Итак:
Wilson Center Pandemic Flu event
Transcript of Osterholm and Branswell inside. This is part one of three. Second part will be Helen Branswell. Third will be Q&A.I am not sure if this is of any use to anyone. If you are familiar with
the beast and have been keeping up with Flu news,
the things Doctor Osterholm says are not so shocking to our ears. I have bolded some important passages but this may be unecessary. I thought it might help if people were trying to pick choice passages
for showing
the unaware.
I also added some arbitrary sub-titles to break it up a bit. I estimate
the accuracy of
the transcript at
about 95%. Some words may have got subsituted or missed out, phrasing mashed. Spelling errors may also have sneaked in.
Finally, I'm not sure as to
the legality of this. Having a written r
ecord of comments made off hand (essentially) may be embarassing or legally awkward somehow,
for the good Doctor.
But here's
the transcript FWIW.
Start of Doctor Osterholm approx 8 minutes in, but with no timestamp on
the webcast, hard to tell.
Started a few s
econds be
fore Doctor. O speaks.
BEGIN TRANSCRIPT
HOST: very pleased to have Mike kick us off, so I'll turn
the floor over to him.
DOCTOR OSTERHOLM:
Thank you Jeff,
for the introduction I'd like to thank all of you
for being here today and
for the Wilson Center
for allowing this activity to take place. It's one that I could say at
the outset, its one that would not have taken place later than this to help wake people up to what is I believe is an inevitable situation coming down
the line.
Let me make just two comments as I start in what will be a relatively brief and un
fortunately somewhat high level overview, and we'll get it to Questions and Answers but:
I have been in public health
for nearly thirty years at
the ground level, having been involved in
the earliest days of things in like Toxic shock syndrome and HIV/AIDS, antibiotic
resistant emerging infections, bioterrorism and so
forth, and I can tell you that without a doubt if you were to add up my entire public health career concerns, worries and in some cases nightma
res, if you added
them all toge
ther,
they collectively do not meet
the concern
the worries and
the nightma
res that I have
about the issue of a pending pandemic event influenza, and today and I'll share with you
their construct.
The o
ther thing that I want to give you
the sense with of this is that in 9/11 of 2000 actually I published a book called "Living Terrors" a book on
the bioterrosim and
the concerns we had in terrorism in general, and in that book I specifically talked
about the World T
rade Center Towers and
the Al Qaeda and if you had asked me in
the year between
the years 9/11 2000 and 9/11 2001 what
the likelihood of events of 9/11 unfolding as
they did despite what I had talked
about, I would have told you it was probably
about 1 in 10,000, you know in some number like that.
I want to leave you today that
the risk of a pandemic influenza event is 1. It is going to happen. It is not *if* it is going to happen, it is when and where and how bad. And that I think has to be
the understanding we have today as we talk
about this issue.
This is probably
the most important slide that I have in my entire repertoire of thousands of slides. And what this really points out is that we live in a very different world today. Just in
the last 150 years we have gone from a world
population of
about 700 million to a world
population today of 6.5 billion. In 1918, one of
the dates we'll come back to,
the world had 1.8 billion people. Today roughly 1 out of every 9 people who have every lived is on
the face of
the Earth. In addition we have changed how we get around this world, and this concept of a global one-stop, non-stop world is a reality. Although we have not increased
the speed at which we get around
the world, and from
the 1950's with jet travel, what goes around
the world, and
the dependency we have on o
ther parts of
the world
for our everyday lives, is huge. That is an overlay
for understanding today's concerns of Pandemic influenza.
THE P
ANDEMIC FLU VIRUS
Now let me just give you a very brief
primer (
for those of in
the audience that have expertise in
the area you can take a brief break)
for those that don't let me just remind you that influenza type A,
the kind that causes pandemic and causes
the annual intra year concerns we have with annual flu, basically is made of a series of different virus that can be characterised by
their different Hemagglutinin antigens and neuraminidase antigens, HA and NA -- or as you know come to know it, H and N
then some number (and I'll come back to that).
Human disease historically has been caused by three subtypes of, Hemagglutinin H1, 2, 3 and two subtypes of neuraminidase.
