The Next Pandemic: Are We Prepared?

so ladies and gentlemen please take your seats if i could please have your attention for a few safety and housekeeping announcements in the event of an emergency please remain calm and walk do not run to the nearest exit emergency exits are located at the front left and rear left of the room please look around you and note the location of the exits near exit nearest you it is not the same way you entered this program is being webcasted to maintain quality of the feed we need to limit movement in the room however if you need to use the restroom there are two marked single stall restrooms located in the entrance hallway near guest registration self-serve beverages are available in the back of the room if you become thirsty during the program please silence your cell phones now if you could and thank you for your attention and cooperation the program will begin momentarily afternoon everyone my name is kirk johnson i'm the director of the museum the sand director of the national museum of natural history it's my pleasure to welcome you here to the next pandemic hopefully it's not actually the next pandemic right here the uh you might think the natural street museum is not a natural place to have something like this but i would suggest that a natural museum is probably the best place to have a meeting like this this museum that you're in is the world's largest natural stream museum it has 145 million objects and we say that objects whatever but the reality is is that our species has been collecting the natural world for the last 300 years and preserving those objects in museums and this is the place where we have what we know about planet earth so the records of collecting over the expansion of humans over the last 300 years preserved and accessible to research scientists at any given year there's about 400 phds working behind the scenes publishing 7 or 800 papers last year over 400 new species were described by scientists working in the building at the same time every year we welcome about six million visitors most of those visitors are tourists which means the next year is a different six million which means in a decade you might get as many as 50 million people in this building world's largest collection wrapped with scientists visited by the world's largest visiting audience for public science education and we live in interesting times with human population growing there are so many things happening on the planet where humans interface with the natural world and where things like pandemics can emerge just a couple of examples if you were to go in the other side of this building into the sixth floor you'd walk into a collection that has 640 000 birds skins collected over the last 300 years from all around the world other side of the building 590 000 examples of mammals so a huge collection of actual organisms that carry the genetic code of their species but also carry other features of their environment as they live they became biological data collectors recently several thousand these birds were were sampled for evidence of the 1918 influenza pandemic because we had birds that were collected around 1918. you can't go back to 1980 and we collect those birds we have those birds and we sampled 25 and 6 tested positive for the influenza so we have in our collections effectively fossil examples of diseases and when diseases break out there are times when those outbreaks are the actual vectors are not known and a classic example is the honta virus which was discovered in a museum collection so we've come to realize that our museum collections aren't just historical artifacts they're actually research tools in fact they're scientific infrastructure that allow us to investigate emerging scientific issues in areas of emerging infectious diseases and food security in this invasive species and pests etc so it's an interesting time to be in a museum and i welcome you here today we are going to be opening an exhibit next spring called outbreak epidemics in a connected world and this really will map the museum perspective on disease the fact that human health and environmental health and animal health is all related we call it one health and the exhibit will discuss a lot of emerging infectious diseases and present them to this huge public a couple years ago we did an exhibit called genome about the human genome discovery and it was a great exhibit because most scientists have a pretty great understanding of what's happening in human genomics but the general public has almost no clue what a genome is and to take the tools of the museum and interpret something like genomics for the public provides a bridge between specialists and the world and we'll do the same thing for emerging infectious diseases with the outbreak exhibit one of your speakers later today is dr sabrina schultz who is the curator on staff here who's the lead curator for the uh exhibit so all that to be said we i'd like to introduce our first speaker who's someone who i just met a moment ago but i really enjoyed his work over the years john barry is a best-selling author and historian he's currently a distinguished uh scholar at tulane university where he's focused very much on the fate of the gulf coast i came to know him from his book rising tide the great mississippi flood of 1927 and how it changed america he's also written a book entitled the great influenza the story of the deadliest pandemic in history published in 2004. the great influenza was ranked by the national academies of sciences that is that year's uh outstanding book on science and medicine he's the only he was the only non-scientist on a federal infectious disease board of experts he was on the team that developed non-pharmaceutical interventions to mitigate a pandemic he's also advised both the bush and obama white house on pandemic preparedness so with that i'd like you to help me welcome john barry to the podium [Applause] thank you and thanks for coming and thanks for putting together this conference i want to give you a very quick summary of what happened in 1918 and what we might learn from it the estimates of the death toll start at 35 million and go to 100 million adjusted for population that would be approximately 150 million to 400 million today most of the dead were adults aged 20 to 50. probably about between three to eight percent of the entire population of people in those age groups died in certain subgroups it was