MMWR: interim results: target A (H1N1) 2009 monovalent vaccination coverage USA 2009, October-December

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In July 2009, the Advisory Committee on Immunization Practices (ACIP) issued recommendations for use of the influenza A (H1N1) 2009 monovalent vaccine (1). Recognizing that the vaccine supply would not be ample immediately but would grow over time, ACIP identified 1) initial target groups, consisting of approximately 160 million persons, and 2) a limited vaccine subset of the target groups, initially estimated at 42 million persons (and more recently estimated at 62 million persons), to receive first priority while the 2009 H1N1 vaccine supply was limited (1). ACIP recommended expanding vaccination to the rest of the population as vaccine supplies increased. To estimate 2009 H1N1 vaccination coverage to date for the 2009--10 influenza season, CDC analyzed results from the National 2009 H1N1 Flu Survey (NHFS) and the Behavioral Risk Factor Surveillance System (BRFSS) survey, conducted during December 27, 2009--January 2, 2010, and December 1--27, 2009, respectively. The results indicated that, as of January 2, an estimated 20.3% of the U.S. population (61 million persons) had been vaccinated, including 27.9% of persons in the initial target groups and 37.5% of those in the limited vaccine subset. An estimated 29.4% of U.S. children aged 6 months--18 years had been vaccinated. Now that an ample supply of 2009 H1N1 vaccine is available, efforts should continue to increase vaccination coverage among persons in the initial target groups and to offer vaccination to the rest of the U.S. population, including those aged =65 years (2).

To provide both timely estimates of 2009 H1N1 vaccination coverage and reliable estimates of coverage in priority populations (e.g., the initial target groups and the limited vaccine subset*), CDC used two separate surveys, NHFS and BRFSS. NHFS is a new survey, scheduled to operate from October 2009 through June 2010 to track 2009 H1N1 and seasonal influenza vaccination coverage nationally on a weekly basis. NHFS is a random-digit--dialed telephone survey based on a rolling weekly sample of respondents with landline and cellular telephones. Monthly targets were set to achieve approximately 4,889 completed interviews from landline households and 1,111 from cellular-only or cellular-mostly households, or approximately 6,000 interviews in all. To determine influenza vaccination status, respondents were asked whether they (or their child) had received "an H1N1 flu vaccination" since September, and if so, in which month.† The NHFS estimates presented in this report show the percentage of respondents interviewed during the week of December 27, 2009--January 2, 2010, who reported receiving vaccine from October 1, 2009 to the date of interview. Unvaccinated NHFS respondents also were asked: "How likely are you to get an H1N1 flu vaccination between now and June 2010?"

Because the weekly sample sizes from NHFS are not large enough for reliable estimation of vaccination coverage among persons in individual initial target groups, CDC also used BRFSS, which collected vaccination coverage data for most of the initial target groups on a monthly basis. BRFSS conducts state-based, random-digit--dialed telephone surveys of the noninstitutionalized U.S. population aged =18 years to determine the prevalence of health conditions and health risk behaviors. Since 2001, BRFSS has included questions on seasonal influenza vaccination in its core survey. To determine 2009 H1N1 vaccination coverage, BRFSS respondents in 49 states (all except Vermont) and the District of Columbia were asked if they (or their child in 39 of these states and the District of Columbia) had been vaccinated for the "H1N1 flu" since September, and if so, in which month?§ BRFSS results in this report represent the percentage of respondents who reported receiving 2009 H1N1 vaccine during the period from October 1, 2009, through the date of interview during December 1--27, 2009.

For both NHFS and BRFSS, respondents with missing influenza vaccination information were excluded. Results from both surveys were weighted to reflect selected demographic and geographic population estimates and analyzed by statistical software that accounts for survey design. Statistical significance of differences was assessed by t-test. For NHFS, the Council of American Survey and Research Organizations (CASRO) response rate for the first 13 weekly sample groups was 34% for landline telephone respondents and 26% for cellular telephone respondents; the cooperation rate was 43% for landline and 57% for cellular. During December 2009, the BRFSS median CASRO response and cooperation rates were 50% and 74%, respectively.¶

From October 10, 2009 to January 2, 2010, the weekly NHFS percentage of U.S. residents who reported they had received at least 1 dose of 2009 H1N1 vaccine rose to 20.3% (Figure). According to NHFS data, of the 24 million vaccine doses administered in the United States through mid-November, an estimated 21 million (85%) went to persons in the initial 2009 H1N1 target groups. By the end of December, this percentage had declined to 74% (48 million of the 65 million doses administered). For the survey week December 27, 2009--January 2, 2010, NHFS data indicated that 29.4% of children aged 6 months--18 years (22 million) had received at least 1 dose of vaccine, including 33.0% of children aged 6 months--4 years (Table 1). Among children aged 6 months--9 years, an age group recommended to receive 2 doses of 2009 H1N1 vaccine, 34.6% (95% confidence interval [CI] = 26.6%-- 42.6%) had received at least 1 dose; among these children, 17.8% (CI = 10.1%-- 25.5%) had received 2 doses.

According to NHFS estimates, vaccination coverage was 27.9% among persons included in the 2009 H1N1 initial target groups and 37.5% among those in the limited vaccine subset, two populations estimated to number 160 million (CI = 144--176 million) and 62 million (CI = 51--73 million) respectively in the United States (Table 1). Among BRFSS survey respondents during December 1--27, estimated coverage for specific initial target groups was 38.0% for pregnant women, 22.3% for health-care personnel, and 11.6% for adults aged 25--64 years with high-risk medical conditions. Among NHFS respondents during November 29--December 26, coverage was 13.9% for adults who live with or provide care for infants aged <6 months (Table 2).

