Call Transcript
1. Introduction: Eleni Sotos, MA, National Coordinator, Collaborative on Health and the Environment
I’d like to welcome everyone to the November National Partnership Call. It’s titled Avian Flu and Pandemics: Global Health Threats and Disaster Preparedness. My name is Eleni Sotos. I’m the National Coordinator of the Collaborative on Health and the Environment. The moderator for this call will be Steve Heilig, the Director of Public Health and Education for CHE and for the San Francisco Medical Society.
We have some resources on the CHE website, provided by our speakers, that you may want to review during this call – if you have a computer in front of you, and web access. Please visit the URL for our website, at www.HealthAndEnvironment.org. If you go to our website, you will see a “What’s New” box on the left-hand column. Here you’ll see the announcement for today’s call. Just click on the links to that call, and the resources will appear as you scroll down. Just note that one of the resources from Dr. Rutherford is a PowerPoint Presentation. So it may take a moment to load. I would also like to announce that next month’s National Partnership Call has been scheduled for Friday, December 16th, at 9am PT, Noon ET. On this call, we will be discussing the neurodevelopmental impacts of pesticides. I’d now like to turn the call over to Steve.
2. Welcome and Science Update: Steve Heilig, MPH, Director of Public Health and Education for the UCSF Medical Society and CHE, and Alison Carlson, Coordinator of CHE’s Fertility/Early Pregnancy Compromise Working Group, Senior Research Fellow, Health and Environment Program
Thank you, Eleni, and I would encourage people who are interested in following along with the first speaker’s PowerPoint to try to do that now, if you are online, because it does take about 2 minutes to load, or so. We start all of our calls with some sort of science update. These are always brief, 2-minute presentations or so. Today, we are going to feature a new CHE resource that actually came out of a conference last year here at Stanford. Our presenter is Alison Carlson, who is the coordinator of our working group, and a research fellow with CHE. She’s going to tell about a new report on fertility and early pregnancy compromise.
Alison Carlson: Thanks for the opportunity to share about this, Steve. I’m obviously very excited about the Vallombrosa documents. In early 2005, CHE’s working group on fertility and early pregnancy compromise – which I coordinate – collaborated with CHE partner Linda Giudice, to convene this workshop. At the time, Dr. Giudice was Director of both Women’s Health at Stanford and their reproductive endocrinology and infertility clinic. This small meeting was held at a place called Vallombrosa Center in Menlo Park, California. The workshop was titled, “Understanding Environmental Contaminants and Human Fertility Compromise – Science and Strategy.”
We gathered 40 experts in reproductive health and infertility, as key researchers across relevant disciplines – toxicology, biology, epidemiology, clinical medicine – with practitioners and representatives of reproductive medicine and professional societies, as well as the infertility patient-support groups and a number of women’s health and reproductive rights advocacy organizations. Our goals were to basically review and assess the findings from diverse research disciplines, concerning links between environmental contaminants – heavy metals and chemicals, basically – and fertility compromise. We wanted to identify the core points of agreement about the existing data, and what an expanded [inaudible] could or should include, going forward. Also, to consider where we are in terms of recommendations for educational initiatives and preventive interventions. We also wanted to build a community of informed voices, strategically, in support of enhanced research programs and funding.
Outcomes of the workshop yielded 3 publications. Two of which have just been released. The first is called, “The Vallombrosa Consensus Statement.” This scientific consensus statement is modeled loosely on the well-known Wingspread statement on endocrine disruption, from 1991. It reflects core points of scientific agreement from the Vallombrosa discussions, on what we can say with certainty or confidence about the science behind contaminant impacts on fertility. And then, what the science tells us is likely to be true, but requiring confirmation. In other words, what’s likely, and with some concerted research focus could move up into the certainty category. Then there’s a section on major uncertainties and key priorities for future research. This document was geared or written for other scientists, federal agency or institute program officers, directors and the like.
A second document is called, “Challenged Conceptions.” It’s a lay companion piece to the statement. We’ve referred to it as a background or a monograph. It was written for the sophisticated lay reader – infertility organizations, foundation and environment program officers and the like. It introduces the science landscape. It includes tables of chemicals of concern, listed with common sources of exposure and associated fertility effects. It has a pretty extensive list of resources for further information. A summary of key concerns of reproductive medical practitioners and the health-affected groups. Also, an addendum addressing questions patients and doctors might have about doing individual biomonitoring as a potential diagnostic tool in specific infertility cases. Then the last outcome of the Vallombrosa sessions is that the journal called Seminars in Reproductive Medicine we’ll be publishing write-ups for the science presentations in early 2006.