These are key because
the Hemagglutinin is a very important part of
the virus in terms of getting into
the human cell. If
the Hemagglutinin doesn't have
the right receptors or right chemical structure to get into
the human cell, it may be floating out
there in
birds or whatever, but it's not likely to infect humans.
The Neuraminidase is a very important part of
the virus: it allows it basically to get out of
the cell, so that even if a human gets infected, will
they
themselves
then be infectious, and capable of transmitting
the virus.
All known subtypes of Influenza A can be found in
birds, and only two subtypes, H5 and H7 have caused severe outbreaks of disease in
birds as we now know it today.
The natural
reservoir
for influenza virus, all of
them, is wild aquatic
birds. And not just in
the Far East, although that has been a very important source, but
across the world. And
for whatever reasons and we may go into those on a scientific basis,
they have not
then made
the jump of change in
the Hemagglutinin and Neuraminidase structu
res to b
ecome human pathogens, only but rarely.
Now
the way Influenza virus get out of
the bird population, and in this case from wild
birds to domestic
birds (and
there is a difference by
the way) is that
the virus has to change.
METHODS OF CHANGE: REASSORTMENT
AND R
ECOMBINATION
There are two ways
the virus can change to b
ecome this new virus,
the one we are most concerned
about. One is reassortment
the o
ther is one called r
ecombination.
We have t
raditionally thought of pandemic,
the emergence of a virus out of
the wild
birds to humans as
the result of reasssortment. Reassortmewnt occurs when this very promiscuous indiscrete and sloppy virus is in a lung cell of, we used to think pigs, potentially humans, and it comes into close contact with ano
ther type of influenza virus which is already human adapted.
This cartoon from
the New England Journal of Medicine shows on
the left side in this case, H5N1, this unique virus that we'll be talking
about and has caused us such concern, and if it were to infect ei
ther in a pig or a human
population, a co-infected with an already existing influenza strain such as
the common
H3N2, which is
the one we
see year after year, and was
the cause of
the pandemic of 1968 [you'll get a new virus].
These two will swap genes very easily.
There are 8 genes in
the Influenza virus and if it acqui
res enough [genetic] material from
the human adapted strain, keeps
the important disease causing and immunologically distinct characteristics of
the new strain well you'll get a new strain of
the virus that now will infects humans and will cause lots of problems.
That is how we t
raditionally have thought that pandemics start. H5 has not done that since its first documentation in 1997.
Instead what we
see is a series of "point mutations",
these g
radual changes where
the virus keeps passing and passing and passing through living specimens, I.e. primarily
birds, and with each of those passing
the changes occur get it closer and closer to what would be in
the sense a
result of a cataclysmic event like a r
ecombination. Why might that be a possibility? This gives you some sense of how that world has changed.
in 1968
the year of
the last pandemic,
there were 788 million in mainland china. In 1968 in a very different social political and
economic time,
there was 5.2 million pigs in china. Today
there are 508 million pigs. In Po
ultry
there were 13.3 million chicken. Today
there are over 13 billion, and I might add
the average life expectance of a chicken today, from time of hatching to harvest is
about 18 weeks. So that you can
see that in a years time you have to triple that number in
the sense of what passes through
the system. [Please check figu
res here]
What we have today is an ideal incubation, kind of
the forest fire of
forest fi
res, because
the potential is instead of you know, a mountain state park or a national
forest somewhere you basically have a virgin
forest from San Francisco to New York, kind of thing that can burn.
This virus will not burn itself out in
the current environment of Asia, because of this ongoing potential
for the virus to be transmitted.
Each one of those transmissions, each one of those infections
results in ano
ther opportunity
for this virus to continue those mutations that accumulate over time and is what is driving what we believe is,
the concern
ultimately unleashing a pandemic strain.
ABOUT P
ANDEMICS
Now to understand Pandemic influenza epidemiologically: pandemics are an epidemic that b
ecomes very widespread, effects a whole region, a continent or
the World.
Now we got to acknowledge that technically every year we have a pandemic of influenza in terms of
the seasonal flu. That really does meet that definition, but that’s not what we are talking
about with a pandemic. What we are talking
about really is this new virus emerging
for which
there is very little human protection from previous experience of
the virus,
the virus may have characteristics that make it more likely to cause severe disease.
