This is 178 pages long but each page/session can be scanned or viewed without downloading. Speakers were Fauci, Fineberg, Ferguson, Gellin, Gerberding, Goodman, Leavitt, Stohr, Treanor & Webster. The list of workshop participants is long.
I found it interesting to read something from 3 years ago and compare the recommendations then to where we are now.
Some comments of interest:
Page 13: We do not know why so many young people died from influenza in 1918?1919. Certainly the stereotypical explanation has cited complications?particularly bacterial complications, although a 1976 review in the New England Journal of Medicine suggests that they might not have been the reason for so many deaths. Case reports, a review of the pathology literature, and recent experiments with influenza virus constructs containing genes from that pandemic strain suggest other potential explanations for the high incidence of shock and death associated with that pandemic.
Page 100: And when you really start to peel the onion and look at what?s there, it is clear that 1918 was not unique. It looks like 1830-1832 had a very similar picture of deaths primarily between 20 and 35 year olds, and a very classic W shaped curve again, just like we saw in 1918. Whereas, if you get into the 1880, you get into the other ones, there are at least 10 in the last 300 years; they really fall into two camps, those that had the classic accelerated or exaggerated Y shaped curve, and those that had the W shaped curve. Which would suggest to me, that there are several mechanisms for pandemics to occur?
Page 55: Tamiflu is under patent from Roche. It costs about $3 a pail to buy the drug in bulk.
Page 57: PARTICIPANT: We are talking about the availability of new technologies and new approaches. While on the science side that makes a great deal of sense, we are overlooking the supply side. Can we actually provide the new technologies, and what is the surge capacity per item? Given all the orders for antivirals, it?s going to be years before they are actually going to be filled. Today two companies own 80 percent of the market for N95 masks and have no surge capacity. The United States also lacks surge capacity for mechanical ventilators. The country has 105,000 ventilators, and in any one day 70,000 are in use; during flu season 100,000 are in use. Unless we are prepared to spend money to create capacity that will not be used except during a crisis, we can develop all the technologies we want, but our actual ability to bring a stockpile to market is going to be limited.
During the anthrax situation, the biggest problem many of us in the states faced concerned reagents for testing for bacillus anthracis?they just did not exist. We couldn?t make them fast enough. Even though scientists might come up with wonderful diagnostics for influenza, I question how many will be available during a crisis. Wonderful new technology tools may have little applicability if they are not available.
Page 133: PARTICIPANT: I have a couple of comments on the theme that history can lead us to ask certain questions. First, in the seventeenth century, when crossing the ocean took at least 6 weeks and sometimes 10 to 12 weeks, influenza made it from England to the colonies. Those were small ships. One would have thought that in a population as small as 50 and no more than 250, the virus would have burned itself out on that voyage. Information on the population of the ship that carried the disease and the exact duration of the voyage might be useful to your modeling.
The other point is that in the 1889?1890 pandemic, the third wave was the most lethal wave. In researching 1918, I found that public health officials were concerned about that. New York City was the only major city I know of that did not close its schools, but it did quarantine cases. Unlike practically everywhere else in the world, New York experienced peaks in the second and third wave, yet the killing was much more level. Philadelphia had less than one-third the population of New York City yet experienced a higher peak death toll. On a per capita basis, the death toll for Philadelphia and New York was almost identical, but the fact that the peaks were so different, and that the virus moved to the latter city so much more slowly, may be worth investigating. I can not imagine that the quarantine was effective enough to account for the lower peak death toll. Perhaps the fact that fear, prompted people to stay off the streets and normal traffic dropped significantly brought movement below a critical mass.
Page 159: However, human studies will be invaluable in answering questions such as: Are some patients super shedders of influenza viruses? Which influenza virus strains transmit more easily from one patient to another? At the present time, we do not have enough data to answer such questions.
Page 167: PARTICIPANT: [snips] Just to follow-up on the issue of funding and how we are going to do this. .. We have already discussed you do not need an H5N1 in a world of 6.5 billion people today to create economic chaos for 12-18 months.