So the Statement and Challenged Conceptions are posted in downloadable PDF format online in several places. You can find them on CHE’s web pages, along with meeting program, the participant list, and a bibliography. That’s if you go to www.HealthAndEnvironment.org. Then select “Working Groups.” Go to the “Infertility,” home page. You’ll find that all there. I should note, also, that an interactive HTML version of the statement has been posted on OurStolenFuture.org, with a glossary. The glossary terms are easy-to-read, pop-up form. So that’s fun.
We hope that you will find time to check out these publications. We welcome your borrowing from them, linking to them, posting them, citing them and sharing them with your networks and constituencies. I guess I should say a last note, which is that we did a small, hardcopy print run of the lay background, or Challenged Conceptions, so that it can be made available at meetings and conferences. We’re happy to share those with you while they last if you can provide reimbursement for shipping costs. If you’d like to see a copy or have any questions, just e-mail me at Alison@HealthAndEnvironment.org.
Steve Heilig: Thank you very much, Alison. Alison has done incredible work on this. There’s more to come. As she said, the documents are on the CHE website.
Today’s topic is Avian Flu. This is a little different than some of our calls that are focused more strictly on environmental health, per se. But obviously, this is a huge issue, which you’ve probably been unable to avoid reading about. Reports in the public media and in the scientific literature range from extremely alarming, to trying to reassure people.
Influenza pandemics are recurrent in human history. The most recent huge one was less than a century ago. It did kill more people in 24 weeks than have been killed in the last quarter century by HIV-AIDS. So the potential of a huge impact in every sector of our life is being noted here, with the Avian Flu. The first human cases were reported in China, just this week. The issues are, of course, many. Modern travel is just one new factor; There are over 150,000 people a month coming in to San Francisco International Airport, in some months of the year, from Asia. The issues of crowding, of what antivirals and vaccines might be available, and if they will be effective, what the flu is, what the real risks are and what the lessons might be in terms of prevention and response for public health, are very complex.
We have some really amazing speakers today. The beginning primer on what the flu is will come from Dr. George Rutherford, Professor of Epidemiology, Preventive Medicine and Pediatrics at UC San Francisco, he went on to become a State Health Officer in California and State Epidemiologist. Now, he’s with the Institute for Global Health at UCSF.
3. First Speaker: Dr. George Rutherford, Professor of Epidemiology, Preventive Medicine and Pediatrics, University of California, San Francisco and former State Health Officer and State Epidemiologist for the California Department of Health Services
Thanks very much, Steve. It’s a pleasure to be on the call with everyone. There are some extra slides at the end of the PowerPoint that in a longer version of this talk, I would have used. But I left them up; in the case anybody wanted to refer to them.
I wanted to start off a little bit with the virology of the influenza virus. Influenza virus is an RNA virus that has 3 major subtypes: A, B and C. It’s Influenza A that we’re talking about, today. In fact, Influenza A has been associated with most major pandemics and epidemics. There are two antigens on the surface of Influenza A. One called Hemagglutinin, and the other neuraminidase – which have specific biochemical functions. For our purposes, they’re really just antigens to which organisms – host organisms – will develop antibodies.
The structures of the Hemagglutinin and neuraminidase antigens periodically change over time. There are two types of change. One is “drift,” which is minor change within the same subtype. Eventually, if you accumulate enough point mutations, so that peoples’ immune systems no longer recognize the virus, it could result in an epidemic.
The other is, “shift,” which is much more dangerous. What that means is there’s a complete change in either the Hemagglutinin or the neuraminidase moiety on the surface of the cell. That occurs because there’s a gene segment that’s been exchanged between a human strain and an avian strain, or a swine strain and an avian strain. These shifts will typically result in transmissible and pandemics.
I’m going to the second slide, now. There have been 15 Hemagglutinin subtypes identified, and 9 different neuraminidase subtypes identified. You can see that they all occur in avian species. By birds, I mean everything from ducks to chickens to swans to vultures and everything in-between. Fewer occur and have been found in humans and swine and horses. Actually, there’s currently a small outbreak among greyhound dogs at racetracks in the Southeastern US. I think H9N9, but I’m not dead sure of that. Suffice it say that these things can line up in any different combination. So you can have H1 with any of the 9 neuraminidase subtypes. The predominant human-circulating strain now is H1N1 and H3N2. But you get a feel for the amount of difference that there can be.
