CDC's Anne Schuchat Discusses H1N1 Vaccine

November 6, 2009

Liza Mundy

On a Wednesday toward the end of October -- the time period when government officials had once predicted there would be 160 million doses of swine flu vaccine ready for shipping -- Anne Schuchat paid a visit to the Department of Education. Schuchat, a career government medical officer, was there for a screening of "Sid the Science Kid," in which the PBS character talks about vaccines and why it's a good idea to get them. The episode is called "Getting a Shot: You Can Do It!"

Schuchat, who enjoys talking to children -- they ask things like whether you can give flu to your dog -- also chatted with an audience of kids, to underscore the pro-vaccine message.

Problem was, at that point many of the kids likely couldn't get the shot, because production of the vaccine was behind schedule. Far from 160 million, the government had a fraction of that number of doses. This, too, was, Schuchat's problem: Her other meetings that day consisted of explaining to reporters and members of Congress why the vaccine was not, yet, available to most Americans.

"I'm disappointed that we're not in better shape," Schuchat says now, two weeks later. At this point -- with shortages likely to persist into December -- she knows people are begging their doctors and health departments.

"The way I'm looking at this: This is a marathon," Schuchat says.

Until now, Schuchat, a D.C. native who is the chief health officer for H1N1 response with the Centers for Disease Control and Prevention, has worked on public health issues largely behind the scenes. Now, in briefings, webcasts and outreach sessions, she is one of the most prominent faces of the response to swine flu.

"It's a thankless situation, because there's always going to be a screw-up when it comes to a mass immunization campaign," says Arthur Allen, a journalist who is the author of "Vaccine: The Controversial Story of Medicine's Greatest Lifesaver," a history of vaccine development.

"Historically, there's no mass immunization campaign that isn't screwed up," he says. "There's too many things that can go wrong. You're damned if you do, and damned if you don't."

Schuchat, you might say, is among the damned. It is her job to encourage acceptance of the vaccine while tamping down anger about its tardy arrival; to raise awareness without freaking people out; to convey what researchers are learning about this flu and its eccentricities; and manage a whirl of skepticism, dudgeon, confusion, fear, paranoia and very legitimate questions.

"This virus is circulating much later than the annual flu viruses," she pointed out in May, when swine flu had emerged and lingered. She and others noted that it seemed to be striking young people more than the typical seasonal flu, which tends to be very hard on the elderly.

And, to predictions that the vaccine may arrive in large quantities just as the virus is abating, she offered this caution: 1957. Back then, she said, flu seemed to peak in the fall, "and people thought, you know, we don't need to bother to vaccinate." Then "there was a big, big wave after the first of the year."

For a mild-mannered public servant, it's a trial by fire. The odd thing, says her brother Charlie, is that "she seems to thrive on it."

Alarming the public just enough

It's a delicate task under the best of circumstances, managing public response to a health problem. Experts have found that people tend more toward apathy than excessive worrying.

"People generally don't panic," says Kristine Sheedy, a CDC communications strategist. In fact, it can be surprisingly hard to get people to change what they are doing. It's also possible to stoke indifference: If officials are perceived as over-hyping the problem, people will retreat further into inaction. CDC focus groups leading up to the vaccination program bore this out: People "who describe what's been going on as media hype just say . . . 'I'm not going to change my life or behaviors,' " Sheedy says.

Conversely, "over-reassuring and minimizing a threat . . . actually presents a risk" of making people worry more.

"What we want to do is be more toward the middle," says Sheedy -- that is, alarm people just enough so they'll get the vaccine.

Easier said than done, but Schuchat seems as well-equipped as anybody. In CDC briefings, she is low-key and validates the public's right to be angry. "I appreciate the frustration people are seeing as they are unable to find vaccine," she said at one briefing. "We all had hoped to have more vaccine by now than we have."

Her eyes half-moons of sympathy, she genuinely winces when she reports bad news. "Each one of these saddens me greatly," she said when discussing pediatric deaths. During meetings, she wears the uniform of the public health service commissioned corps, on her chest a panel of ribbons recognizing efforts that include reducing Group B strep in newborns.

