The Next Pandemic
Are We Ready?

Summary

New cases of the life-threatening MERS coronavirus in the Middle East and the H7N9 bird flu virus in China have prompted questions about the world’s readiness to confront potential resulting pandemics. This Forum event examined risks associated with these particular viruses, vaccine technologies to combat them, strategies to track them, global preparedness plans and lessons learned from past deadly outbreaks such as SARS and H1N1.

 

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Presented in Collaboration with PRI's The World and WGBH

Background Articles

Image Credit: CDC/ Cynthia S. Goldsmith and Thomas Rowe

  • Jonathan Allen

    How improved has the accuracy of pandemic flu become over the past decade?

  • David Fedson

    Questions for the HSPH Forum panelists

    1. In 2009, pandemic vaccination in the US affected only 2-4% of all cases, hospitalizations and deaths. In mid-December 2009, 65-70 million doses of pandemic vaccine were being distributed throughout the US. At the same time, Mexico (where the pandemic started) received its first 835,000 doses. When we ask, “are we ready?”, what do we mean by “we”? Should global equity be an important consideration when deciding who gets pandemic vaccines? What measures would be needed to ensure a modicum of equity in the global distribution of what are likely to be limited supplies of pandemic vaccines?

    2. Recent developments in influenza vaccinology indicate that it might be possible to obtain the genetic sequences for the hemagglutinin of a new pandemic influenza virus within two weeks of its initial isolation. This means that instead of waiting many weeks (or a few months) to secure a seed strain, vaccine production might start immediately. Will this make a meaningful difference in the timeliness and number of doses of pandemic vaccine that might be available for the US and the rest of the world?

    3. The production efficiency (number of doses per egg or unit of cell culture) for a live attenuated influenza vaccine (LAIV) is 50-100 times greater than it is for an inactivated vaccine. If all of the world’s pandemic vaccines could be supplied as LAIVs, people who live in developing countries that don’t have vaccine companies might actually be able to obtain supplies of vaccine in time to protect some of their people. This assumes, however, that the existing egg-based or cell-culture capacity for producing LAIV is sufficient. Unfortunately, the egg-based production capacity of Medimmune/Astrazeneca is small. Could pandemic LAIV be produced in the egg and cell culture facilities of companies that otherwise would produce inactivated vaccines? Would regulatory officials allow this to happen? Would company executives be able to make the “deals” that would be required to make this work? Would governments be willing to order companies (and regulatory officials) to ensure this is done? Would WHO be willing and able to force the issue?

    A note on the underlying arithmetic – In the US, Sanofi Pasteur alone has the capacity to produce approximately 450 million doses of a monovalent inactivated vaccine each year, or almost 40 million doses per month. Adding an adjuvant might yield a four-fold increase in the number of doses – 160 million doses per month. In contrast, the same facility might be able to produce 2-4 billion doses of monovalent LAIV per month. This suggests that if the existing egg and cell culture production facilities of all developed country vaccine companies could be enlisted (almost all of which are used to produce inactivated vaccines), they could produce in one month enough doses of a live-attentuated pandemic vaccine to supply the entire world. If vaccine companies in developing countries joined in, the world might be able to produce enough vaccine to vaccinate all who are candidates for vaccination within three months of the emergence of a new pandemic virus.

    4. Producing pandemic vaccines is only the first step. Once produced, vaccines must be packaged, approved by regulatory authorities, ordered and paid for, distributed and, finally, administered to patients. The infrastructure requirements for an effective global pandemic vaccination program would be enormous. If billions of doses of a live attenuated vaccine could be produced each, could they actually be administered to patients? Likewise, if approximately I billion doses of inactivated adjuvanted pandemic vaccines could be produced in one month, would the infrastructure be in place to quickly vaccinate patients? Would supplies of syringes and needles and the numbers of trained vaccinators be sufficient?

    5. Laboratory and clinical evidence suggests that treating patients with modern drugs that have immunomodulatory activities (e.g., statins, ACE inhibitors, ARBs, metformin, PPAR agonists) might reduce pandemic mortality. Unfortunately, influenza scientists and health officials who fund their work and count on their advice (including WHO) have shown little interest in undertaking research to determine whether such treatment would work. If the idea is worth pursuing, what is needed to get their attention?

    Submitted by:

    David S. Fedson, MD

    Visiting Scientist

    Department of Environmental Health

    Harvard School of Public Health

    References

    Fedson DS. Pandemic influenza: a potential role for statins in treatment and prophylaxis. Clin Infect Dis 2006; 43: 199-205.

    Fedson DS, Dunhill P. From scarcity to abundance: pandemic vaccines and other agents for “have not” countries. J Public Health Policy 2007; 28: 322-40.

    Fedson DS. Treating influenza with statins and other immunomodulatory agents. Antiviral Res 2013; 99: 417-35.