Avian influenza is important, because the influenza viruses are viruses of waterfowl in nature, especially ducks. But they can spread to domestic poultry and other migratory birds and mammals. Among the mammals, especially important are pigs, horses and humans. When there are low-pathogenic avian influenza viruses circulating in domestic poultry – which is the species that … the magic of avian poultry is that they’re all crowded together in the… Think of the Foghorn Leghorn cartoons and the hen houses. With mutation, they can gradually develop highly pathogenic forms through drift.
However, when you have a pig or a human who is infected simultaneously with human influenza and/or swine influenza and avian influenza, the genes can resort. They can rearrange themselves. So you take the neuraminidase genes from the avian influenza and insert them into the genome of a human or a swine influenza that has the right kinds of attachments – coding genes – to be transmissible from human-to-human. That’s when you would get into real trouble. That is, in fact, drift.
So if you look at the little cartoon on the next slide, there are 15 hemagglutinins and 9 neuraminidases in waterfowl. They can either directly infect humans – as has been in the case in Southeast Asia – or they can infect swine. If swine are infected simultaneously with human and avian strains, you can end up with this resorted virus, which can affect humans and then result in human-to-human transmission. Resortment can also occur in humans. You don’t need that much of a magic ingredient in all this.
The next slide, which is a fairly complicated graph, is a cartoon of over time, what influenza pandemics and epidemics look like. On the left-hand Y-axis, there is disease incidence, which is the dashed white line. You can see that there is a pandemic period with very high incidence, followed by 4 epidemics, then followed by a new pandemic and a 5th epidemic. The pandemics represent major antigenic shifts. The epidemics represent drift. You can see that after you have a pandemic, the population will be exposed to the virus. There’ll be some high background levels of immunity. There’ll be some minor variations or drift that goes on. There’ll be another epidemic. The antibody levels in the population will increase. Another epidemic further increases it. And eventually, the epidemics will be blunted down, as the prevalence of antibody in the population increases.
Eventually, there’ll be a shift, which has absolutely nothing to do with the human antibody levels. It’s a completely separate phenomenon. When that shift happens, there’ll be a new pandemic of influenza, with increasing antibodies shown in that lavender line, to the new strain. There’ve been 3 major influenza pandemics in the 20th Century. There were actually 2 or 3 in the late 19th Century, as well. The 1918 and 1919 so-called Spanish Influenza was an H1N1 Type A influenza virus. It resulted in somewhere between 20 and 40 million cases, worldwide – and more than a half million excess deaths in the US. In 1957 and 58, there was the so-called Asian flu, which was an H2N2. That resulted in 2 million deaths, worldwide – and 70,000 in the US. In 1968 and 69, the Hong Kong Flu, which actually is still with us, is currently in the vaccine strains of the H3N2. It resulted in a million deaths worldwide, and 34,000 excess deaths in the US. I should add that the CDC currently estimates that – quite apart from these pandemics and inter-pandemic epidemics – that at baseline, there are about 36,000 deaths from influenza, and 200,000 hospitalizations from influenza, each year. That’s the background and this is the base, and this is built upon that base.
The next slide, I think, is a particularly telling graphic, which shows the mortality rate per 100,000 people per year from infectious diseases in the US. There are certainly two notable things on here. One is that the rates of decline from the 800 per 100,000 per year at the turn of the century – down below 50 per 100,000 by 1960. That’s the first thing to note. The second thing to note is there’s this massive spike in 1918 and 1919 from influenza. So you see it approaches 1000 per 100,000. That means that of every 100,000 people living that year, almost 1,000 of them died. Or, 1 percent of the population died of influenza. An extra number got influenza. You can also see the tail end of the graphic in the 1980s and 90s, as it starts going up. That’s a function of HIV infection.