There have been at least 10 pandemics r
ecorded in
the last 300 years,
the most notable one is
the 1918 one, but let me tell you as we start to study previous ones, 1830-32, 1766,
there clearly were o
ther pandemics that had an impact that
for the time and
population may not have been that dissimilar from 1918.
In 1830-32, was similarly severe in a smaller
population as we saw in 1918-1920. You'll
see lots of numbers thrown around
about how many people died in 1918 and 1919. Let me just say that I refer back to a publication that
recently appeared in
the bulletin of Medical History which basically was an examination by a group of historians that went back and actually took country by country data and
they came up with an estimate of minimum of 50 million and
they actually said in
there that
they believed that it could have been as high as high a 100 million people perished in 1918-19 experience.
Now pandemics occur when a novel influenza strain emerges from
the bird population through o
ther animal species into humans that:
a) can be readily transmitted between humans, so it's got to have
the right lock and key to get into
the lung cell i.e that Hemagglutinin has to change just enough, keeping
the bad disease causing properties but now readily affecting humans. Today H5N1 only has a little bit of that, it occasionally gets into humans but not readily.
2) it has to be genetically unique, meaning that
there is not a whole lot of us out
there that have pre-existing antibodies, so that when it starts to spread it will spread unchecked and
3) what really makes it a different situation is increased virulence, with
the increased ability to cause disease in a different way. And I'll share with you that not all influenza virus, even pandemic strains, were created equal. Pandemics are different with regards to
their
population mortality rates and cannot be characterised by a single risk predictive
model.
So today when people talk
about pandemics in previous history please do not allow yourself to think that that idea, "
there is only one kind of pandemic".
There is not. And I'll show you this right here.
[SLIDE CHANGED]
These are
the three pandemics documented during
the 20th century. In
the United States,
for which we have probably some of
the best data (
these are
the data of [something Simonson?] and
the NIH,) you can
see that in 1918-19
there were roughly 500,000 excess deaths in this country. In
the pandemic in 1957 and 58 and
the pandemic 1968-69
respectively
there were 60-40,000 increase excess deaths, which when you think
about influenza every winter kills between 35-50,000 Americans, you can argue that
the bottom two numbers while
for the population being smaller
then that it is now, s
till it wasn't that major a departure from what we are talking
about could potentially be
the situation.
Now
the 1918-19 pandemic is one we must study. And I'll come to that in a moment because I believe that
the H5N1 virus if it is to be
the pandemic strain, and again I said
there’s a chance of one that
there will be a pandemic, I am not going to tell you that it will be H5N1. Everything in my science bag tells me that that's
the case but tomorrow we could be surprised and a new virus
pop up somewhere else, re-assort and spread, so we have to keep our eyes open 360degrees
across the board.
But in that particular pandemic we now know retrospectively that it was an H1N1 strain(of course we didn't have viriological technique back
then). we have now completely sequenced this virus ei
ther from specimens from pathology specimens, from soldiers who died in 1918 and
for which we have excellent r
ecords, or from exhumed bodies that came from perma
forst, and collectively now,
the virus has been totally sequenced. 200 million to 1 billion people were infected as I pointed
about more than 50 to 100 million died. It killed a disproportion of healthy young ad
ults: "
the W curve".
H5N1: VIRULENCE
AND DISPROPORTIONATE DEATH
T
raditionally we think of pandemic influenza or
for that matter inter-pandemic years like every o
ther year, we expect to
see a U shaped curve, with
the highest rates deaths in
the very young and very old. In 1957 and 68, that U shaped curve generally was just pushed up at all levels i.e. a rising tide. IN 1918
the curve was very different. It was a classic W shape curve, affecting
the very health of use
the most and I'll come back to that in a moment.
Ano
ther thing that happened in 1918 a summary of 13 studies, throughout
the world, actually demonstrated that among pregnant women 23-71 per cent died, 55 per cent overall median death rate which also is important, in
the sense, observation because pregnancy in
the human condition is
the single most precarious immunologic time in our lives because
the woman is carrying something biologically that in part doesn't belong to her, it's not her, in
the same time as working very hard as working very hard to protect that thing from any ins
ult. And immunologicaly
the immune system is at a very precarious trigger point in terms of what happens so if you have a virus that can actually impact
the immune system you can
see some very deleterious effects as we saw in 1918.