As a world, we invest all the time in things that are insurance policies. Today, some of the best funded fire departments in this United States exist in our major metropolitan airports; airports that have not had a plane crash in 50 years. Airports that have incredible equipment, and never can leave the airport compound, because they have to be there. And we pay for that day in and day out, because we have made a decision if it ever does happen, you have to be able to respond in the force that is equivalent for a plane crash. We do that with our federal oil reserves. We have spent billions of dollars stockpiling oil in the salt domes of the Gulf States. I think we have to change our mind set to say that this is an insurance policy that we are not going to sit here and try to scare you and say this H5N1, although many of us think that still is a real possibility, but it is going to happen. And we need a Manhattan-like project that encompasses many of the issues that have been discussed here today; it is going to be an economic insurance policy.
To follow-up on the previous comment about the international piece, I would remind people that if we totally protected ourselves, if we had 300 million doses or 600 million, depending on the two dose regimen in the United States, we would still be devastated, because the economic consequences of a worldwide pandemic minus the United States would still have incredible implications. We saw it during SARS. The computer industry of this country shut down, because no one realized that 95 percent of the computer chips in the world were made in the Kwong Dong province of China. And when they couldn't travel, nothing else traveled. And if you start looking at the consequences here, we can demonstrate to our policymakers that this is in fact a very wise use of resources.
And so, I would urge us to take a step back, get away from this idea that if we could just keep expanding inter-pandemic flu, not that no one does not want to do that, because that is like motherhood and apple pie. But I think we are ready for a sea change. We are at a point where if we do not do it now, we are not going to it.
And then I would just add one last piece. I have absolutely no doubt about it, and all of you in this room will be part of it, there will be a post 9/11-like commission one day that will ask the questions why we did not do what we could have done, when we could have, because people were afraid that we would scare people, or that somehow we would be seen as scare mongers, that we have not put it together.
And I guarantee you, just as many of the very fine people who pre-9/11 said I wish I had done more, ended up being identified and well documented in that 9/11 commission report. There will be post-pandemic flu commission, make no doubt about it and the people in this room are going to be the people who are on the front line. So, it is time that we either make a decision that we are going to actually not live for another 20 or 30 years, whenever the pandemic occurs, trying to do this, and actually for once set out an international policy that says to our world leaders you can not afford not to do this.
I found it interesting to read something from 3 years ago and compare the recommendations then to where we are now.
Some comments of interest:
Page 13: We do not know why so many young people died from influenza in 1918?1919. Certainly the stereotypical explanation has cited complications?particularly bacterial complications, although a 1976 review in the New England Journal of Medicine suggests that they might not have been the reason for so many deaths. Case reports, a review of the pathology literature, and recent experiments with influenza virus constructs containing genes from that pandemic strain suggest other potential explanations for the high incidence of shock and death associated with that pandemic.
Page 100: And when you really start to peel the onion and look at what?s there, it is clear that 1918 was not unique. It looks like 1830-1832 had a very similar picture of deaths primarily between 20 and 35 year olds, and a very classic W shaped curve again, just like we saw in 1918. Whereas, if you get into the 1880, you get into the other ones, there are at least 10 in the last 300 years; they really fall into two camps, those that had the classic accelerated or exaggerated Y shaped curve, and those that had the W shaped curve. Which would suggest to me, that there are several mechanisms for pandemics to occur?
Page 55: Tamiflu is under patent from Roche. It costs about $3 a pail to buy the drug in bulk.
Page 57: PARTICIPANT: We are talking about the availability of new technologies and new approaches. While on the science side that makes a great deal of sense, we are overlooking the supply side. Can we actually provide the new technologies, and what is the surge capacity per item? Given all the orders for antivirals, it?s going to be years before they are actually going to be filled. Today two companies own 80 percent of the market for N95 masks and have no surge capacity. The United States also lacks surge capacity for mechanical ventilators. The country has 105,000 ventilators, and in any one day 70,000 are in use; during flu season 100,000 are in use. Unless we are prepared to spend money to create capacity that will not be used except during a crisis, we can develop all the technologies we want, but our actual ability to bring a stockpile to market is going to be limited.