That’s avian influenza in humans. What about avian influenza in birds. Avian influenza in birds goes on all the time. It’s really this resortment of events that has to occur in order to get the pandemic. But the base ingredient is avian influenza, or epizootics, which are the animal form of epidemics of avian influenza. There’ve been 21 outbreaks recognized of highly pathogenic avian influenza viruses, worldwide, since 1959 – 5 of which resulted in – I don’t know how you say, “pandemics in animals.” Panzootics, probably. In 1983, in Pennsylvania, there was an H5N2 strain. In 1997 in Hong Kong, which was the precursor to this outbreak of H5N1. In 2003 in the Netherlands was H7N7. And now, back in Asia, with H5N1, with ongoing outbreaks of domestic poultry and wild birds, and some limited spread to humans.
There were no isolates between 1997 and ’03. Since ’03, there’ve been outbreaks in poultry and wild birds in a number of countries—now having spread to Europe. There are 126 cases in humans, 64 deaths – which is a 50 percent case-fatality rate. There are a couple of potential human-to-human transmission events, a few handful of concerning events. There’s H5N1 in pigs that’s been found in China, which can lead to these resortment events. There’s some evidence for increased virulence of serial strains of H5N1 in mammals, through mouse experiments. H5N1 has become completely endemic in wild birds. Therefore, killing everybody’s chickens and turkeys isn’t going to do very much to stop the spread, because the birds will fly and they’ll migrate. That’s wherein the problem lies. I’ll stop there. Thanks, Steve.
Steve Heilig: Our next speaker is Dr. Larry Brilliant. It’s hard to describe his career, but I will simply say that he’s a Medical Epidemiologist who was director of the successful smallpox eradication program in India. He’s Cofounder and Co-Chairman of the Seva Foundation, which has given over 2 million people sight – primarily in the Himalaya region. He just this year spent 6 months in Asia, following the tsunami, there – working primarily on the eradication of polio in India, and has just convened a high-level invitational meeting on avian influenza and what the best approach to prevention and response should be. Dr. Brilliant, please tell us about your meeting.
4. Second Speaker: Dr. Larry Brilliant, Epidemiologist and Chair of the Seva Foundation
Steve, thank you very much. It’s really a pleasure to be here. And George, that was a terrific overview, thank you.
The meeting that we had in San Francisco last weekend – which was called PAN-Defense 1.0 – was an attempt to bring together citizens from lots of different walks of life, as well as people from the WHO, UNICEF, CDC, and the Department of Defense. It was sponsored by 5 schools of public health and representatives from 9 or 10 universities, as well as industry - Kleiner Perkins, Levi Strauss, Sun Microsystems.
We just tried to get enough creative people who could think outside of the box, I suppose. We had about 1/3 of the people there that were epidemiologists or flu-ologists. The idea being, “Could we come up with half a dozen novel interventions that would make a difference, to prevent, mitigate or reduce the consequences of a pandemic, should it occur?” We have a couple of findings that we can share with you and some of the suggestions that we’ve come up with. First of all, Finding Number 1 was that this really is an avian disease. We have too many ostriches and too many chicken-littles. Somewhere between those extremes, the punditry has frightened and paralyzed much of the country and the world, in fact.
It’s not so surprising. We as a society are ill equipped to deal with low-probability but highly catastrophic events. I think all of us have burnt into our subconscious – almost like Close Encounters of the Third Kind – that map of Katrina, inching closer and closer. We’d like to think in terms of the pandemic, with that degree of certainty. How sad the world is, when you think of meteorologists as our template for certainty! But it doesn’t work like that. We have an aptly unknowable event, with unknowable probability. It is certainly a low probability that there will be a pandemic of the epic proportions of 1918. But it is a non-trivial probability. And we have people who can canton ate a series of truthful statements. There will be a pandemic. There’s a certainty of that.
The pandemic – if it’s H5N1 and it becomes humanly transmissible – will kill many tens of millions. That’s true. But these are not necessarily the same pandemic. Then an argument might be made, except the flu specialists don’t like it, that there’s a pandemic every year. George alluded to the 3, 4, 5 or 600,000 people who will die, this year. It’s called “Winter Flu.” What we’re really concerned about is that 100-year storm. That 100-year storm has a low but non-trivial probability of occurring. Our group focused on, “Could we take the best planning methods from business and from foundations, and apply it to a public health problem?” We came up with 6 interventions that we’re going to rally around over the coming months.
