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FluTrackers interviews Dr. Jeremy Brown - NIH Director of the Office of Emergency Care Research - January 9, 2019

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  • FluTrackers interviews Dr. Jeremy Brown - NIH Director of the Office of Emergency Care Research - January 9, 2019

    From the National Institutes of Health web site link:
    "Jeremy Brown, M.D., is Director of the Office of Emergency Care Research, where he leads efforts to coordinate emergency care research funding opportunities across NIH. He also serves as NIH?s representative in government-wide efforts to improve emergency care throughout the country.
    He is the medical officer for the SIREN emergency care research network which is supported by both NINDS and NHLBI. In addition, he is the medical officer for several other grants focused on emergency care. Prior to joining NIH in 2013, Brown served as research director in the George Washington University?s Department of Emergency Medicine, where he founded an HIV screening program and received three NIH grants focused on a new therapy for renal colic."

    1. You have an extensive background in emergency care including authoring the platinum standard in emergency care books: Oxford American Handbook of Emergency Medicine. What motivated your interest in this specialty?

    I was drawn to emergency medicine because it was natural fit. I enjoy taking care of patients with acute medical problems, and the fast pace of the ER suits my need for excitement. I must feel challenged by my work, and the ER provides those challenges every shift.

    2. As Director of the Office of Emergency Care Research for the National Institutes of Health what are your goals? How involved is your office in national and global "on the ground" responses to emergencies - for instance the current ebola outbreak in the DRC?

    The goals of the office are to provide research opportunities to improve the care of patients with medical emergencies. Some of the work is done in the pre-hospital setting, improving the care of patients who are treated by paramedics, and some is focused on the emergency department. That covers everything from the best way to treat acute traumatic brain injury, how to quickly and accurately diagnose a patient with chest pain, and testing a new medicine for the treatment of kidney stones. Think about all the myriad problems for which people come to the ER: those problems are the ones we want to help with by doing research.

    The Office of Emergency Care Research is focused on research within the US healthcare system. It is the CDC that manages the surveillance and response to outbreaks overseas, but the NIH is deeply involved too, for example in running trials testing new vaccines.

    3. You have a new book out last month on the topic of pandemics titled Influenza. Why did you write it and what most concerns you most about an influenza pandemic? What is the most important lesson from the 1918 pandemic?

    Several years ago I was reading about the Great Flu of 1918, and the devastation it caused. It killed more than 675,000 people in the US alone. Worldwide, somewhere between 50-100 million died. Because I treated so many patients with influenza in the ED, I started to wonder: what has changed over the last century? What did we know about influenza then, and what is the state of our scientific knowledge today? How was it treated back then (with whiskey, enemas and bloodletting, it turns out) and how can we treat it today? Why is influenza a seasonal virus? These and many other questions started me on a journey to get to know influenza, and I share what I discovered in this book.

    Studying the 1918 pandemic teaches us so much, and among the most important lessons is this: we need to carefully plan for outbreaks of infectious disease. Preparation does much more than reaction.

    4. Of the novel avian influenzas that have recently infected humans which do you think is most likely to donate significant genetic material to a global pandemic strain: H5N1, H7N9, H5N6, or other?

    It is of course impossible to predict which of these might contribute to a future pandemic, because the flu virus is such a master at mutating. It swaps its genetic material so easily between strains that infect us and that infect and other animal species, like birds or swine. Even the well-studied and now common virus like H1N1 could, under the right conditions, mutate into a far more virulent strain, and take us all by surprise.

    5. Do you think with the current flu vaccine production capacity, a vaccine will be readily available in the 6 months after the start of a global pandemic? Do you think an effective universal seasonal flu vaccine is a possibility?

    Currently it takes about 6 months to manufacture a vaccine and distribute a new influenza vaccine. Cell based and recombinant flu vaccines may shorten the process, but we have to remember the challenge of the ?last mile?; how do we distribute the product to where it is most needed? And we need to remember that even in a good year, the flu vaccine is only 50-60% effective. In recent years it has even been lower than that. So even if we manage to distribute a vaccine during a pandemic, it will only be one part of the response.
    The universal vaccine, one that covers any strain of influenza is the holy grail of flu vaccine research. It would target that part of the virus that remains constant, but doing that is surprisingly difficult. It is easy to make a vaccine against some viruses, and really hard to do so against others. Take HIV for example. Back in 1984 the Secretary of Health and Human Services announced that an HIV vaccine would only be two years away. We are still waiting. The universal flu vaccine is also likely to be many years away ? which is why the NIH has just published a new strategic plan to develop a universal flu vaccine. And in 2018 a new NIH sponsored study began to test an experimental new vaccine developed in Israel that could protect against many current and emerging strains of influenza.

    6. Do you think that personal protective equipment (PPE) should be encouraged in the general population in the event of a flu pandemic? Do you think school closures would flatten the local outbreak curve to make the situation more manageable for officials?

    Before we encourage the use of PPEs and close schools. We must be very careful to explain what it meant by the term ?pandemic?. As I explain in my book, it can mean different things to different people, and irresponsible use of the word can be very costly.
    Most people think of a pandemic as a disease that spreads and kills thousands of people. That description was also the WHO?s official definition of the word: an infectious disease that causes ?enormous numbers of deaths and illness.? But in talking about the 2009 influenza outbreak, the WHO used a more academic and narrow definition that focused only on prevalence, not severity. After this was pointed out by an astute CNN reporter, a WHO spokeswoman announced that the organization had erred in using the more apocalyptic definition. ?It was a mistake, and we apologize for the confusion,? she said, noting that the word painted ?a rather bleak picture and could be very scary.?

    But assuming the description of a pandemic was appropriate, PPEs should be reserved for those providing health care and performing high risk procedures on sick patients. The rest of the population would be better advised to avoid crowds, stay home and follow meticulous cough etiquette and hand hygiene. School closures might also be an option ? but that is simply an instance of avoiding crowds.