    Fedson DS. How will physicians respond to the next influenza pandemic? Clin Infect Dis 2013. Epub on 8 November

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    Can you please elaborate on work being done in the early detection space? Are social media sources being considered? If yes, how is this being integrated into conventional communication channels (Governments, vaccine manufacturers, points of care)?

    Thank you,

    Navid

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    Please comment on the advantage of PSC recombinant technology for rapid production of vaccine with genetic fidelity to the pandemic threat –

    Lisa M Dunkle, MD

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    Dear panel,
    The attached questions have been compiled by the Seminar on International Health Policy at Tufts University. We will be watching and participating in the live webcast and hope that you can respond to some of these questions.
    With regards, Rosemary Taylor

    Questions for the “Next
    Pandemic: Are we ready?” Forum

    #1 Massachusetts has been commended for its highly coordinated response to the H1N1 outbreak in 2009. Should states be allowed to establish their own guidelines and protocols
    for vaccine distribution and school and business closure, or should pandemic
    preparedness plans be mandated for implementation in all states? How do you get
    an entire society to systematically prepare systematically for a pandemic?

    #2 As evidenced by the SARS outbreak in Canada, hospital settings can be counterproductive in
    the containment of a pandemic. What steps can/should be taken to prevent nosocomial and health care worker infection, either through modification of current infrastructures or the establishment of separate facilities or infrastructure designed for pandemics?

    #3 Considering the logistical issues involved in vaccine production, including delay and
    limited supply, how big a role, and specifically what role will vaccines play in controlling future pandemics?

    #4 Priorities for the distribution of vaccine to members of a community reflect both
    scientific evidence and social values. Is there an empirically-based strategy for vaccine prioritization that you believe would contain the spread of an epidemic effectively and equitably?

    #5 How should we determine which countries should be allocated available vaccine supplies; who can/should be given the authority to make this decision?

    #6 One issue experienced during the outbreak of SARS was a lack of technology to test
    infection status (as opposed to exposure), which complicated quarantine procedures
    and travel advisories. Is this a topic that will or should receive significant investment and attention when thinking about preparing for the next pandemic?

    #7 If the US is serious about preventing the spread of a pandemic within its borders, how much
    should it invest in prevention efforts and public health infrastructure in other parts of the world where potential pandemics may be developing?

    #8 Lack of cooperation among countries in the face of a pandemic can be damning to
    international efforts at containment. How can we ensure that pandemic-control
    efforts are not sabotaged by a state or body that refuses to collaborate with the international community?

    #9 What do you believe is the government´s responsibility in preserving social equity in the
    face of a pandemic? (For example, providing emergency supplies to those who cannot afford them or reimbursement for lost income as a result of quarantine)

    Compiled by the members of the Seminar on
    International Health Policy at Tufts University:

    Maria Campbell, Emily Caplan, Lauren Jayson, Rose Pollard, Kimberly Ritraj, Amanda Rizzo, Fiona Weeks, Emma Wise,

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    The middle-east is going through an instable politico-social situation. What position does tackling the pandemic threat have amid all the priorities?

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    Dear madam or sir

    Here is a question that I am hoping could be discussed in today’s webcast:

    “Skilled communication with the public is crucial to mitigate the impact of an outbreak while preventing the uprise of panic.

    However, if in the end our control strategies were successful enough to make the outbreak look mild, the public might in retrospect perceive the warnings as exaggerated and based on vested commercial interests.

    In that sense success could create public distrust and harm compliance in future outbreaks. Hence my question is: how do we strike the right balance when it comes to mass communication?”

    Thank you and best wishes from Oxford!

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    Thanks for organising this important event. I would like to pose the following question:

    A lot of academic research in the area of pandemic preparedness and response has been done. Many conferences and workshops have been organised regarding these issues and long lists of policy recommendations have been produced. These issues obviously need a global, multisectoral, and multi-disciplinary approach. However, to free up funds for initiatives and programmes to tackle these issues, political will is imperative. There seems to be a gap between academics and politicians. A fair number of academics have expressed that they are frustrated that politicians do not see the urgency and importance of these issues (although I think very often politicians are left out as stakeholders in the conferences and workshops mentioned above). What can be a good strategy to address this gap between academics and politicians?

    Best regards,
    Peter Lutz

  • Kristen Lally

    QUESTION SENT TO THE FORUM EMAIL ADDRESS

    Hi,

    I have a couple of questions for the forum:
    I recently heard a podcast on the Rinderpest virus being eradicated in 2011, a deadly disease that Affected animals and was just as dangerous as smallpox.
    Could one of the speakers explain how it is determined that a virus is eradicated, and if it actually still exists as does
    Smallpox in labs throughout the world and is there a possibility that a rogue nation or terrorist could unleash
    An airborne virus that would decimate much of the worlds population.

    Thanks,

    Jack