That makes it of great importance to us today because
there are two
recent studies to suggest that H5N1 is “deja vu all over again” of 1918-19. And in fact a study of a Boston group and additional studies that are coming out very shortly in several major publications, support that in act
the H1N1 pandemic strain basically created an over exuberant immune
response in
the host, its what we call a "cytokine storm".
Why is it
then that people in 18-40 group were at highest risk: because who has
the strongest immune
response in our general
population? You spent
the first 18 years of
the life generally building up your immune system and un
fortunately
for the two or three in
the room over age 40 its on
the way down after that. So in a sense, it really goes at
the very opposite of what we usually think of in influenza, it goes
for the very healthiest of all of us.
The clinical picture and epidemiology as we now know it in South East Asia, with those H5N1 cases we have is this exactly, both in terms of laboratory based data and
the epidemiology. This is a cartoon from a paper I published in
The New England Journal of Medicine in May which basically just shows this H5n1 in
the upper left hand corner setting off a whole cascade of events in
the immune structure of
the host
ultimately
resulting in
the severe Acute
Respiratory St
ress syndrome we
see in cases of H5N1.
Let me just ell you at
the outset we are not much better able to handle Acute
Respiratory Dist
ress Syndrome any number of cases today than we were in 1918. So don't go back and say it's different today, it's not 1918. Un
fortunately folks it is 1918 all over again, even from a clinical
response standpoint.
COMPARING
THE PAST WITH
THE POSSIBLE
These are data which give you a sense of what I was talking
about in
the W shaped curve,
these are actual data from Boston. [
SEE SLIDE]
The top graph is
the actual historical data from 1912 to 1916
for the months September October, November. On
the left axis is actually
the death rate per 100,00.
For the top graph, 100, 200, 300, 400. On
the bottom where it may be cut of
for some of you, is 0-9, 20-29, 30-39, 40-49, 50-59, 60-69. (PLEASE CHECK) Note historically
the rates are highest in
the very young
for pneumonia and Influenza like illness and g
radually increases with ages, again this is a rate per absolute
population so it's not just absolute numbers.
Look what 1918 did in September to October
for Boston, an event replayed over and over again around
the world.
Now
the axis is 1000, 2000, 3000, 4000, 5000 reaching 57 000 per 100,000 ie 5.7 [CHECK PLEASE!] per cent. You can
see what happened is a slight increase, well a ten per cent increase based on historic data in
the very young, but when you look at
the rate
for 20-29, 30-39 it approached almost 6% of
the population died during that time. That’s a remarkable concept to think
about happening again today. And of course it came down over time.
So that in a sense this is what we all worry
about. if we take
the 1918 numbers and people will throw numbers out all
the time, and I can't tell you what happens if H5N1 comes and it follows this pattern, will be like.
All I can share with you is that if you take today’s
population and you extrapolate
the 1918 data,
the exact rate of deaths and cases, you can expect to
see in a state like Minnesota in a state where we have almost 5 million people, 3 million living in
the Twin Cities, you
see 18,000 deaths in our city, over
the period of a year to a year and half, but more notably in
the US 1.7 million, worldwide if you take
the lowest estimate of 30 million, all
the way up to upper bound of what was
the 1918 number of 384 million. Just to give you a sense remember that HIV/Aids in
the space of 30 years has killed somewhere in
the name of 30 million. That is a horrible tragedy and yet in comparison you understand what we are talking
about here.
Now we have this situation in Asia,
the actual number of cases in
the last several years is not completely clear, it is somewhere on
the level of 120 cases and 60 something deaths, but you can
see the spread that has occurred in both
birds and humans.
"What's
the issues here in terms of pandemic preparedness?"
VACCINES
There are really three aspects: ei
ther prevention, treatment or collateral damage
response, i.e. what happens beside
the pandemic. In terms of vaccination I know Helen will be talking more
about this, in terms of prevention we have vaccination, anti-viral
therapy and prophylaxis.
In terms of vaccination I would just say that
for those in
the audience who are old enough to remember a slide rule as your primary tool
for ma
thematical calculations understand that today's vaccine, procurement
development and actually production doesn't vary a whole lot from what it did in
the time of
the slide rule.
We have a couple of new tweaks on it, but we are basically producing
the vaccine with cell...with chicken egg, c
ulture based approaches
the same way we did in 1950.