worse than that there were numerous studies of pregnant women that had case mortality rates from 23 to 71 in virgin populations it was not unusual for 20 to 30 percent of the entire population to die and although the focus has often been on the young adults who died they are not the only people who died uh look at children uh even in the west where case mortality was the lowest the 1918 pandemic killed as many children aged one to four as today die of all causes over 20-year period it killed as many children aged 5 to 14 as die from all causes over a 10 to 15 year period and remember that well over half the deaths occurred in a period of weeks about 10 weeks in the fall of 1918 so just think of the impact that would have today even a non-lethal pandemic could sicken between 60 and 100 million americans 2 billion people worldwide that would overwhelm the medical system use up antibiotic stocks for secondary infections destroy the timing of just-in-time inventories devastate the economies so we need to extract every lesson we can from 1918 and the first lesson is we need to put a lot more resources into vaccine research particularly universal vaccine but in the interim improving technologies on vaccine manufacture second to inform policy choices we need to continue to study events therein the virus itself we continue to learn more about it particularly jeff taubenberger when you one of your speakers it's epidemiology cecile the boot is certainly an expert there another speaker and we also need to look at it from an interdisciplinary perspective i believe there is plenty warren from 1918 still i give you three examples of untouched data i know of studies of several hundred thousand people in institutions that relates directly to the effectiveness of hand washing that data has not been touched there is excellent data on quarantine by a brilliant pioneer epidemiologist strongly signature suggesting i think proving that quarantine is pretty useless in influenza that's untouched maybe most important i think there's data from the 1889 pandemic and from 1918 and from a recreations in 1920 about the first person in a household to become sick with the disease i think that would certainly deepen and might challenge some of our understanding of how the disease spreads but to me the main lessons involve what today we call risk communication which happens to be a phrase i despise because it implies managing the truth and i don't think you manage the truth i think you tell the truth in 1918 chiefly because of the war but not entirely for that reason they did not tell the truth or close to it the disease was known as spanish flu at national public health leaders called it quote ordinary influenza by another name the surgeon general of the united states said quote you have nothing to fear if ordinary precautions are taken and what was true nationally was also true locally the false reassurances were almost everywhere at camp pike arkansas a doctor reported his hospital closed overwhelmed doctors and nurses dead thousands of soldiers sick and dying in barracks and miles of double rows of cots he says everywhere there is only death and destruction seven miles away in little rock the newspaper reported spanish flu is playing the grip same old fever and chills now i think society is built on trust and these false reassurances these efforts to keep morale up quickly led to a loss of trust and authority it was alienating deracinating isolating and as a result society began to disintegrate as one person said the disease kept people apart you had no school life no church life it completely destroyed all family and community life people were afraid to kiss one another they're afraid to eat with one another it destroyed those contacts and destroyed the intimacy that existed amongst people uh in philadelphia there was a doctor who lived 12 miles from his hospital there were so few cars on the road as he went home every day he started counting them one day on a drive of 12 miles there was not a single other car on the road he said the life of the city has almost stopped on the other side of the world in new zealand another doctor stepped outside of his hospital and said i stood in the middle of wellington city at two o'clock on a weekday afternoon and there was not a soul to be seen it was a city of the dead there were people starving to death not because it wasn't food but because people were afraid to deliver food to them victor vaughan who had been the dean of the university of michigan medical school was serious sober person not given to overstatement said if the present rate of acceleration continues for a few more weeks civilization could just disappear from the face of the earth that's what happens when people lose trust in each other and in authority and to test my hypothesis or the hypothesis that the truth does make a difference there was one city that did tell the truth and it was an entirely different experience in san francisco the mayor the city council labor leaders business leaders all put their names on a full-page ad huge print said wear a mask and save your life now the mask didn't do a damn bit of good but that is a very different message than this is ordinary influencer by another name and in san francisco the city was extremely well organized certainly nobody starved to death blocks were well organized teachers when schools closed they volunteered as orderlies telephone operators delivering things the san francisco paper said one of the most thrilling episodes in the city's history was the story of how gallantly the city behaved during the epidemic that's what happens when you do tell the truth so i think the lesson is clear public compliance with recommendations will be difficult under any circumstances sustained compliance will be much more difficult in mexico city in 2009 for example masks were recommended on public transit free ones distributed usage peaked at 65 percent and four days later it was down to 27 percent so if we expect compliance with recommendations authorities need to get out front and stay out front they need to be totally accessible they need to stay ahead of internet rumors and the final lesson is not from 18 1918 it's from 2009. planning does not equal preparation there was a lot of planning done between 2004 and 2009 but when that very mild pandemic hit it was as if at least by authority figures none of that made any difference you look at irrational responses in china egypt