Number 1 – we’ve created a lobbying group called “Stop Flu.” It will take the president’s plan – which, as it becomes legislation and has funding placed next to it… And we will look at it and bring in representatives of all of our organizations, and try to find the things that we can support, and the things that we feel differently about, we will argue for. Primarily, the allocation of such a small amount of money for international efforts to stop the flu where it begins. There are some novel ideas that have come out of this group and many other groups. There’s nothing special about our group. But the idea of a dipstick, rapid, inexpensive field test for the H5 virus is important, the idea being if we can find it more quickly, obviously, then we respond with vaccines and/or antivirals. Should we have vaccines at that time, or would neuraminidase inhibitors be enhanced? Also, there is the idea of a poultry-exchange program; peasants who right now are placed in impossible positions. To report a sick chicken means to lose, through culling, one’s livelihood. We cannot eradicate pandemic flu on the backs of peasants who have no other source of livelihood. We had a lot of aviary specialists with us at this meeting. They’ve suggested the creation and support of an exchange program, where-if a farmer in Cambodia reports a sick chicken, then vaccinated chickens are brought in of the same species and acclimatized, to replace them. Things of that nature. I’m not a real fan of mass-vaccination programs of 14 billion chickens. We’ve never succeeded in a mass-vaccination program of human beings. Chickens are easier to vaccinate, but harder to find when they are in small clusters.
The second thing we came up with was something called “FESS Up,” which is the flu-expanded surveillance system. It would include various efforts in developing countries, to support existing programs of the Red Cross, the WHO and Ministries of Health, to rapidly detect new cases of novel viruses – H5N1 being only one.
The third, which came from – interestingly – some of the Republicans amongst us – was to create an emergency health voucher system. I would spend more time with it, if there were questions about it. But the very idea is that in influenza, the deaths from the disease itself are only one source of suffering. There will be other deaths – many other deaths. From heart attacks where people can’t get to emergency rooms, deliveries that will not take place under proper circumstances. People will not be able to get their diabetes medicine, because we have no surge capacity and no excess capacity left in our hospitals. Steve knows this very well. In a stressful situation like Katrina, the hospital and healthcare systems in New Orleans were challenged. But in a pandemic, all healthcare institutions and many places would be stressed. These vouchers would be able to go to any doctor and any healthcare program, irrespective of the HMO or PPO they’re part of.
We have a number of other suggestions that we can go over, if you want. We agreed that we would convene another meeting of the same group of 42 people, in Washington, in March – while Congress is in session. We will invite many more people to that meeting. We hope that it will begin to snowball, as people start to think practically about the steps that we can do to mitigate and reduce the consequences of a pandemic, should it occur. Thank you.
Steve Heilig: Thank you very much, Larry. We will now hear from Dr. Shelley Hearne, who is Executive Director of Trust for America's Health, and someone who’s been very active in preparedness planning and infrastructure for public health. She has a link on the website, to the latest report from the Trust.
5. Third Speaker: Dr. Shelley Hearne, Executive Director of Trust for America’s Health
I was asked to follow up and provide some perspective, in terms of disaster-response planning. Some of the activities that are going on in the event a pandemic were to hit. Let me put this in the context of public health. We’ve been looking at these issues for quite a while, I think. 9/11 first put up on their radar screens in a rather intensive way for the nation, in terms of our ability to respond to a major health emergency. It brought on, along with Anthrax attacks in 2001, some of the issues that, “Whether it’s bioterrorism or what public health experts have been long saying is the concern about natural disaster impacts or infectious disease outbreaks or even in the context of chronic disease clusters, that the all-hazards preparedness of a public health system had been long-neglected for many, many years. There have been significant gaps that need to be strengthened and improved.”
There has been progress made in strengthening that. These are the same systems that would respond for a pandemic event. Let me just quickly encapsulate. If you had a properly functioning 24/7 rapid-response public health emergency system capacity, roughly what it would look like is that you would have – 1) the rapid-detection capabilities for emergency disease threats. That would be both on a global perspective, the ability to catch with a transparency and international framework, the early emergence of a pandemic. Theoretically, it’s argued if you could contain that. Or, the ability to understand who was hit and where it’s impacting, locally.
The other is the intensive investigative capabilities to quickly diagnose a rising disease threat. These are the nationwide health-tracking capacities. Again, whether it’s Anthrax or asthma, it’s the basic disease-surveillance capabilities in this country.
The third critical issue is the ability to have mass-containment strategies. Which include plans, which include the surge of workforce and equipment, and pharmaceuticals that would be needed in the event you either had the capability of doing wide scale vaccination or antidote administration. Or again, what has been discussed for a pandemic, but likely would not be effective, is the ability to do isolation or quarantine, if necessary.
