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Oct. 30, 2002 — Editor's Note: For the latest thinking on public health strategies including flu vaccination, adult immunization, and bioterrorism, Medscape's Laurie Barclay spoke with Julie L. Gerberding, MD, MPH, the recently appointed director of the Centers for Disease Control and Prevention (CDC), shortly after she spoke at the 40th Annual Meeting of the Infectious Diseases Society of America. Dr. Gerberding is an associate clinical professor of medicine in infectious diseases at Emory University in Atlanta, Georgia. As acting deputy director of the National Center for Infectious Diseases, she helped orchestrate the CDC's response to the anthrax outbreak last year. In 1998, she joined the CDC as director of healthcare quality promotion, and she developed the CDC's patient safety initiatives and other programs to prevent infections, antimicrobial resistance, and medical errors.

Medscape: How prepared are we for a bioterrorist attack?

Dr. Gerberding: CDC's level of preparedness is high and constantly increasing. We are building terrorism preparedness and response capacity on the framework of public health infrastructure. Likewise, we are expanding our overall capacity to respond to public health emergencies and threats as an indirect consequence of the investments in terrorism preparedness. These investments include enhancing preparedness planning efforts; increasing biological and chemical laboratory capacity; establishing multiple rapid response teams; improving communication capabilities and effort; and increasing the numbers of Epidemic Intelligence Service Officers (known as CDC's "Disease Detectives") to meet the demand from states in need of specially trained epidemiologists. We are scaling up, speeding up, and streamlining terrorism response and public health emergency operations. Our preparedness is very high, but we're not done yet.

Medscape: If there is no immediate bioterrorist attack, how can we maintain heightened awareness to recognize an attack?

Dr. Gerberding: Since 9/11, CDC has been working aggressively to improve the level of preparedness among front-line clinicians and laboratorians. As new information and guidance becomes available, it is disseminated to these groups. This keeps our first lines of defense informed and serves to remind them that terrorism is still a very real threat. Distance learning programs, web broadcasts, printed brochures, peer-reviewed articles, Morbidity and Mortality Weekly Report reports and guidelines, professional society meetings, and public health forums are some of the major ways this is being accomplished.

Medscape: Besides learning more about potential bioterrorism agents, what else can primary care and first responder physicians and healthcare workers do to prepare for a potential attack?

Dr. Gerberding: Healthcare personnel must remain alert to cases of "suspect" illness or unusual clusters of common illnesses and know how to report them to local health departments. In addition, they should learn about the emergency plans for managing the medical aspects of a terrorism attack in their community and how they might contribute. Preparedness training is a integral part of all terrorism situations — tabletop exercise, scenario role playing, and full-scale exercises are the best way[s] to enhance preparedness.

Medscape: Is the CDC recommending passive syndromic surveillance systems of other systems for local and state health departments to use to increase surveillance for potential bioterrorist outbreaks?

Dr. Gerberding: CDC is not recommending widespread syndromic surveillance to detect new events at this time. We are evaluating the feasibility and utility of syndromic surveillance and other methods of electronic detection. The most important steps to ensure timely recognition of a terrorism attack remain educating healthcare providers to recognize and report suspicious cases or events; converting paper laboratory reporting systems to electronic (or real-time) reporting systems; and ensuring that surveillance information is evaluated, interpreted, and acted upon in a timely manner.

Medscape: Please summarize pertinent points concerning the recently released recommendations for adult immunization and for influenza vaccination.

Dr. Gerberding: Influenza vaccine is recommended annually for persons at increased risk of influenza-related complications, their household contacts, healthcare workers, and all persons aged 50 to 64 years. Groups at increased risk of complications include persons aged 65 years and older and persons six months to 64 years of age with chronic heart or lung disease, such as asthma, diabetes or metabolic diseases, renal failure, hemoglobinopathies such as sickle cell anemia, persons who are immune-compromised because of either medications or illness (eg, persons with HIV/AIDS, persons on immune system-suppressing drugs such as cancer chemotherapy or chronic steroids), children on chronic aspirin therapy, and women who will be beyond their first trimester of pregnancy during influenza season. Beginning in 2002, the Advisory Committee on Immunization Practices (ACIP) is encouraging when feasible vaccination of children six to 23 months because this age group is at increased risk of influenza-related hospitalization.