Grown in chicken eggs takes, 6 or more months. We use reverse genetics. One of
the new techniques does allow us to develop prototype vaccine we do have a live attenuated vaccine now, but a very [small part of
the market?] and it must s
till be grown in chicken eggs.
We need an immediate and comprehensive program
for developing
the cell c
ulture system
for vaccine production with surge capacity.
We can make some vaccine now with
the current existing H5N1 strain, at
the best that will be a priming dose. Most of us agree we will need two doses of a new vaccine effective against H5N1, if that were to be
the emerging pandemic strain.
We could use
the current virus to some degree,
the problem with that is you'll s
till need
the circulating virus to get
the ultimate protection, just like
the annular flu what we need to do in terms of changing
the vaccine year after year, so that means we won't even have
the seed virus until
the pandemic begins, which if it takes six months, means we won't even have any production
for almost that time period.
Current annual international capacity
for influenza vaccine production using egg c
ulture is approximately 300 million trivalent doses, as we now have, or 900 million monovalent.
That assumes a dosage of
the current size we use in our vaccines [is correct]. As Helen will talk
about, NIH has
recently done it's initial analysis suggesting we need 12 times
the amount that we need to provide protection on an individual now with this as opposed to what we use everyday
for H3N2.
Now we hope we can bring that number down. But it s
till means we are even going to have a shorter supply than this. Almost all
the World's influenza supply is produced in 9 countries. Which 12% of world's
population.
Make no mistake
about it. Just like in 1976 when we nationalised
the H1N1 vaccine as part of [something?] and wouldn't let any o
ther country have it, any country who has a plant within it's border will not allow that vaccine to leave it's countries boundaries, so in a sense we've already greatly leashed down
the number of people who would even have access to any vaccine.
Production capacity will not increase significantly in
the next few years. Understand that this is not
about money anymore. Money is a necessary part of
the equation, but a question of
the infrastructure. If I said to you today "we want to build a 150 story building in downtown New York and we have all
the money in
the world we wanted, it doesn't matter but I want it done by Christmas"
there's no way in Hell that will happen.
It won't happen
for years even under a crash program. Today
for us to build this new vaccine infrastructure on a worldwide basis, and however we paid it, it will take years to occur, that's if we launched a Manhattan-like project tonight.
Finally new and more timely methods of production are desperately needed.
ANTIVRIAL DRUGS
In terms of
the antiviral drugs, let me just say, we are really only concentrating on
the Neuramindase inhibitors,
the two bottom drugs [on
the slide],
the top one you know as Tamiflu.
The top drugs,
the two M2 protein inhibitors are likely not to play much of a role because right now most of
the strains we have coming out of Asia are
resistant of
the drug and would quickly develop
resistance if we used this on a widespread basis.
Let me just point out here we don't know if
these will work.
There are conflicting data which says "yes
they will work against an H5N1", but o
ther data which suggest that
the cytokine storm, this immune
response is different than in a typical H3 and N2 infection and it may not work. So I would not
for a moment suggest not working on this issue, but let's be clear:
We don't know.
LOGISTICAL ISSUES
The s
econd thing is I would tell you is again
the same pipeline issues that are operative with
the vaccine are operative here. People have
these wonderful orders in
for Neuraminidase inhibitor drugs which
they don't tell you will take years to fill, as at current capacity production.
Let me just very quickly briefly say, we've got o
ther issues: facilities and staffing.
You have no vaccine. You have no anti-viral drug and I'll point out in a moment you have no masks
for these:
Who's going to come to work? Where are
they going to come to work?
Right now, we have gnawed our healthcare down, even in
the developed world, to
the bone and we are sucking calcium.
The bottom line is we will be operating in gymnasiums and community centers, wherever we can find space.
And we have to wonder: "who is going to show up
for work?"
Would YOU show up to work? Would your loved ones show up to work if
they were being exposed to a life threatening infection with virtually no protection?
Worker and patient protection will be key. Medical devices and
therapy, we will run out of those quickly. We will run out of all
the o
ther drugs.
Today we have a global just-in-time
economy that provides all our pharmaceutical products. Right now in this country we have a shortage of 7 major antibiotics and 3 paediatric oncology drugs. All because of
the fact that one plant somewhere in
the world makes
them and all it takes is just ONE glich in that operating supply chain...and
they go down.