BRFSS estimates of 2009 H1N1 vaccination rates generally were higher among non-Hispanic whites than among non-Hispanic blacks. However, this difference was statistically significant only among adults aged 25--64 years with high-risk conditions (13.1% [CI = 11.1%--15.1%] versus 5.4% [CI = 2.5%--8.3%]) and health-care personnel (25.6% [CI = 22.5%--28.7%] versus 7.6% [CI = 3.3%--11.9%]).

Among the December 27--January 2 NHFS participants who had not yet received 2009 H1N1 vaccination, 10.9% (CI = 7.4%--14.4%) said they definitely intended to get vaccinated by June 2010; an additional 22.5% (CI = 18.6%--26.4%) said they would probably get vaccinated. Among parents of unvaccinated children, 21.1% (CI = 10.7%-- 31.5%) said they definitely intended to have their children vaccinated, and 17.7% (CI = 10.6%--24.8%) said they probably would have their children vaccinated.

Reported by

JA Singleton, MS, TA Santibanez, PhD, PJ Lu, PhD, H Ding, MD, GL Euler, DrPH, Immunization Svc Div, GL Armstrong, MD, Div of Viral Diseases, BP Bell, MD, National Center for Immunization and Respiratory Diseases; M Town, MS, L Balluz, ScD, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Development of 2009 H1N1 vaccines began immediately after the virus emerged in late April 2009. By late June, several manufacturers had begun the process of producing vaccines; within 4 months, vaccines had been licensed by the Food and Drug Administration, and the first lots of vaccine were released for use in the United States. By mid-December, approximately 85 million doses had been shipped to providers around the country. During October 5--December 31, a period of limited vaccine supply, vaccination efforts focused on those groups at highest risk for influenza or influenza complications or persons in close contact with those at high risk (1). This report indicates that, by the beginning of 2010, an estimated 20% of the population, or 61 million U.S. residents, had received 2009 H1N1 vaccine. Of persons in the groups initially targeted by ACIP for vaccination, an estimated 28% reported receiving 2009 H1N1 vaccine. The highest coverage (approximately 38%) was achieved among persons in the limited vaccine subset, as defined by ACIP, indicating that public health efforts largely were effective at directing available vaccine to those persons who needed it most.

Overall, the 29% 2009 H1N1 vaccination coverage among children aged 6 months--18 years was similar to estimates of seasonal influenza vaccination coverage (24%--27%) for this age group during the 2008--09 influenza season (3,4). Among children aged <5 years, who have been recommended for seasonal influenza vaccination since 2006 (5) and who have been among the groups most severely affected by 2009 H1N1, first-dose 2009 H1N1 influenza vaccination coverage was 33%, approaching seasonal influenza vaccination coverage estimates (35%--43%) during recent seasons (3,4).

Hospitalization rates and mortality from 2009 H1N1 influenza have been high among pregnant women (6,7). The 38% 2009 H1N1 vaccination coverage among pregnant women in this report was higher than the rate typically achieved (15%--25%) for seasonal influenza vaccination (8). However, the CI around this estimate is large (24%--52%). A separate system, the Pregnancy Risk Assessment Monitoring System (PRAMS), is collecting data, including influenza immunization coverage, from approximately 30,000 women with live births in 31 states and will provide more precise estimates in the future. To improve influenza vaccination coverage among pregnant women this year and during future seasons, efforts should continue to urge obstetricians and other health-care providers to provide influenza vaccine to pregnant women.

The results in this report show that nearly 90% of adults aged <65 years with medical conditions that increase their risk for influenza-related complications remain unvaccinated. Among adults hospitalized with 2009 H1N1 infection, approximately three fourths had at least one high-risk condition (e.g., asthma, chronic obstructive pulmonary disease, diabetes and chronic cardiovascular disease) (9). Given the increased supply of vaccine, efforts to encourage 2009 H1N1 vaccination among persons at increased risk for 2009 H1N1 influenza complications should be strengthened.

Seasonal influenza vaccination coverage among health-care workers historically has been below 50% (8). Efforts to vaccinate health-care workers began when 2009 H1N1 vaccine first became available, but according to the BRFSS survey, during December 1--27, only 22% of health-care workers reported having been vaccinated. Unvaccinated health-care workers who become infected risk transmitting the virus to their family members or patients, who often are at high risk for severe influenza. The current high percentage of unvaccinated health-care workers highlights the need to strengthen measures to improve their influenza vaccination coverage.

Among adults with chronic medical conditions, NHFS and BRFSS show lower vaccination coverage among blacks than whites. Similar disparities have been identified for seasonal influenza and pneumococcal polysaccharide vaccination (4). The finding of lower 2009 H1N1 vaccination coverage among black health-care workers suggests that access to care is not the only barrier to influenza vaccination and highlights a role for targeted outreach efforts.

The findings in this report are subject to at least three limitations. First, the NHFS results presented in this analysis are based on data collected during a single week of interviews, and all results are based on self-report or parental report of 2009 H1N1 vaccination. Because of the limited size of the NHFS sample, confidence limits around estimates are large and final estimates might differ. Second, BRFSS and NHFS are subject to selection bias because of noninclusion of households with only cellular telephones (BRFSS) and households with no telephone service (BRFSS and NHFS). Finally, CASRO response rates and cooperation rates were low, particularly for NHFS.

Although influenza activity has declined in the United States in recent weeks, cases of 2009 H1N1 influenza, including cases of severe disease, continue to occur. The epidemiology of 2009 H1N1 influenza over the months ahead is unknown, but another rise in incidence, as occurred during the winter of the 1957--58 pandemic, remains possible (10). In addition, increases in influenza activity from seasonal influenza also might occur as the season progresses. Vaccination remains the best way to prevent influenza infection and influenza-related hospitalizations and deaths.

