently we were on I was on a phone with the Centers for Disease Control and they were they were saying first of all that there is evidence that the herd immunity for influenza in general and particularly for this virus might be much lower than we had anticipated you know I was always thought that it needs to get up there like 85 percent and there there was an estimate that it could be as low as 30 percent or 25 or 30 percent but they but they're they're articulating a broad range here they're being very safe you know their confidence limits are as broad as I mean it's like anywhere from maybe 30 percent up to 65 percent but I think I think in general what we're hearing is that the herd immunity of threshold might be lower for influenza and per inch one in one in particular Hill do you have any other thoughts about that? I haven't heard it yet it's a it's a it's pretty much a well I shouldn't say it's a craps you there are actually scientists that are really really trying to look at this in a special house but it requires a lot of you know individual geographical you know cohort studies in order to do to gain that information I have a feeling that we'll have some retroactive a retrospective information about that but I think it's safe to say that where we're at here in California we're still very far from being able to experience any kind of herd immunity as a result of the number is infected of individuals vaccinated but I mean the the the story will play out and we'll we'll see what happens it may be that it was a lot lower than we thought do we take a couple more yeah I was just yes David hi um I would call after the September 11th events there was an increased focus in public health federal and state public health efforts for disaster and emergency barriers absolutely and the grumblings that I heard for other departments in public health was that there was a diversion of funds to areas that might not be viewed as the most beneficial these of those calculations are hard to perform now we're not because when I'm thinking of H1N1 response I wouldn't argue at all that it was unwarranted that I mean it seems that it was very comprehensive if I move in and very well done and fully integrated my question is how much flexibility the U.S. director as the state have to allocate funds to what they view as important given the large amount of organizational infrastructure you just showed me and then also with that flexibility that you might have are there other departments that necessarily because you have a limited amount of resources receive less at these times and how is that decision process well first of all when you're on your sort of basic comment just just let me say that that globally I think what we have to say is public health in terms of public funding is still way upside down as much as we've been concerned about H1N1 we still have to look at the data and say what's really killing people and how much money is distributed if you look at the department of public health for example and look at how much money we get for infectious diseases versus chronic diseases it's just totally upside down so let me just say that as the baseline I don't want to sort of on the other hand have we was the infusion of resources appropriate and wasn't put the good news absolutely I mean just to give you an example of that here in California that one of the major things that by the way it wasn't so much 9-11 for public health it was 10-11 you'll remember the anthrax thing that's what really got things going for public health you know that people started seeing the threats of bioterrorism but we've been able to put together a laboratory response network and in this particular point of respiratory disease laboratory response network that served us extremely well for this we were we were outstanding among the states and our ability usually through this process I talked about you know using the laboratory to be able to monitor you know whether it's influenza if it's influenza what what serotype is that type of thing normally on a given year we we see maybe 2,000 samples through the entire season we don't really need to see a whole lot more than that in this this time we we've we've been once again this was a tremendously cooperative in fact the majority the work was done by something like 34 local health department laboratories but as a result of the collaborative weapon effort between the local the and the state lab we processed over 14,000 samples in a period of about six to eight weeks that never could have been done if we hadn't gotten resources that we've gotten as a result of nine 1011 and some of the resources we've built a lot of the epidemiology capacity that's been that's been enhanced at the local level particularly throughout the state was a result of previous investments in public health so that that's that the real question was about flexibility and I I have to sadly report the flexibility is is near zero you know that every dollar the state department receives almost every dollar comes with very very specific and that's that's whether it comes from the federal government or whether it comes from the state through a general fund it's there's all there's very very very very specific as to how that money can be used and very little opportunity for for moving that money around an example right now is we're we're into preparing for phase four what they're called in public health emergency response supplemental funds phase four from the federal government and we're being told that that money only be used for the vaccination program you know which you know that is our major activity right now but in other words not a single dollar of that can be used to support our epidemiology and surveillance activities a lot of that money will go to local jurisdictions but they similarly would be so I would you know one of the major struggles we have in public you know publicly funded public health is is the very very stringent you know requirements on how that money is to be used and very little flexibility we have at the at the state level to to move monies around did you have another what was just a question but then where did you get the money I mean you you obviously did an amazing program here yeah so where did that money come from the federal government also that was oh yeah like I said this is all I I can't I mean I think we we've in the state would receive something over a hundred million dollars just during during 2009 to mount this activities about 70 percent of that goes to local jurisdictions but so we've gotten a huge infusion of resources although I want to give credit to the fact that the governor in the legislature back in 2006 where I had enough for thinking to actually put to put stockpile huge resources that we've been able to tap into during this for example this was all around you remember the avian influenza scare you know that was another scenario that could lead to a pandemic wasn't quite the similar situation here but we stockpiled over 50 million of these N95 respirator which is the formally approved mass that needs to be worn by healthcare worker to protect themselves with this particular kind of a virus similarly we we ended up stockpiling something in the neighborhood of nine million courses of Tamiflu at the state level most of that is still available to us but so some of those resources came to us from state state resources but so it's been a combination of state and federal monies that have allowed us to move forward but I appreciate you're asking those questions because you know it helps helps you understand how these kinds of things are funded and how we you know relate to the federal government and to the local jurisdictions and getting resources out there so that you know one of the things I wanted to talk about at the end was operations and just give you some some sense of you