Under a crisis, where we shut down border and where we have a major decrease in international t
rade and traffic and travel we will
see tremendous collateral damage from o
ther conditions we think of being routinely treated
for.
For which now those drugs will not be available.
They just won't make it through
the supply chain.
O
ther medical devices, let's take masks I mentioned. Today two companies in
the world, both American companies own well up to 90% of
the market share in
the masks know as
the N95
respirator mask. Today those companies have virtually no surge capacity whatsoever to make more masks. Those masks are made off-shore with in addition
their masks are actually made by obtaining raw materials from 2nd and 3rd tier counties.
The bottom line is we will run out of masks very quickly. And again, think of
the panic.
And fear that will just be
there: "I can't get a vaccine, I can't get an antiviral drug that will work and I can't get a mask. What do I do?"
Ethical issues around allocation of
resources and so on will be huge. Use r
ecovered volunteers how will we be bringing
these people into
the system?
They may not be healthcare workers but
they will be doing healthcare work, if
there are people who have had
the virus and lived.
Finally corpse management.
In 1969 in this country,
the average time from a casket being constructed to
the time it was in
the ground was months. Today it is a little over two and a half weeks. Today we will run out of caskets
overnight.
S
econd of all our crematorium capacity is limited. We will find it very hard to process
the number of bodies we will expect to have. When that begins to happen, let me tell you it adds a whole 'no
ther dimension to
the concept of fear and panic, and what it means to know that we can't even manage
the bodies that come from a situation like this even with a relatively
modest pandemic.
SCARCITY OF SUPPLIES
Finally
the collateral damage
response. Everything from pharmaceutical products, food, equipment parts are all going to shut down with
the global just-in-time
economy shuts down. And I have no doubt it will happen.
In
the Foreign Affairs [insert link] piece I extensively discussed
the SARS situation and as much as it was a very limited
response (and Helen will talk
about that),
the global implications were huge.
CONCLUDING REMARKS.
Finally, let me just conclude by saying “what do we do?”
I think frankly from my perspective, we Pray, Plan and Practice.
If Katrina taught us nothing else, it's not enough to have something on paper. It's also something of much greater magnitude than just that chessboard step. It's
the whole game we've got to figure out in advance such as
the private supply chain.
It's not a matter of if, it's when and where. Am I telling you it will be H5N1? I'm not. I think it will be but no matter
there will be more pandemics. If we can't stop Tsunamis, Hurricanes and Earthquakes we surely can't stop pandemic influenza ei
ther.
Lack of international political will and support right now: Most of
the world doesn't get this.
I have to tell you that as much as our own government has done, we don't understand, that this will make
the catastrophic events of
the past weeks, pale in comparison. At a minimum assuming we will have virtually no vaccine
for 6-8months and supplies remain limited. And our best analysis maybe 1 and half per cent of
the world will have access to vaccine within
the six months. But even if our country had that luxury,
the global
economy will s
till collapse.
And finally I think that given
the viral characteristics,
the epidemiology we are
seeing, we have to understand that
there is more than just a passing
resemblance between
the 1918-20 experience and
the current H5N1.
There really is a
model here we have to look carefully at.
We can't be surprised if
the Levees break here. And I'm afraid that as a World we will be.
We have to understand
these are
the implications, this is what we are facing. And if we do nothing else we have to plan as if "what if this is tonight, what if it is one year, what if it is five years from now". And we need to move all three of those toge
ther.
Thank you very much.
[muted applause]
[END TRANSCRIPTION]
Transcribed by Nick Wellings 21 Sept 2005
http://www.curevents.com/vb/showthread.php?t=22803 Добавлено в 00:02 Part Two: Helen Branswell's Talk
Here's Part TWO.
I think Helen B's talk is a little better than's Doc O's. I think she may have been reading from notes.
Again
there are probably errors here, I added a few titles, and bolded bits, probably too much bold. I'd estimate this is mostly accurate transcription, as sual I left out hesitations and wordsalad jumbles. And as usual [?] means [Not sure what
they said]. I had thought of adding an Editorial type opinion when she talks
about drugs expiring, and my thought was that might not happen as
they have longshelflives, unless people are expecting this thing within 2-4 years.