The findings in this report are based, in part, on NHFS contributions by M Montgomery, K Copeland, N Davis, and others at the National Opinion Research Center, Chicago, Illinois; data collected by state BRFSS coordinators; members of the CDC H1N1 Vaccine Coverage Monitoring Team; and members of the CDC Behavioral Surveillance Branch, Atlanta, GA.

CDC. Use of influenza A (H1N1) 2009 monovalent vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-10).CDC. National Influenza Vaccination Week---January 10--16, 2010. MMWR 2010;58(51&52);1444.CDC. Influenza vaccination coverage among children and adults---United States, 2008--09 season. MMWR 2009;58:1091--5.CDC. Vaccination coverage estimates from the National Health Interview Survey: United States, 2008. Updated July 22, 2009. Available at http://www.cdc.gov/nchs/data/hestat/vaccine_coverage.htm. Accessed January 14, 2009.Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2008;122:805--11.Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009;374:451--8.Louie JK, Acosta M, Jamieson DJ, Honein MA, California Pandemic (H1N1 Working Group. Severe 2009 H1N1 influenza in pregnant and postpartum women in California. N Engl J Med 2010;362:27--35.CDC. Prevention and control of seasonal influenza with vaccines---recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-8):26.Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 H1N1 influenza in the United States, April--June 2009. N Engl J Med 2009;361:1935--44.Henderson DA, Courtney B, Inglesby TV, et al. Public health and medical responses to the 1957--58 influenza pandemic. Biosecur Bioterror 2009;7:265--73.What is already known on this topic?

Since 2009 H1N1 influenza vaccine first became available in October 2009, public health agencies have directed limited vaccine supplies toward groups of persons who can most benefit from the vaccine.

What is added by this report?

By the end of December 2009, an estimated 61 million persons (20% of the U.S. population) had been vaccinated, including 27.9% of persons in the initial target groups, 29.4% of children, 11.6% of adults aged 25--64 years with underlying medical conditions, 22.3% of health-care personnel, and 13.9% of adults caring for infants aged <6 months.

What are the implications for public health practice?

Now that there is ample supply of vaccine, efforts should continue to improve vaccination coverage among persons in initial target groups, as well as to offer vaccination to the rest of the U.S. population, including those aged =65 years.

FIGURE. Weekly estimates of influenza A (H1N1) 2009 monovalent vaccination coverage among U.S. residents aged =6 months --- National 2009 H1N1 Flu Survey, week ending October 10, 2009, through week ending January 2, 2010

Alternative Text: The figure above shows weekly estimates of influenza A (H1N1) 2009 monovalent vaccination coverage among U.S. residents aged =6 months for the week ending October 10, 2009, through the week ending January 2, 2010. During that period, the percentage of persons reporting receipt of 2009 H1N1 vaccination increased to 20.3%

Age group/Priority group

U.S. population (millions)

H1N1 vaccination coverage

No. surveyed†

% vaccinated (95% CI§)

Estimated no. of persons vaccinated (millions) (95% CI)

Initial target group

H1N1 vaccination coverage

No. surveyed§

% vaccinated (95% CI¶)

Adults aged 25--64 years with high-risk conditions**

Adults living or caring for infant aged <6 months (NHFS¶¶)

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

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MMWR: A (H1N1) 2009 monovalent prevent vaccination campaign - Arab, Illinois, October 16th to December 31, the target region of 2009.

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On July 29, 2009, the Advisory Committee on Immunization Practices (ACIP) recommended a phased approach for administration of influenza A (H1N1) 2009 monovalent vaccine, with certain high-risk groups* in the United States receiving the first doses (1). In Illinois, state authorities gave responsibility for initial vaccine administration to local health departments and hospitals. This report describes the vaccination campaign of the Skokie Health Department (SHD), during October 16--December 31, 2009. The SHD campaign initially was planned to cover the 67,000 persons residing in Skokie only, but that plan was expanded on November 4, when, in response to a nationwide vaccine shortage, the state health director urged local health departments to vaccinate any person in the ACIP priority groups regardless of jurisdictional boundaries. SHD, with the assistance of 1,075 volunteers, either administered or distributed to medical providers 40,850 H1N1 vaccine doses during a 9-week period, including 8,904 doses administered at 52 Skokie schools and day-care facilities, and 12,876 doses at mass vaccination clinics visited by residents of 193 of the 1,313 Illinois municipalities. At the time of the campaign, widespread illness from 2009 H1N1 in Illinois, with highly publicized deaths, contributed to a public sense of urgency about vaccination. Consistent with published studies (2,3), mass clinics in Skokie were an effective means to vaccinate large populations rapidly. The campaign highlighted the need for flexible plans, including the possibility of vaccinating persons who resided well beyond SHD's jurisdictional borders.

SHD is one of six state-certified local health departments in Cook County, Illinois, and typically administers 3,000 seasonal influenza vaccinations each year. Beginning in July 2009, following ACIP guidelines, SHD staff members used census data and direct contacts with schools and medical practices to estimate that 38,900 residents and commuters† were members of the initial priority groups recommended by ACIP for vaccination, including 14,900 children in schools or day-care facilities. Based on priority group calculations, on September 27, SHD ordered 40,000 doses of influenza A (H1N1) 2009 monovalent vaccine through the Illinois Department of Public Health (IDPH). SHD initially targeted children in schools and day-care facilities. Planners anticipated that area health-care providers and retail pharmacies would have sufficient vaccine by mid-October to begin vaccinating the other high-risk target groups. SHD mass clinics were scheduled for early December to ensure all residents would have access to the vaccine. During October 5--16, SHD received 15,000 doses for schools and day-care facilities, 67% of the doses in the nasal spray formulation. SHD received an additional 25,000 doses during November 6--16. In all, SHD administered or distributed 40,850 doses,§ in what evolved into a five-phase campaign (Figure 1, Table) that resulted in SHD administering influenza A (H1N1) 2009 monovalent vaccine to persons who resided far beyond the village boundaries (Figure 2). Overall, 54% of vaccine recipients at SHD clinics were not residents of Skokie.