The last component of that 24/7 disaster responsibility is really a streamlined and clear communications capability. With one, your healthcare workers, so that they can be talking to each other and other frontline responders. Just as importantly, the ability to honestly and quickly inform citizens about the nature of emergency of the event or attack, what their risks of exposure are, and how to seek treatment and take care of themselves, their neighbors and family – in the event of an emergency. And also, what are the steps that families can do to help protect themselves.
So, where are we, in terms of this pandemic planning, in the context of disaster preparedness? Katrina was certainly a wakeup call that the supposed disaster-response systems that were in place are not realistically structured and well connected in collaborating, to respond to major events. The point that Trust For America’s Health has been saying for a number of years is that – and I’ll put it in the context of Katrina – that if you had a pandemic event hit, it would be like a major Category 5 hurricane hitting every state simultaneously, if it were a pandemic event. Obviously, this is a worst-case scenario. I think Dr. Brilliant helped touch upon the issues of probability. But regardless of if this were to hit in the next year, or if this is the 100-year storm that we anticipate down the road, there are basic systems of preparedness that we need to have in place.
The good news is, the federal government did just release its long-anticipated - in fact, it’s been 10 years in the making - pandemic plan. The good news is, it was a really important step toward a comprehensive level of preparedness. I think it reflected some very good work by the top professionals at HHS. But there are some extraordinary and highly disturbing gaps that still remain in that plan. Let me just highlight, in terms of while there has been a plan put out there, there is still no money to back that up. Grand ideas, but while the president has talked about that it would take $7 billion to start the first phases of implementing that plan, actually just yesterday, the dollars got cut out of the Health and Human Services appropriation bill. Once again, politics and actually the issues of vaccine liability seem to have trumped – actually, moving forward – this plan.
The second issue I just want to raise about the national strategy document is that there is still not the kind of level of detail and substance that we need to have specifically for how the economy and business operations and transportation would be functioning. It’s important to recognize preparedness is not just a health component. But you need to have these plans - the instant command structure - not only at the federal, state and local level for health, but it needs to be reaching out and helping encourage businesses, faith-based groups, hospitals and doctors, in terms of how they have to be planning. If a major pandemic were to hit, the reality is with the waves of the pandemic hitting, you may have absentee rates as high as 30 percent of the workforce not coming in. There’ll be questions about who will keep the electricity running, water, food supplies, et cetera.
What I would invite people to take a look at on the website, at HealthyAmericans.org, is extensive information – in terms of both the federal plan and the status with some of the state plans. While all states now do have pandemic plans, many of these are still not public documents. They have not been reviewed and approved by outside sources. They are often just an overview of what needs to take place – versus operational activities. It is very important that the public get engaged in this pandemic planning process. Certainly what we’ve learned from Katrina is that the assumptions made by government officials do not necessarily reflect the interest and needs of the public. The greater the discourse, the more transparency in both the plan development and implementation – the better chance that we would be able to have a situation of controlled chaos versus panic.
There is also a brochure in there that literally takes you through the various steps in pandemic planning. Individuals and businesses can be taking now, to ensure both business continuity and community continuity, should a pandemic hit. This includes everything from the types of contingency planning that’s needed, how to maintain a healthy workforce, and a healthy environment. How to consider incentives for if someone is sick, not coming to work. Again, also, individual recommendations on what people can do for themselves, in terms of preparedness. I’d invite everyone both to consider looking at that, to look at their own personal planning in the context, also, of advocating for smarter or seamless and more realistic pandemic planning taking place at the government level, at both federal, state and local. With that broad overview, details available on the website, let me turn it back to you, Steve.
Steve Heilig: Thank you very much, Shelley. Now, Phil Lee, our chair and public health leader – do you have a comment you want to make before we continue?
6. Commentary by Dr. Phillip R. Lee, former Assistant Secretary of Health and Human Services and current Professor of Human Biology at Stanford University and at UC San Francisco.
A couple of things. First of all, on George’s presentation, there is work that’s been done at the national lab at Livermore on early detection. First of all, in the airborne detection of infection. They’re developing systems where you can put machines on airplanes, for example. This doesn’t just relate to influenza, but it relates to other infections, as well.