india britain france even some to a lesser extent the united states and again planning does not equal preparation which means i think maybe the biggest challenge to the public health community is to get political leaders to make rational decisions in crisis situations and that is where leadership in the public health community really matters thank you [Applause] good afternoon i'm michael caruso i'm the editor-in-chief of smithsonian magazine the magazine that not coincidentally you've all seen on your chairs if you like what's in there we did three stories in this issue all about influenza if you like what's in there it's due to the efforts of terry monmoney the our deputy editor um and jenny rothenberg grits who's here our senior editor if you uh don't like what's in there it's it's my fault i have one of those impossible roles here introducing a man who needs no introduction especially to the people in this room but i'm going to plow on anyway so bear with me when it comes to thinking about epidemics everybody wants to talk to tony fauci he's been america's point man on infectious disease for 33 years now he's led our nation through every infectious disease crisis through those years from aids to ebola to zika dr fauci is a member of the national academy of sciences he has 42 honorary doctoral degrees he's received the presidential medal of freedom and his citation reads that it is for his commitment to enabling men women and children to live longer healthier lives with his broad appreciation for the public good and his nonpartisan nerves of steel dr fauci oversees a 4.9 billion dollar annual budget uh the stories in our new issue of smithsonian magazine and this event itself grew out of an answer that dr fauci gave us that was posed to him on stage at another event of ours a couple years ago we asked him what concerns you most what keeps you up at night and his answer was simple two words pandemic influenza okay we thought let's hear more about that ladies and gentlemen dr anthony fauci [Applause] thank you very much for that kind introduction so following that encouraging story from john i'm going to tell you a little bit about the next step that i think john was very clearly referring to about what we need to do regarding preparation and that's what i'm going to talk about in my 10 minutes namely preparing for the future and pandemic influenza so the first thing that i want to do is to make the the point that when you look at influenza the preparation for seasonal influenza essentially should be the preparation for pandemic influenza in a perfect world and the perfect world that i hope we get to within the next period of years we certainly are trying hard for that is the development of what john alluded to is a universal influenza vaccine and let me tell you why as someone who's an infectious disease person that i am concerned about are capabilities today against any kind of influenza so i want to break it up into three quick parts first of all the current seasonal influenza vaccines are not consistently effective and that's a fact that we just have to face if you look at from 2004 until the last year when you have a bad year with a mismatch as we saw in 2004-5 you have a 10 percent efficacy at best as we had in 2010 11 you have a 60 percent efficacy compare that to other infections that we have vaccines for measles vaccine is 98.5 percent effective yellow fever is 99 effective polio is more than 90 percent effective now there are a lot of reasons for that we all know about the drifts we all know about the mutations we all know about the fact that the response against the hemagglutinin although it can be very effective drifts from year to year and sometimes shifts but this is the stark reality of how we address seasonal influenza now pandemics do occur you just heard from john about the mother of all pandemics but we've had three since then in 1957 1968 and the most recently in 2009 however the response after the fact is not effective now john alluded to the 2009 h1n1 pandemic in which we actually had a bit of warning and i want to show you what the response was of those of us who were going as quickly as we possibly could so it was the swine flu the first thing is that we were expecting as we always have that the next pandemic would come out of china or the far east when in fact it did not it came right in our western hemisphere somewhere around california and mexico now you recall and i'm sure people in this audience do recall that at the end of the 2008 nine season as things were calming down in march the way they do it usually peaks in january all of a sudden in march and april we started to see a new kind of influenza and so we felt let's make a vaccine for that influenza and this is march this is what happened in april so it wasn't in 1976 shoot from the hip and get into trouble as we did then by vaccinating everybody when we never got the epidemic we knew we were gonna get a pandemic so in april this is a picture of my good friend ann shuket and i testifying before our appropriations committee in april saying and you could go back and see what we said is that it's april it takes about six months to get a vaccine going so if we start working now may june july august september october if we have the vaccine by october then we'll be prepared for the inevitable pandemic however what happened the children came back to school and instead of having an epidemic or a pandemic that peaks in january and february it peaked in september as graphically shown on this slide so what's wrong with this slide the blue line is where the red line should be and the red line is where the blue line should be in other words the percent of illnesses peaked before we had the vaccine available which became available it would have been wonderful if it had a peak in january but it didn't it peaked in september so even though we have some warning about a pandemic even then with our current capabilities it doesn't work well this is a picture notice the the expression on tom frieden and mai and jesse goodman explaining to the house oversight committee about the vaccine that we were supposed to have in time we didn't and then there's the third thing and that is chasing after potential pandemic outbreaks i refer and others refer to them as pre-pandemics it is costly and it is ineffective and let me just give you a couple of examples you all recall the h5n1 the chicken virus that started in hong kong jump