Five-Phase Campaign

Phase 1. Vaccination clinics were held during October 21--November 20 at 39 public and private schools and 13 day-care facilities in Skokie. Vaccinations were offered to children, staff members, and caregivers of children aged <6 months. Overall, 8,904 persons received vaccine, 53% of the estimated target population. At school clinics, a greater percentage of persons aged =19 years (71%) received vaccine than persons aged 6 months--18 years (49%), based on the actual target populations. Among those vaccinated at school and day-care clinics, 40% resided outside of Skokie.

Phase 2. During October 16--November 24, SHD administered 2009 H1N1 vaccinations to persons who volunteered to assist in the vaccination campaign. SHD also offered vaccine to emergency medical services (EMS) personnel from Skokie and seven neighboring municipalities, and a regional private helicopter 911 service. Altogether, SHD vaccinated 254 EMS workers, or 24% of the actual target population; 179 (70%) worked for municipalities other than Skokie.

Phase 3. During November 9--25, because approximately 48% of the vaccine allocated for schools had not been utilized, a total of 8,141 doses were distributed to 30 Skokie medical practices that had placed vaccine orders with IDPH; an additional 2,717 doses were distributed to a local hospital. Because of an ongoing national vaccine shortage and preferential ordering of single-dose syringes, which were not yet available, the medical practices had received only 3% of their 20,850 ordered doses by mid-November, and a four-hospital system in the area had received only 10% of 120,000 ordered doses. SHD did not collect information regarding the recipients of these vaccine doses; the medical practices signed an agreement with IDPH to abide by ACIP guidelines.

Phase 4. SHD conducted four mass vaccination clinics during December 3--12 that were open to anyone in the ACIP priority groups, ignoring jurisdictional borders as requested by IDPH. An online appointment system and a phone bank were established to schedule vaccinations, limiting participants to 600 per hour. At the clinics, 12,876 persons were vaccinated; 73% of recipients resided outside of Skokie.

SHD was able to modify procedures rapidly to improve clinic flow. For the first clinic, several hundred persons arrived well before the scheduled start time and could not be allowed to enter the building, which contributed to a slow start and resulting waits of 1--2 hours. For the remaining three clinics, SHD implemented refinements to reduce the entire vaccination process time to <30 minutes per vaccinee. Refinements included establishing an adults and teens express vaccination room, reorganizing patterns within the building to maintain a continuous flow, ensuring adequate staffing, and opening 1 hour earlier than scheduled to accommodate early arrivals. Overall, 25 persons were vaccinated per vaccinator, per hour.

Phase 5. During December 14--31, because of increased vaccine supply, IDPH opened 2009 H1N1 vaccinations to any person aged =6 months. SHD administered an additional 3,261 doses at the village hall, the public library, and to the homebound. At the same time, SHD distributed 3,780 doses to neighboring health departments, Skokie medical practices, and a long-term care facility.

Staffing and Communication

SHD, which has a staff of 18 persons, including one physician, two full-time nurses, and one part-time nurse, relied on 1,075 community volunteers to administer vaccinations and fill support roles; most of these persons had never served in large vaccination clinics and had no previous emergency preparedness training. Volunteer recruitment efforts included a letter from the mayor to all Skokie boards and commissions, Internet postings, e-mail requests, and broadcast messages on the local emergency radio station and cable television news. Recruiting messages described specific tasks that would be assigned to volunteer support staff members, such as assisting with completion of consent forms or movement of persons through the clinic. The 172 volunteer vaccinators included 108 nurses, 36 nursing students, 22 paramedics, four physicians, and two pharmacists; many volunteered on more than one occasion.

Teleconferencing was established and used along with mass e-mails for simultaneous communication with schools and day-care facilities. Local medical practices and retail pharmacies received regular updates via blast fax. Skokie residents and businesses were kept informed of the vaccination campaign through local newspapers, flyers, billboards, Internet postings, 10 radio station updates, five cable television spots, and 12 mass e-mailings. Twice, "reverse-911" calls with critical clinic information were sent to village businesses and residences. Monthly visits to the Village of Skokie website doubled during December, from 17,000 to 34,000. Chicago news coverage was instrumental in promoting the availability of vaccine in Skokie; within 4 days of Chicago news coverage, all mass clinic appointments had been filled. To defray costs of the campaign, SHD received $260,000 in federal Public Health Emergency Response funds, distributed through IDPH.

C Counard, MD, A Rigoni, MPA, J Lockerby, MPA, A Tennes, MPA, R Czerwiniski, D Prottsman, MPA, M Slankard, MPA, A LeTendre, MPA, B Silverberg, P Hanley, JD, H Mueller, JD, B Nowak, MBA, B Gilley, MIT, M Aleksic, M DiFrancesca, C Ballowe, B Johnson, MS, B Jones, S Reisberg, MSN, C Braden, MPH, J Hartford, B Neirick, D Codd, B Kok, D McLin, C Starks, J Gaulin, L Kaplan, M Maggi, D Mohrlein, H Coleman, P Staffney, J Prendi, MPA, L Gooris, K Norwood, J Silva, N Wyatt, H Peters, J Scher, B Riplinger, J Gill, J Lyerly, D Nygren, J Puff, L Rukavina, C Markoutsas, I Kalota, J Reichert, N Tharwani, S Collins, L Brangan, Village of Skokie. K Whitney, Municipal GIS Partners, Inc. D Nimke, MPH, private epidemiology contractor. C Conover, MD, LG Gallagher, MPH, K McMahon, Illinois Dept of Public Health. D Swerdlow, MD, National Center for Immunization and Respiratory Diseases, CDC.