During the anthrax situation, the biggest problem many of us in the states faced concerned reagents for testing for bacillus anthracis?they just did not exist. We couldn?t make them fast enough. Even though scientists might come up with wonderful diagnostics for influenza, I question how many will be available during a crisis. Wonderful new technology tools may have little applicability if they are not available.
Page 133: PARTICIPANT: I have a couple of comments on the theme that history can lead us to ask certain questions. First, in the seventeenth century, when crossing the ocean took at least 6 weeks and sometimes 10 to 12 weeks, influenza made it from England to the colonies. Those were small ships. One would have thought that in a population as small as 50 and no more than 250, the virus would have burned itself out on that voyage. Information on the population of the ship that carried the disease and the exact duration of the voyage might be useful to your modeling.
The other point is that in the 1889?1890 pandemic, the third wave was the most lethal wave. In researching 1918, I found that public health officials were concerned about that. New York City was the only major city I know of that did not close its schools, but it did quarantine cases. Unlike practically everywhere else in the world, New York experienced peaks in the second and third wave, yet the killing was much more level. Philadelphia had less than one-third the population of New York City yet experienced a higher peak death toll. On a per capita basis, the death toll for Philadelphia and New York was almost identical, but the fact that the peaks were so different, and that the virus moved to the latter city so much more slowly, may be worth investigating. I can not imagine that the quarantine was effective enough to account for the lower peak death toll. Perhaps the fact that fear, prompted people to stay off the streets and normal traffic dropped significantly brought movement below a critical mass.
Page 159: However, human studies will be invaluable in answering questions such as: Are some patients super shedders of influenza viruses? Which influenza virus strains transmit more easily from one patient to another? At the present time, we do not have enough data to answer such questions.
Page 167: PARTICIPANT: [snips] Just to follow-up on the issue of funding and how we are going to do this. .. We have already discussed you do not need an H5N1 in a world of 6.5 billion people today to create economic chaos for 12-18 months.
As a world, we invest all the time in things that are insurance policies. Today, some of the best funded fire departments in this United States exist in our major metropolitan airports; airports that have not had a plane crash in 50 years. Airports that have incredible equipment, and never can leave the airport compound, because they have to be there. And we pay for that day in and day out, because we have made a decision if it ever does happen, you have to be able to respond in the force that is equivalent for a plane crash. We do that with our federal oil reserves. We have spent billions of dollars stockpiling oil in the salt domes of the Gulf States. I think we have to change our mind set to say that this is an insurance policy that we are not going to sit here and try to scare you and say this H5N1, although many of us think that still is a real possibility, but it is going to happen. And we need a Manhattan-like project that encompasses many of the issues that have been discussed here today; it is going to be an economic insurance policy.
To follow-up on the previous comment about the international piece, I would remind people that if we totally protected ourselves, if we had 300 million doses or 600 million, depending on the two dose regimen in the United States, we would still be devastated, because the economic consequences of a worldwide pandemic minus the United States would still have incredible implications. We saw it during SARS. The computer industry of this country shut down, because no one realized that 95 percent of the computer chips in the world were made in the Kwong Dong province of China. And when they couldn't travel, nothing else traveled. And if you start looking at the consequences here, we can demonstrate to our policymakers that this is in fact a very wise use of resources.
And so, I would urge us to take a step back, get away from this idea that if we could just keep expanding inter-pandemic flu, not that no one does not want to do that, because that is like motherhood and apple pie. But I think we are ready for a sea change. We are at a point where if we do not do it now, we are not going to it.
And then I would just add one last piece. I have absolutely no doubt about it, and all of you in this room will be part of it, there will be a post 9/11-like commission one day that will ask the questions why we did not do what we could have done, when we could have, because people were afraid that we would scare people, or that somehow we would be seen as scare mongers, that we have not put it together.
And I guarantee you, just as many of the very fine people who pre-9/11 said I wish I had done more, ended up being identified and well documented in that 9/11 commission report. There will be post-pandemic flu commission, make no doubt about it and the people in this room are going to be the people who are on the front line. So, it is time that we either make a decision that we are going to actually not live for another 20 or 30 years, whenever the pandemic occurs, trying to do this, and actually for once set out an international policy that says to our world leaders you can not afford not to do this.
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