Second – they’ve now developed, although it’s at the very early stages of development, what they call, “Pre-symptomatic diagnosis.” That’s a technology that potentially – in the right hands – could be developed and made available very widely. There’s some work going on that isn’t really publicized, but I think would be very important to link into this kind of planning process.
The second, and this relates to Larry’s presentation, is the notion of the dipstick. I think the work that’s being done at the national lab at Livermore may be very relevant to that. Also, in terms of the participation - this relates to Shelley’s presentation, and also to Larry’s - in the response to Katrina, we saw the consequences of what was really the dismantling of the federal response system for natural disasters. When that was moved to FEMA, which is a non-substantive agency (before the Bush administration put FEMA into Homeland Security and then moved these functions which didn’t belong in FEMA but to the substantive agencies), we saw the consequences of not only inept leadership, but a totally dismantlement of a system that was at least quite workable. I think one of the things that you all need to look at, Larry, in your meetings, is both the organization - because the government does have responsibility - but also that we have a federal system, and you have to have a request from a state government for an emergency to be declared. Even though it’s obviously coming.
A key need for a much-improved inter-connected response -and Shelley, I know you’ve been very concerned about this and working on this - is the linkage and the strengthening of capacity at the state and local level. Also, one final point: The studies that have been done by Roz Lasker in her group at the New York Academy of Medicine, at the Center for Collaborative Strategies and Health - their report on redefining readiness indicated very serious problems in the public’s acceptance. The public doesn’t accept what the government tells them. They trust their doctors, but they don’t trust the government, and that was even before Katrina. I think that report needs to be looked at, and that group needs to be involved in this kind of a planning process. They’re now doing 4 demonstrations with Kellogg funding. They’re mainly looking at terrorist response. But it’s just as relevant to an avian flu or other epidemic problem.
7. Questions/Comments/Discussion
Cheri Forrester: Yes. I’m Dr. Cheri Forrester. I have a clinical question. With the sort of hysteria that’s been generated, patients have become pretty hysterical about influenza, in general. I’ve gotten a huge number of requests from people who personally want to stockpile Tamiflu. And I have a strong feeling that it will be used inappropriately and promote resistance. I’ve been declining it, but wonder if any of the presenters can express an opinion on this?
Steve Heilig: A very good question. Any speakers?
Phil Lee: Steve, I can comment on that. Yesterday at the Palo Alto Medical Foundation, we had a presentation by the public health director of the Palo Alto Clinic, and their Chief of Infectious Disease. They specifically recommended not stockpiling of Tamiflu. The same question that Cheri raises. But others have recommended very strongly not stockpiling. Otherwise, it’s going to be chaos.
Steve Heilig: I’ve heard that, too. And resistance issues. Can anybody say anything briefly about that?
Larry Brilliant: I can speak a little bit to resistance issues. But before I do that, let me say that this is one of these things that are extraordinarily difficult. This is not an easy answer. The correct answer from the public health point of view is, of course you should not stockpile Tamiflu for healthy people, for a low-probability event that isn’t occurring now. On the other hand, if you honestly surveyed epidemiologists in the field and you asked them if they’re stockpiling Tamiflu for their families, you would find the vast majority are. We did that experiment at our own meeting. Two-thirds of the epidemiologists and public health people were stockpiling Tamiflu for their own families.
It’s a very difficult thing to answer, when someone comes to you. The right answer, from a public health perspective, may be different than that for an individual family.
As far as the resistance goes, there are a couple of studies that are now circulating the journals that have anecdotal suggestions. That the virus has become, in some cases, resistant to neuraminidase inhibitors, Tamiflu particularly, not Relenza so much. As of right now, none of those have been published. The moment they’re published, it will create quite a stir. People will be immediately put on alert of that.
I would say that every antiviral - the virus will eventually become resistant to it. It’s just a question of time. If you dose 12 billion chickens with something that looks a little bit like Tamiflu, which is one of the suggestions the Chinese have been working with, you increase the probability of ultimate resistance. Right now, Tamiflu and Relenza are the two drugs that seem to have the most promise.
Shelly Hearne: Can I also just ad a policy perspective to this? The federal plan which was just released does now make a commitment for stockpiling enough Tamiflu for 25 percent of the US population. So the US government would be making a commitment that should a pandemic hit, rather than individuals having to stockpile, there would be government stockpiles that could be targeted for critical areas and needs to address the public. That is a WHO recommended level. Many other countries have already hit those stockpile levels. The one twist here comes with money. The federal government made that commitment, but it is asking for the states to pay for the majority of the actual purchasing of those antiviral medications.