The 2009 H1N1 vaccination campaign presented substantial challenges to SHD. The initial, two-part plan devised in July was to offer vaccine first to children, the largest ACIP target population in Skokie, through school and day-care clinics during October and November. Planners anticipated that community medical providers would, at the same time, vaccinate members of the other ACIP priority groups, and SHD would finish up with four mass clinics in December, targeting Skokie residents who had not yet been vaccinated. However, because the vaccine shortage prevented many persons at high-risk for complications from 2009 H1N1 strain from getting vaccinated, the SHD plan quickly became to vaccinate a broader population as requested by IDPH, including persons who resided outside the village limits.

CDC has indicated previously that the convenience of school-located vaccination clinics might improve pediatric vaccination rates for seasonal influenza and during outbreaks of vaccine-preventable diseases (4). During an outbreak of pertussis at an Illinois high school, the vaccination rate among students, which had increased from 16% to 37% in the 3 months after parents and health-care providers were first notified, rose to 68% after a 4-day school-based vaccination clinic (5). The 49% 2009 H1N1 vaccination coverage among children in Skokie schools and day-care facilities is substantially higher than the preliminary vaccination rate estimates for this population nationally (36.8%) and in Illinois (37.5%) (6). However, caution should be used in comparing the Skokie coverage rate, which was calculated from administrative data, with national and state survey data.

Large numbers of community volunteers were essential to the success of the Skokie vaccination campaign; most were identified through established relationships. Effective use of volunteers during public health emergencies requires a clear organizational framework and well-defined job duties. This level of support will be required for future efforts to rapidly vaccinate the entire Village. Historic accounts of the 1918 influenza pandemic in the United States describe a similar reliance on volunteers to carry out local response efforts (7).

Rapid vaccination of the United States population during a pandemic is achieved through local efforts. SHD was able to quickly adjust its 2009 H1N1 vaccination plans at multiple junctures as the event unfolded and to provide vaccine to many persons not included in original plans. These adjustments were possible because of strong support from village officials of public health initiatives, an early commitment to administer 40,000 vaccine doses, and well-established lines of public health communication at the state and local level.

This report is based, in part, on contributions from school and day-care administrations and staff members, the Skokie Park District administration and staff members, and approximately 1,000 persons who volunteered their services to the vaccination campaign.

CDC. Use of influenza A (H1N1) 2009 monovalent vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-10).Schwartz B, Wortley P. Mass vaccination for annual and pandemic influenza. Curr Top Microbiol Immunol 2006;304:131--52.Fontanesi J, Hill L, Olson R, Bennett NM, Kopald D. Mass vaccination clinics versus appointments. J Med Pract Manage 2006;21:288--94.CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2009;58(No. RR-8).CDC. Use of mass Tdap vaccination to control an outbreak of pertussis in a high school---Cook County, Illinois, September 2006--January 2007. MMWR 2008;57:796--9.CDC. Interim results: state-specific influenza A (H1N1) 2009 monovalent vaccination coverage---United States, October 2009--January 2010. MMWR 2010;59:363--8.Jones MM. The American Red Cross and local response to the 1918 influenza pandemic: a four-city case study. Public Health Rep 2010;125(Suppl 3):92--104.

What is already known?

Local health departments typically provide services based on jurisdictional borders; this policy presented a challenge to 2009 H1N1 vaccination campaigns.

What is added by this report?

The Skokie Health Department in Illinois rapidly modified existing plans to accommodate persons in vaccine priority groups from a wide geographic area; overall, 54% of vaccinations were administered to persons who resided outside of Skokie.

Implications for public health practice?

During pandemics, vaccine shortages are likely to occur; where appropriate and permissible, mass vaccination clinics that cross public health jurisdictional borders can improve access to vaccine.

FIGURE 1. Number of doses of influenza A (H1N1) 2009 monovalent vaccine administered or distributed by Skokie Health Departmnent (SHD), by date and campaign phase* --- Skokie, Illinois, October 16--December 31, 2009

Alternate Text: The figure above shows the number of doses of influenza A (H1N1) 2009 monovalent vaccine administered or distributed by Skokie Health Department (SHD), by date and campaign phase in Skokie, Illinois from October 16- December 31, 2009. In all, SHD administered or distributed 40,850 doses, in what evolved into a five-phase campaign.

Campaign phase

Period in 2009

Site

Recipient group

No. of doses administered or distributed

Neighboring health departments

FIGURE 2. Residences of Illinois recipients of doses* of influenza A (H1N1) 2009 monovalent vaccine administered by the Skokie Health Department --- Skokie, Illinois, October 16--December 31, 2009

Alternate Text: The figure above shows residences of Illinois recipients of doses of influenza A (H1N1) 2009 monovalent vaccine administered by the Skokie Health Department during October 16-December 31, 2009. In all, SHD administered or distributed 40,850 doses, in what evolved into a five-phase campaign that resulted in SHD administering influenza A (H1N1) 2009 monovalent vaccine to persons who resided far beyond the village boundaries.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

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MMWR: Update: target activity---USA, 1 August 30, 2009, 4, 9, 2010

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The emergence and spread of the 2009 pandemic influenza A (H1N1) virus (2009 H1N1) resulted in extraordinary influenza activity in the United States throughout the summer and fall months of 2009 (1,2). During this period, influenza activity reached its highest level in the week ending October 24, 2009, with 49 of 50 states reporting geographically widespread disease. As of January 9, 2010, overall influenza activity had declined substantially. Since April 2009, the dominant circulating influenza virus in the United States has been 2009 H1N1. This report summarizes U.S. influenza activity* from August 30, 2009, through January 9, 2010.