Medscape: Is there any evidence that unusual strains of influenza are being developed or have been used as bioweapons?

Dr. Gerberding: CDC is not aware of any unusual strains of influenza being developed and/or used as a bioweapon.

Medscape: What plans or programs does the CDC have to increase levels of influenza immunization among those at highest risk?

Dr. Gerberding: CDC has developed an influenza education/media campaign to encourage people at high risk of complications from influenza to seek a flu shot. We intend to create and maintain high visibility of messages through the use of multiple materials, media channels, and spokespeople from mid-September through December. Television and radio public service announcements, print materials, video news releases, media briefings, collaborations with private sector partners, and special events (eg, National Adult Immunization Awareness Week) will be used to disseminate influenza vaccine-related recommendations, information, and updates. In addition, CDC and HHS [Department of Health and Human Services] will work with five demonstration sites to improve influenza and pneumococcal vaccination rates in African-American and Hispanic communities. The demonstration sites will organize partnerships of public health professionals, medical providers, and community members (eg, large health plans, insurers, minority health professional organizations, churches, local community groups, and civic leaders) to develop a community-based plan that will identify African-American and Hispanic individuals and offer immunization services to them.

Medscape: Why did the CDC recommend flu vaccination for young children (six months to two years) only starting next March instead of for this flu season?

Dr. Gerberding: The ACIP published the 2002 influenza recommendations on April 12, 2002. One of the principal changes from the preceding year concerned the use of influenza vaccine for healthy young children. Because young, otherwise healthy children are at increased risk for influenza-related hospitalizations, the ACIP decided this year to encourage influenza vaccination of children aged six to 23 months when feasible. However, they did not make a full recommendation for annual vaccination of this group because of several concerns they felt needed to be addressed before this could be done. These concerns include increasing efforts to educate parents and providers regarding the impact of influenza and the potential benefits and risks of vaccination among young children, clarification of practical strategies for annual vaccination of children since some will require two doses in the same season, and reimbursement issues. The ACIP will address these issues in future meetings and will provide updated information as these concerns are addressed. A full recommendation could be made in the next one to three years. Vaccination of children over six months of age who have certain medical conditions continues to be strongly recommended.

Medscape: How can physicians reach their adult patients to get them more fully vaccinated?

Dr. Gerberding: A number of strategies for reaching adult patients with information about influenza can be found on the Web at: http://www.cdc.gov/nip/publications/adultstrat.htm The strategies include standing orders, computerized record reminders, chart reminders, home visits, mail and telephone recall reminders, expanding clinic access and hours, and patient education.

Medscape: Does the CDC have plans for addressing the fragility of the vaccine production system, so that we avoid shortages in the future? How have we overcome the recent flu vaccine shortages?

Dr. Gerberding: Projected influenza vaccine production for the 2002-03 season, based on aggregate manufacturers' estimates, is approximately 94 million doses. This is more vaccine than was ever produced in a single flu season. All three manufacturers report that influenza vaccine production is proceeding satisfactorily. According to the manufacturers, approximately 80% of the total production is anticipated to be distributed before November 1.

Medscape: What is the latest recommendation for smallpox vaccination: healthcare workers only, active duty troops only, all who wish to be vaccinated? What is the rationale?

Dr. Gerberding: The final decision on smallpox vaccination will be made by HHS and the White House. We don't have a time frame on when this decision will be made.

Medscape: Please comment on the likelihood that smallpox infection could spread from those vaccinated to those who are immunocompromised?

Dr. Gerberding: Vaccinia is presumably transmitted by direct person-to-person contact, and steps should also be taken to reduce this likelihood in healthcare settings. The most critical measure in preventing inadvertent implantation and contact transmission from vaccinia vaccination is thorough hand-hygiene after changing the bandage or after any other contact with the vaccination site. Transmission of vaccinia is also a concern in settings when close personal contact with children or other persons is likely — for example, parenting of infants and young children. In these situations, the vaccination site should be covered with gauze or a similar absorbent material, and a shirt or other clothing should be worn, and careful attention to hand hygiene (hand washing) practiced. Reviewed by Gary D. Vogin, MD

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Laurie Barclay, MD is a staff writer with WebMD. Medscape Medical News is edited by Deborah Flapan, a news coordinator at Medscape. Send press releases and comments to news@webmd.net.   Medscape Medical News 2002. © 2002 Medscape

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ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.