Phil Lee: Isn’t it 75 percent, Shelley?
Shelly Hearne: It is 75 percent. And it actually would be a $510 million unfunded mandate on states. But the result will be that based on where you live and how a state’s budget is, you are more likely to have access to Tamiflu or not.
George Rutherford: The other thing that I think is important to point out is that these plans don’t call for using Tamiflu for prophylaxis, but actually for treatment of actual disease. A lot of the antivirals that are used right now today for regular winter flu or endemic flu or whatever you want to call it, are used in nursing homes when there has been an outbreak, when there have been cases of regular H1N1 or H3N2 influenza, and people are prophylaxed through the influenza season. Because that creates such a huge strain on drug, the decision’s been made to stockpile doses to use for treatment, rather than prophylaxis. Although, one could imagine situations in which you would try to prophylax people. For instance, healthcare providers working in influenza wards, or something like that.
Steve Heilig: We’ll take another question.
Michele Ginsberg: Can someone comment on the likelihood of different susceptibilities with severe illness in different age groups? I think the Library of Congress said that younger are more susceptible. I don’t know in Asia, whether it’s a reflection of those who have more exposure. But any comment, in terms of the susceptibility for different age groups would be helpful in our planning.
Steve Heilig: George, do you have anything on that?
George Rutherford: Yes. There’s a graduate student at UC Berkeley in demographics. He has a lot of data. He’s been looking at mortality and differential mortality as a result of the 1918-1919 influenza. So he has straight vital statistics data, but he also has cohort data from US Army Civil War veterans who would have been in their 70s at the time of the 1918-1919 flu. They actually have, essentially, VA records for these people. It’s quite a remarkable dataset. He thinks that a substantial number of deaths occurred in people with tuberculosis. I think others would say that there’s thing early-20th Century pathologists could recognize, and that was pulmonary tuberculosis and where are all the path records. But it’s an interesting theory. Because it would say that people who can play it out and people who have underlying lung disease have less capacity to withstand a major infectious hit to their lungs. The other thing that happened in the late 19th Century – which I’ve asked them to look at – was the invention of the automatic cigarette rolling machine. And whether some of this could have been early emphysema, where these deaths occurred. But if you look at the actual death patterns, the deaths were more pronounced among males than females. It was more pronounced in 30-year olds than in other age groups, from the 1918-1919 influenza.
In Vietnam, Thailand and Cambodia, there have been some child deaths. The first case in Hong Kong, in 1997, was in a child. But I think these children are also involved in caring for ill chickens. So I suspect it’s more of a dose phenomenon than anything else. But this business about underlying pulmonary disease sort of bothers me. I think we can quickly add to the list underlying immune deficiency. In 1918-1919, if you had an underlying immune deficiency, you were dead. Before the era of solid organ transplantation or therapeutic immuno-suppression, let alone HIV. So we have sort of a nasty combination of a lot of people who are immuno-suppressed. When you throw asthma into the equation, a lot of people with possibly somewhat compromised respiratory capacity from asthma, from emphysema, from smoking or from whatever, or in the developing world from tuberculosis - that could create a highly susceptible, a population that’s not more susceptible to actually acquiring it, but more susceptible to severe and lethal consequences and infections.
Steve Heilig: Thank you, George. We also have an overall aging population, as well. We are coming up on our hour, here. One more question?
David Kimball: I’m the Bolinas Disaster Coordinator. I’m a lay person, as far as healthcare providers. The first question had to do with the anxiety of patients. We’re finding that the best thing we can do is give people information, so that on an individual level, they can take control of their lives. One of the phrases that we’ve been using is that as a community, we are as ready as you, as an individual are. Can somebody point me to the best website that a lay person would go to, to prepare themselves, their family and contribute to their local community’s preparedness?
George Rutherford: CDC.
Steve Heilig: Thank you. We are up on our hour, here. I’m going to take the prerogative to make one point regarding Dr. Larry Brilliant, because we have a lot of creative minds on here. He is the recipient of an award that allows him to make a huge wish with an incredible amount of resources behind it. If you just go to Seva website – Seva.org – you will see some information on that, and how to submit ideas.
So thank you very much to all of our speakers. This has been really, I think, quite a useful call. We will, again, have more information on it on the website, soon.