Viral Surveillance

During August 30, 2009--January 9, 2010, World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories in the United States tested 310,151 respiratory specimens for influenza viruses; 81,179 (26.2%) were positive, 80,951 (99.7%) of those specimens were positive for influenza A, and 228 (0.3%) were positive for influenza B. Of the 61,726 influenza A viruses for which subtyping was performed, 61,332 (99.4%) were 2009 H1N1 viruses. Only 29 viruses (<0.1%) were seasonal influenza A (H1), 52 (<0.1%) were influenza A (H3) viruses, and 313 (0.5%) were influenza A, but could not be subtyped because of specimen quantity or quality.

CDC has antigenically characterized 944 viruses that were 2009 H1N1, one seasonal influenza A (H1N1), seven influenza A (H3N2), and six influenza B viruses collected since September 1, 2009. A total of 942 (99.8%) 2009 H1N1 viruses tested were related to the A/California/7/2009 (H1N1) reference virus selected by WHO as the 2009 H1N1 vaccine virus; only two viruses (0.2%) showed reduced titers with antisera produced against A/California/7/2009.

One seasonal influenza A (H1N1) virus was related to the influenza A (H1N1) component of the 2009--10 Northern Hemisphere influenza vaccine (A/Brisbane/59/2007). The seven influenza A (H3N2) viruses collected during September 22--November 1, 2009, showed reduced titers with antisera produced against A/Brisbane/10/2007, the 2009--10 Northern Hemisphere influenza A (H3N2) vaccine component, and were antigenically related to A/Perth/16/2009, the WHO-recommended influenza A (H3N2) component of the 2010 Southern Hemisphere vaccine formulation. The six influenza B viruses tested belong to the B/Victoria lineage and are related to the influenza vaccine component for the 2009--10 Northern Hemisphere influenza vaccine (B/Brisbane/60/2008).

Antiviral Resistance of Influenza Virus Isolates

CDC conducts surveillance for resistance of circulating influenza viruses to both classes of influenza antiviral medications: adamantanes (amantadine and rimantadine) and neuraminidase inhibitors (zanamivir and oseltamivir). Since September 1, 2009, 39 (1.3%) of 2,926 total 2009 H1N1 viruses tested by neuraminidase inhibition assay and/or by detection of a single known mutation in the virus which confers oseltamivir resistance, H275Y, have shown oseltamivir resistance. This proportion of oseltamivir-resistant 2009 H1N1 viruses might overestimate the prevalence of oseltamivir-resistant 2009 H1N1 viruses in the United States because most of these viruses were tested because of clinical suspicion for oseltamivir resistance. Three additional cases of oseltamivir resistance among 2009 H1N1 viruses have been identified by other laboratories where antiviral resistance testing also is performed; thus, a total of 42 oseltamivir-resistant 2009 H1N1 viruses have been reported to CDC since September 1, 2009.

Since April 2009, a total of 52 oseltamivir-resistant 2009 H1N1 viruses have been detected in patients in the United States. Forty (77%) of the 52 patients had documented exposure to oseltamivir through either treatment or chemoprophylaxis; exposure to oseltamivir in nine (17%) patients has not yet been determined, and three patients (6%) had no known exposure. One seasonal influenza A (H1N1) was tested and was resistant to oseltamivir. One influenza B virus was tested and was not resistant to oseltamivir. None of eight influenza A (H3N2) viruses tested were resistant to oseltamivir. All tested viruses were sensitive to the neuraminidase inhibitor zanamivir. One seasonal influenza A (H1N1) virus was found to be sensitive, and nine (81.8%) of 11 influenza A (H3N2) and 834 (99.6%) of 837 2009 H1N1 virus isolates tested were found to have resistance to the adamantanes (amantadine and rimantadine).

State-Specific Activity Levels

The largest number of states to date reporting widespread activity occurred during the week ending October 24, 2009, when 49 jurisdictions reported widespread activity.† During the week ending January 9, 2010, no jurisdiction reported widespread activity. The early widespread state-specific activity contrasts with the previous three influenza seasons (October to May), when state-specific influenza activity did not reach comparable levels until mid-February or early March.

Outpatient Illness Surveillance

In the week ending October 24, 2009, the weekly percentage of outpatient visits for influenza-like illness (ILI)§ reported by the U.S. Outpatient ILI Surveillance Network (ILINet) reached 7.7%, the highest level to date this influenza season. As of January 9, 2010, ILI activity had decreased to 1.9% (Figure 1). During the previous three influenza seasons, peak ILI activity occurred later in the season and ranged from 3.5% during the week ending February 17 of the 2006--07 season to 6.0% during the week ending February 17 of the 2007--08 season. As of the week ending January 9, one of 10 regions was reporting weekly percentages of outpatient visits for ILI at or above its region-specific baseline. ILI activity was at or above the national baseline of 2.3% during the entire period of November--December 2009.¶

Influenza-Associated Hospitalizations

Laboratory-confirmed influenza-associated hospitalizations are monitored using a population-based surveillance network that includes sites in 10 states in the Emerging Infections Program (EIP) and sites in six additional states added during 2009.** This season, cumulative hospitalization rates have been highest in children aged 0--4 years, and generally rates have declined with age. As of January 9, 2010, cumulative rates of laboratory-confirmed influenza-associated hospitalizations reported for children aged 0--4 years were 5.9 per 10,000 population by EIP and 9.7 per 10,000 population by the new sites (Figure 2). Rates for other age groups were as follows: 5--17 years, 2.5 by EIP and 3.6 by the new sites; 18--49 years, 2.2 by EIP and 1.7 by the new sites; 50--64 years, 2.9 by EIP and 1.8 by the new sites; and =65 years, 2.4 by EIP and 1.7 by the new sites. In comparison, EIP cumulative hospitalization rates for the entire October-May influenza reporting seasons of 2006--07, 2007--08, and 2008--09, ranged as follows: ages 0--4 years (2.6 to 4.2), 5--17 years (0.4 to 0.6), 18--49 years (0.3 to 0.7), 50--64 years (0.4 to 1.5), and =65 years (1.4 to 7.5) (Figure 2).