Schuchat, 50, attended Murch Elementary in the District; her father, Michael, is a retired attorney who was involved in winning the presidential vote for D.C. Her mother, Molly, has a PhD in anthropology.

Schuchat says she wanted to be a doctor in part because it seemed a way to meet a broad spectrum of people and have a role in their lives. "We were all really different," says Schuchat, who has a brother in the Foreign Service, another who is a lawyer, a sister who is a meeting planner and a younger brother who is a freelance tuba player. That brother, Charlie, recalls what it was like to be behind Anne at Bethesda-Chevy Chase High School after the family moved to Maryland: "I was a pretty good student, but I couldn't compare."

Schuchat went to Swarthmore, then got her medical degree at Dartmouth. During her residency, she found herself working with a group of male AIDS patients. After that crash course in infectious disease, she came to CDC for a two-year stint with the Epidemic Intelligence Service, and never left the agency. An early assignment was to look back at the toxic shock outbreak that occurred in 1980: The desk to which she was assigned still had a tampon box in the drawer, left over from when scientists were trying to understand why healthy women were getting sick and dying. To her, that investigation is a classic triumph of public health. "We learned a huge amount in a short period of time, and changed products so they would be less risky." Since then she has been involved in the response to hantavirus and severe acute respiratory syndrome (SARS). From Atlanta she led the team that handled the 2001 anthrax cases in Washington, a grim memory.

"To have to work on something man-made is really depressing. With H1N1, it's nature. The concept that somebody actually -- that [the anthrax attacks were] an intentional act -- so much suffering and so much disruption, it's very sad."

The other thing she took away from that episode is the importance of communication. During the anthrax terror, she says, "I don't think that communication was optimal. . . . As an agency we've tried to learn from that."

Now, her day job is directing the National Center for Immunization and Respiratory Diseases, where she oversees hundreds of CDC employees. When the virus hit, she was assigned to be the chief health officer for H1N1, which thrust her into a public role. The outbreak began in April when two cases were identified in California. Soon Schuchat found herself doing briefings about what might well be a pandemic, or highly contagious, strain.

Playing catch-up

To prepare a vaccine for fall, they were already late in the game: Late winter is when scientists get seasonal flu vaccines started. They contracted with five vaccine manufacturers. The government purchased the doses for free distribution, and preparations for a mass program began.

As late as July, public officials were making the 160-million-doses-by-October prediction, even as the vaccine, which is grown in chicken eggs, wasn't yielding the quantities hoped for. For her part, Schuchat warned that "influenza vaccine manufacturing is not always as predictable as you would like." And it wasn't: The number was scaled back to some 45 or 50 million doses by late October, then scaled back further. The problem wasn't just the yield; the window of time for production was so narrow. "The virus [reemerged] at such an early time" in the fall, says Andrew Pekosz, an associate professor of molecular microbiology and immunology at Johns Hopkins University's Bloomberg School of Public Health.

Now, Obama administration officials are acknowledging that they over-promised, and are blaming manufacturers for being too optimistic. For Schuchat, the task is trickier. She has to report the shortages but encourage people to get the vaccine when it does arrive. And relay findings from clinical trials, which show that children under 10 need a booster, while pregnant women do not. Meanwhile, people are muttering that the vaccine effort is proof that government shouldn't be involved in health care, while others say it just shows that Big Pharma can't be trusted. Schuchat tries to ignore the politicization: "We're really focusing on the science."

And while she doesn't defend the early predictions, she points out: "People want you to predict." If you do, when it comes to flu, she says, you'll be wrong a lot. Often, just now, she finds herself thinking about the expression "mountains beyond mountains," which means that once you surmount one hurdle, there is always another. "You couldn't have a more gratifying job," Schuchat says, "than being in public health, where your job is solving problems. There's always problems."

Indeed. Not long ago it was Tamiflu shortages. Tomorrow, who knows? "All of us can say that we wake up in the morning never knowing what to expect," says Pekosz. "Her job takes it to a whole new level."