But
the same mesages prevail: you are on your own.
Kind of.
Q&A I have begun, but will take more time.
___________________________
[BEGIN TRANSCRIPT]
HELEN BRANSWELL:
Hi. Welcome to my nightmare.
I've spent
about most of
the last two and a half years
researching pandemic influenza in general, and
the avian strain Mike was talking
about, H5N1, in particular.
That's
the strain,
the renowned Flu expert, Robert
Webster from St. Jude's in Memphis so eloquently described to me last November as: "
The one that sca
res us shitless."
In
the time I have been working on this I have interviewed hundreds of scientists and public health authorities, vetenarians, vaccine and drug makers, health care workers
about this
topic.
While Dr.
Webster's remark was
the most eloquent and a little bit too graphic
for my editor I have to confess, all of those people talked to me in terms that I could not ignore.
The urgency in
their voice was just palpable. A number including leading influenza experts told me
they all suffer sleepless nights.
In that two year period, and I took a three and a half month break to go to
the CDC at that time, I have written 90 articles
about influenza. To put that in a little context, I wrote 41 that mentioned
the one cancer which is hardly an insignificant medical subject and I wrote 6
about diabetes.
The Canadian P
ress which is Canada's rough equivalent of
the Associated P
ress here in
the United States, conveyed my articles to
the major daily newspapers and to
the broadcasters and
the news
websites
across my country....and
they fell into
the great News Void. Or, if
they were run at all,
they were run on
the back pages.
For reasons I can't fathom many news outlets in North America aren't paying attention to this story as a human health issue, as a global security threat as a potential
economic disaster.
There are some exceptions of course and I certainly don't want to suggest that I am
the only person paying attention to this, but
for most news organisations "
Bird Flu" as people like to ra
ther imprecisely call it, really hasn't been on
the radar.
You know
the exp
ression
about ignoring
the elephant that's in
the room with you? I think of pandemic flu as
the elephant people don't
SEE in
the room with
them. Once you do though it's really hard to ignore
the threat it poses.
LEARNING FROM SARS
I was primed though to take this story seriously [by SARS]. I live in Toronto and I covered SARS. I watched what a simple, not very highly transmissible virus did to a
modern city with some of
the finest healthcare facilities available. A city snugly situated in
the developed World.
For four months in
the Spring of 2003, SARS turned Toronto on its ear. Hospitals were locked up tighter than a drum. No visitors were allowed in even initially not even to com
fort
the dying.
In
the early stages all non-urgent surgery was cancelled. Cancer biopsies, joint replacements, organ transplants and o
ther important health proc
edures were delayed, to
the anxiety of
the affected patients and
their families.
We journalists weren't allowed into
the hospitals at that point, but by all reports
they were in chaos. Health care workers were exhausted and petrified
they'd get sick and in fact, a lot of
them did. 43% of
the cases in our outbreak were healthcare workers, and two nurses and a doctor died.
Healthcare workers were even more frightened that
they'd bring
the virus home and infect
their family and indeed that happened as well.
And some will privately tell you that although
they turned up
for work,
there were o
thers who called in sick. Or who pulled rank so as not to have to treat SARS patients.
In
the community,
about 20,000 people were put into quarantine
for ten days apiece because
they'd come in contact with somebody who went on to develop SARS. This is a paramedic [refer to slide], who's doing an interview on
the balcony of his apartment.
Eventually
the World Health Organisation told people not to go to Toronto and while that angered our political figu
res mightily it didn't really change very much because
the damage had already been done.
At that point
tourism in
the city had plummeted. Hotels were empty, major conventions were cancelled. Movie shoots moved away. Concerts wouldn't come to Toronto, Billy Joel and Elton John refused to come and play in our city.
Theatre shows went dark
for a period and some of
them closed:
The Lion King is no more in Toronto.
Restaurants, particularly in Toronto's bustling Chinatown, fell on very hard times. People just hunkered down and stayed home.
And that all of course will happen when a pandemic starts.
Governments may or may not move to close
their borders and block international flights in and out of
their countries. But as Australia's Health Minister Tony Abbot mentioned
recently, "I don't think we'll need to close
the borders because people simply won't travel." that will have a huge impact on
the Hotel and
restaurants industries worldwide and on
the people who work in
them. And as well on airlines and grounded planes mean grounded goods.