In response to the emergence of 2009 H1N1 viruses, the Council of State and Territorial Epidemiologists (CSTE) instituted reporting of 2009 H1N1-confirmed hospitalizations and deaths to CDC. On August 30, CDC and CSTE instituted modified case definitions for aggregate reporting of influenza-associated hospitalizations and deaths. This cumulative jurisdiction-level reporting is referred to as the Aggregate Hospitalization and Death Reporting Activity (AHDRA).†† During August 30, 2009--January 9, 2010, a total of 38,454 hospitalizations associated with laboratory-confirmed influenza virus infections were reported to CDC through AHDRA. The median number of states reporting hospitalizations per week through AHDRA was 33 (range: 25--35).

Pneumonia and Influenza-Related Mortality

Pneumonia and influenza-associated deaths are monitored by the 122 Cities Mortality Reporting System and AHDRA. For the week ending January 9, pneumonia or influenza was reported as an underlying or contributing cause of death for 7.3% of all deaths reported through the 122 Cities Mortality Reporting System, below the week-specific epidemic threshold of 7.6%§§ (Figure 3). The longest period that pneumonia and influenza-related mortality was above the epidemic threshold was for 11 consecutive weeks from the week ending October 3, 2009, to the week ending December 12, 2009. The highest level of pneumonia and influenza-related mortality was 8.1% for the week ending November 21, 2009. In contrast, peak pneumonia and influenza-associated mortality did not occur until later in the three previous seasons, peaking at 7.7% during the week ending February 24, 2007, during the 2006--07 influenza season and at 9.1% in the week ending February 16, 2008, during the 2007--08 season.

During August 30--January 9, a total of 1,779 deaths associated with laboratory-confirmed influenza virus infections were reported to CDC through AHDRA. The 1,779 laboratory-confirmed deaths are in addition to the 593 laboratory-confirmed deaths from 2009 H1N1 that were reported to CDC from April through August 30, 2009. Since August 30, cumulative deaths associated with laboratory-confirmed 2009 H1N1 infection per 100,000 population were 0.31 for persons aged 0--4 years, 0.26 for 5--18 years, 0.38 for 19--24 years, 0.60 for 25--49 years, 1.03 for 50--64 years, and 0.65 for =65 years. For the period August 30--January 9, the median number of states reporting laboratory-confirmed deaths per week through AHDRA was 34 (range: 23--38).

Influenza-Associated Pediatric Mortality

CDC has received 236 reports of pediatric deaths associated with laboratory-confirmed influenza infection that occurred and were reported since August 30, 2009, the start of the 2009--10 influenza season (Figure 4). A total of 195 (83%) cases were associated with laboratory-confirmed 2009 H1N1 virus. Forty pediatric deaths were associated with an influenza A infection for which the subtype was undetermined but likely was 2009 H1N1 based on the predominance of this virus among those circulating. One death was associated with an influenza B virus infection (Figure 4).

Of the 236 pediatric deaths reported occurring since August 30, a total of 43 (18.2%) were among children aged <2 years, 26 (11.0%) were among children aged 2--4 years, 87 (36.9%) were among children aged 5--11 years, and 80 (33.9%) were among children aged 12--17 years. Since the week ending May 2, CDC has received 255 reports of pediatric deaths associated with laboratory-confirmed 2009 H1N1 virus. During the 2005--06, 2006--07, and 2007--08 influenza seasons, the mean number of reported pediatric influenza deaths was 74.

WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza. L Brammer, MPH, S Epperson, MPH, L Blanton, MPH, T Wallis, MS, A Fiore, MD, L Gubareva, PhD, J Bresee, MD, L Kamimoto, MD, X Xu, MD, A Klimov, PhD, N Cox, PhD, Influenza Div; L Finelli, DrPH, National Center for Immunization and Respiratory Diseases; S Graitcer, MD, EIS Officer, CDC.

As of January 9, 2010, the vast majority of influenza activity this season had been from 2009 H1N1. Activity was highest during the week ending October 24, 2009, and has since declined. The number of influenza-associated pediatric deaths reported to date for the 2009--10 season (236) is more than three times the average number (74) reported for the 2005--06, 2006--07, and 2007--08 influenza seasons. Resistance to antiviral neuraminidase inhibitors has been low among the 2009 H1N1 viruses, and the vast majority of 2009 H1N1 viruses tested remain related to the A/California/7/2009 (H1N1) reference virus selected by WHO as the 2009 H1N1 vaccine virus.

January and February are months during which seasonal influenza activity usually increases; thus, increased influenza activity from 2009 H1N1 viruses, seasonal influenza viruses, or both might occur in the remainder of the influenza season. In all three 20th century influenza pandemics (in 1918, 1957, and 1968), multiple waves of influenza activity were observed (3). The 2009 H1N1 virus is likely to continue to circulate through the winter months, resulting in more cases, hospitalizations, and deaths. Although limited supplies of influenza A (H1N1) 2009 monovalent vaccine had previously necessitated prioritizing vaccination among certain groups, approximately 130 million doses have been shipped since the vaccine was released, and most jurisdictions are encouraging vaccination of all persons aged =6 months (4). The 2009 H1N1-related morbidity and mortality described in this report point to the importance of a continued focus on vaccination, both among persons in the initial target groups as well as the rest of the population.