know you would think local health department out there all doing good stuff and you know you know teaching people what they need to do to stay healthy what we have to acknowledge is there's a huge infrastructure in public health that's necessary just to get contracts out you know just to get money out in a in a timely fashion that's also you know the information technology systems we need to have to be able to do that we kind of forget about that has infrastructure to be able to respond and by and large we we felt like we did a good job so other I don't know how much longer we want to go yesterday one two months two months do you have I I see so um that didn't you know do the saving tax do you or do you just like at your local high school or you know you know school you all go oh yeah in fact or is that too old school you know no no not at all there were these big black injector guns oh yeah I mean you know you know everybody I I was that he said but yeah I think they were and people right you find out that made that needy no no and uh you know states and and maybe even with California there's been a lot of variation on how to approach obviously that one of the target groups was virtually all children from uh from bird well from six months to uh you know young adults 24 so there was a lot of push toward uh institution of school-based clinics I think some county I don't know if you did this in Orange County but there there were many counties that in fact spent a lot of their or sent a lot of their early vaccines directly to clinics that were even so you either set up in association with the schools or actually perform in the school obviously that raises serious issues or significant problems that need to be dealt with in other words you can't just herd all kids have come to school you got to talk to the parents to get their permission and let them know what's happening you know which requires all kinds of attention to uh how you do that communication and get that documentation so it's not it's not about you think well hell we'll just get along with school and they're all there and just immunize and that's not quite that easy but I guess the answer to your question is yes actually we encourage that collaboration in fact we haven't had to encourage it I mean local jurisdictions in general got that right off the bat and we're we're developing major uh collaborative relationship with schools to ensure that the early vaccine could get to the priority groups and overall I think we were pretty successful throughout the state but we didn't require you know we we weren't descriptive at the state level about how that be done we just encouraged it and let state step up and decide at a local level how to get that done but there was still a lot of emphasis on using schools to to get that one more question I guess don't yes hopefully just following up on Dr. Borkner's question um within the flexibility that you have of the state with um managing your operations this way is very federal public health model a financial public health model is there a federal version of this perhaps I mean a federal public health model a financial public health model I mean by which there are or is this managed by a committee on how to allocate these to the uh uh the states in managing you know these things go to this well I mean I guess the one way to answer that is that the centers for disease control pretty much dictates the model I mean they they're they're the ones that uh and they're they're not they don't they're they are restricted too you know for example just before we got announcements about this phase per or this per four of this phase four I had the pleasure of meeting directly with the center disease center disease control administrator Tom Frieden and I I asked him I said Tom we need more flexibility in how we could use phase four he said markets all over we've got the office of management and budget has already laid down the guidelines we're gonna we're gonna give to give you the money here's what you got to use before now they you know they still play little tricks and you know how to you know how to do creative financing but overall the the model for how it's it's pretty much dictated so you know like the mass vaccination distribution system we had some flexibility at the state level and how we implemented but basically the model was set out and how you finance it where the money comes from and what proportion has to be spent on this versus this that model is pretty much laid out at the federal level is that is that what you're yeah yeah I'm just trying to figure out where this model is in the ballot you know yeah it's it's and we like to think of it you know I'm I'm a state health officer I'm I'm a participant in a national organization called ASSO the Association of State and Territorial Health Officers you know throughout this whole process we've been on a call with them at least once a week most of the time two or three times a week and it's exactly these issues that we try you know we try to do whatever leverage we can't influence you know decisions that are made by centers for disease control we think are more things we're trying to do at the state local levels and sometimes we're successful in modifying that and frankly we were to say like like for example we were that's probably more than you want to hear but just an example of this kind of negotiations was you know what we got the centers for disease control to agree to is that phase one could be used for just about anything phase two and three had to be used for either planning or implementing the vaccine program we got them to back off on that and retro actively modify the requirements for what phase two could be used for and therefore we could take some of the money that we were otherwise spending on three and four back it into one and two and that gave us the justification for being able to pin a pull down some more for phase four but anyway so there is some there's a lot of jockeying negotiations aren't there's a lot of negotiations lots of negotiations but of pretty limited you know flexibility laterality as to as to what you can do within those guidelines but it's it's dealing with government is is it's generally speaking pretty prescriptive and it's it's not changed it's it's sort of a clarification question all over that because I I'd understood that public health powers basically in the United States system reside at state level so local health departments are effectively delegated powers from you guys and you can kind of tell them what to do but at the federal level it's in theory guidance to you but they control you because they can provide funds and that's an excellent point that's that's a very good thing to point out because in fact even though theoretically or not just theoretically conceptually in law you know the state it has the responsibility and then it's delegated to the locals the fact of the matter is that that in in terms of the day to day power the local health departments and local health officers in particular wield an awful lot of power but as you correctly point out it's the way the money flows and how it flows and under what restrictions that really end up directing a lot of the activity so it's kind of a ying ying yang type of type of issues so that's why it's so important I've been engaged when I was with local here in Orange County and at the state to be engaged in these national organizations that can work effectively with the CDC generally I mean they've got restrictions but they want to work with us they want to try to do every our way so the extent that we can give them the talking points to bring it back to say if you want to do it right here's how you ought to do it and sometimes we get it there and sometimes we don't you know but good good point listen thank you all very much for your attention and your