But let's go back to SARS
for a s
econd. Severe Acute
Respiratory Syndrome was a frightening event in medical history. Don't let anyone tell you o
therwise. It sent shockwaves through
the economies of Asia and Canada. But
for all
the panic that was attached to it,
there were only really six true outbreaks of SARS in
the world, China Vietnam, Thailand- Taiwan excuse me, Singapore and Toronto.
All that fear, all that
economic disruption and only six real outbreaks. What will a global outbreak of disease bring?
From my perspective SARS should have taught us a couple of key lessons and
the first is that in
the modern world, infectious disease travel fast: Jet speed. Pandemic planners tell us we may have up to three months be
fore a pandemic virus hits North America [from
the time a pandemic starts?]. I have no idea why
they are so optimistic. SARS was rampaging through Toronto's hospitals be
fore it even had a name, be
fore
the WHO warned anyone to be on
the lookout
for the disease.
The s
econd lesson, and this is something that was tragically driven home earlier this month in New Orleans: We are not very well prepared
for emergencies.
And
the third is that it doesn't really take very much to tip systems over
the edge.
In
the case of healthcare systems, at least in my country,
there's virtually no surge capacity. On any given day, in any given city: most beds are claimed, especially in Acute Intensive Care units. A bad flu season or an outbreak of norovirus can easily swamp emergency rooms around
the city.
FATALATIES
How
then do we expect
them to cope with a crush of patients a pandemic will bring?
The hundreds of thousands
the ma
thematical
models predict? Don't
forget,
these numbers are in addition to
the load
the hospitals are bearing day after day. And
they could be very optimistic numbers as Dr. Osterholm's p
resentation suggests.
One of
the most commonly cited ma
thematical
models was devised be a delightfully outspoken health
economist at
the CDC in Atlanta, Martin Meltzer. He deliberately used conservative figu
res, attack and fatality rates based on
the relatively mild pandemics of 1957 and 1968. Nothing like
the carnage of 1918 with
the Spanish Flu. He even devised a program called FluSurge, which hospital administrators can use to try to figure out what
the demand
for care will be in
their catchments areas. He says when he runs that program
for hospital administrators,
they invariably blanch.
And
then
there are
the fatality projections. [refer to slide] You can
see lots of
them and
they are confusing.
They are all over
the board.
The first and
the most conservative is
the WHO's estimate of 2 to 7.4 million [deaths]. That's extrapolated from Martin Meltzer's
model.
The s
econd is
the number that's been floated by Dr. Shigeru Omi, director of
the WHO's Western Pacific regional organisation. I have never
seen anything to indicate how he's come up with this number of 100 million fatalities.
The third is
the number that Dr. Osterholm used in his
Foreign Affairs piece, 180 million to 360 million potential deaths, and that's looking at
the population now versus 1918 and looking at breaking it down into age group and laying
the two
across.
The final figure which has been used by a few people that I've
seen and most
recently by Irwin Redlener,
the director of
the National Center
for Disaster Preparedness at Columbia. I don't have any idea how that figure was arrived at, though it looks like someone took
the worlds
population, assumed a 30% per cent attack rate and 50% fatality rate. That's a lot of assuming I think.
At
the current time
there's really no way to know what
the numbers will be, but what is clear is that whatever
the number will be it won't be very pretty.
INFRASTRUCTURE TRYING TO COPE
During SARS, doctors came to Toronto from
across Canada to help out and
they even came from
the United States.
The same thing happened, as it should have, when Katrina decimated New Orleans. Paramedics from Vancouver drove
themselves to Louisiana to pitch in.
In a pandemic, every jurisdiction is going to need every single doctor, nurse, lab technician, orderly and paramedic
they can muster. No one is going to be able to rely on
the cavalry arriving.
So how are we going to cope when
the whole World gets sick in a pattern that could
resemble a wave at a sporting event?
How do businesses continue to function, when a third to a half of
their work
force calls in sick?
How do crops get harvested?
How do grocery store shelves get stocked?
What does it do to our families, our
economies?
[slide I think here]
Sherry Cooper is a very prominent
economist in Canada. She works with BMO and Nesbitt burns, a brokerage house. She and a colle
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