As the season progresses, public health officials should maintain the ability to detect changes in influenza activity. Testing, including subtyping of influenza A viruses to detect both pandemic and seasonal influenza strains, should continue for all hospitalized and severely ill patients, including patients aged =65 years. Timely reporting of all pediatric deaths associated with laboratory-confirmed influenza remains essential to detecting changes in severity of disease among children (includeing reporting no cases). Continued reporting of ILI through ILINet also will be important to tracking changes in influenza activity. Using previously established reporting channels, health-care providers should continue reporting to local or state health departments any particularly severe or unusual influenza cases or any cases among health-care workers and persons at risk for severe complications from influenza (e.g., pregnant women and immunocompromised persons). Institutional closings or clusters of influenza infections in prisons, schools, colleges, and long-term care facilities also should be reported through state and local health departments. In addition, any adverse reactions to influenza vaccines should continue to be reported via the Vaccine Adverse Event Reporting System (http://vaers.hhs.gov/index), and any adverse events after use of antivirals should be reported to MedWatch (http://www.fda.gov/safety/medwatch). Changes in the geographic spread, type, and severity of the circulating influenza viruses will continue to be monitored with updates reported weekly in the online national influenza surveillance summary, FluView.¶¶ Additional information regarding prevention and treatment of the 2009 pandemic influenza A (H1N1) is also available online.***

This report is based, in part, on data contributed by participating state and territorial health departments and state public health laboratories, World Health Organization collaborating laboratories, National Respiratory and Enteric Virus Surveillance System collaborating laboratories, the U.S. Outpatient ILI Surveillance Network, the Emerging Infections Program, the Aggregate Hospitalization and Death Reporting Activity, the Influenza Associated Pediatric Mortality Surveillance System, and the 122 Cities Mortality Reporting System.

CDC. Swine influenza A (H1N1) infection in two children---southern California, March--April 2009. MMWR 2009;58:400--2. CDC. Update: influenza activity---United States, August 30--October 31, 2009. MMWR 2009;58:1236--41.Miller MA, Viboud C, Balinska M, Simonsen L. The signature features of influenza pandemics---implications for policy. N Eng J Med 2009;360:2595--8.CDC. Use of influenza A (H1N1) 2009 monovalent vaccine---recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-10).What is already known on this topic?

The 2009 pandemic influenza A (H1N1) virus emerged in the United States in April 2009 and caused substantial disease worldwide.

What is added by this report?

In recent weeks, declines have been observed in 2009 H1N1 influenza activity; however, rates of influenza-related hospitalizations and deaths among persons aged <65 years during this season have been substantially higher than in recent influenza seasons.

What are the implications for public health practice?

Epidemiologic data in this report support expanded recommendations by CDC that the influenza A (H1N1) 2009 monovalent vaccine be offered to all persons aged =6 months, depending on local availability.

FIGURE 1. Percentage of visits for influenza-like illness (ILI) reported by the U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), by surveillance week --- United States, 2006--07, 2007--08, 2008--09, and 2009--10* influenza seasons

Alternative Text: The figure above shows the percentage of visits for influenza-like illness (ILI) reported by the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet), by surveillance week in the United States for the 2006-07, 2007-08, 2008-09, and 2009-10 influenza seasons. In the week ending October 24, 2009, the weekly percentage of outpatient visits for ILI reported by the U.S. Outpatient ILINet reached 7.7%, the highest level to date this influenza season and a level higher than the three preceding seasons. After peaking, the ILI level decreased to 1.9% in the week ending January 9, 2010.

FIGURE 2. Number of laboratory-confirmed influenza-associated hospitalizations and cumulative hospitalization rates per 10,000 population, by age group and surveillance week --- Emerging Infections Program (EIP) and new sites,* 2006--07, 2007--08, 2008--09,† and 2009--10§ U.S. influenza seasons

Alternative Text: The figure above shows the number of 2009-10 laboratory-confirmed influenza-associated hospitalizations and cumulative hospitalization rates per 10,000 population, by age group and surveillance week from Emerging Infections Program (EIP), and new sites for the 2006-07, 2007-08, 2008-09,† and 2009-10§ influenza seasons. As of January 9, 2010, cumulative rates of laboratory-confirmed influenza-associated hospitalizations reported for children aged 0-4 years were 5.9 per 10,000 population by EIP and 9.7 per 10,000 population by the new sites.

FIGURE 3. Percentage of all deaths attributed to pneumonia and influenza (P&I), by surveillance week and year --- 122 Cities Mortality Reporting Sytem, United States, 2006--2010

Alternative Text: The figure above shows the percentage of all deaths attributed to pneumonia and influenza (P&I), by surveillance week and year for 122 U.S. cities from 2006-2010 from the Mortality Reporting System. For the week ending January 9, pneumonia or influenza was reported as an underlying or contributing cause of death for 7.3% of all deaths reported through the 122 Cities Mortality Reporting System, below the week-specific epidemic threshold of 7.6%.

FIGURE 4. Number of influenza-associated pediatric deaths, by week of death --- United States, 2006--07, 2007--08, 2008--09, and 2009--10* influenza seasons

Alternative Text: The figure above shows the number of influenza-associated pediatric deaths, by week of death in the United States for the 2006-07, 2007-08, 2008-09, and 2009-10 influenza seasons. CDC has received 236 reports of pediatric deaths associated with laboratory-confirmed influenza infection that occurred and were reporting since August 30, 2009.

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