species had a high degree of mortality but didn't develop the capability of going efficiently from human to human we took this very seriously and what happened it was during the george w bush administration he asked for over seven billion dollars and we spent about four or five billion dollars to switch from eggs to cells which i don't think is a very major advance as we'll get to in a second but we made a vaccine we put it in the stockpile and nothing happened but we did do something really good we put a pandemic influenza preparedness plan involving what you see on this slide we approved the vaccine that we had the first adjuvant that h5n1 is available stockpile we didn't use it then what happened is several years later we had the h7n9 same thing chicken virus jumps from chicken to humans high degree of mortality not efficient from human to human it started in 2013. we were quick we made a vaccine in 2013 we stockpiled it there was a mini outbreak in china in 14 15 16 and then what happened in 17 it mutated a little and the virus and the vaccine that we had for the 2013 strain was not protected by the vaccine that we developed for 2017 so we had to go back again and start all over again what is this telling us this is telling us my conclusion that we need to get a universal influenza vaccine it's going to be incremental it's going to be iterative but i think from a scientific standpoint we will get there well we will if i get this okay so just very brief for about 30 seconds there are a number of ways to get a response that is universal against all viruses one of them not the only one and i want to emphasize is that when you look at the hemoglobin in the head and the stem region it's very clear that the sorry this is not working well can we go back one okay there you go so i'm sure people in the audience are very well aware of that that the part that is protective in the current vaccines is the head of the hemoglobin that's the good news the sobering news is that that's the part that mutates or drifts from season to season or shifts when you get a pandemic to make a vaccine with a response against the conserved regions in the stem is one of the ways that we are pursuing and a variety of others are pursuing to try and get a vaccine response that is against virtually all strains so i want to close on this slide we had just written this for scientific america and it's somewhat of a pessimistic statement but i use it not for pessimism but to spur us on to the goal of what we need to do because a hundred years after the lethal 1918 flu that john just described we are still vulnerable and our public health infrastructure has improved greatly but without a universal vaccine a single virus would result in a world catastrophe thank you [Applause] well thanks very much to john and tony for those presentations that nicely set up our first discussion panel which will focus on what scientists have learned about the 1918 influenza pandemic and how that knowledge is helping in the development of intervention strategies aim to prevent or minimize the emergence of a new pathogen i'm andrew peckos from the molecular microbiology and immunology department at johns hopkins bloomberg school of public health and i'm moderating this first panel i'd like to introduce our panelists to my immediate left is jeffrey taubenberger chief of the viral pathogenesis and evolution section and deputy chief of the laboratory of infectious diseases at the national institutes of allergy and infectious diseases his laboratory sequenced the 1918 influenza virus and he's been investigating influenza disease and pathogenesis and clinical studies and animal models using both seasonal and pandemic influenza viruses recently he's been focusing also on development of universal influenza vaccines uh in the center of our panel is cecile vibod who's an epidemiologist in the division of international epidemiology and population studies of the fogerty international center at the nih her research focuses on the epidemiology and transmission dynamics of influenza and other respiratory viruses and at the end of our panel is david vaughn who leads the influenza vaccine development at gsk vaccines and supports gsk efforts to develop rapid response vaccine platforms that can be used to generate vaccines against influenza or any number of potential human pathogens all right i'm going to take my place here at the counter uh we'll be more than happy to take questions from the group but before we do that i just wanted to start with a few questions to the panelists to introduce you to some of the work that they're doing and have them explain some of the important work that they've been focusing on recently so jeff your lab led the efforts to determine the sequence of the 1918 influenza virus and subsequently you investigate why the virus caused such massive amounts of disease in humans could you tell us a little bit about what your efforts to sequence rescue and characterize that virus uh told us about that specific strain and how it uh maybe mediated some of the incredible pathogenesis and disease that we saw in that during that outbreak sure so the influenza was known as a clinical disease in 1918 but influenza viruses were not yet uh known and recognized the thought at the time was that influenza was caused by a bacterial agent although that idea was already waning in 1918 so unfortunately by the time the pandemic came and went there were no opportunities to isolate the causative agent so 20 years ago my lab we used kind of a molecular archaeology approach to try to sequence the the virus from tiny fragments of the genome of the virus still present in fixed preserved autopsy tissues of people who died unfortunately in the pandemic so the effort to do that was difficult back then especially using the technology available but the reason for doing that was to try to understand some of these questions of where did this virus come from why did it cause so much disease uh and why did did it affect people in a way that's different from other pandemics and a lot of these questions are still in not completely answered but we do have we have learned a lot of information but i think the most important thing that i would share in the couple minutes that we have here is that the features that made the 1918 virus as virulent as it were do not seem to be specific to that pandemic they weren't mutations just in that virus they're features that are shared with other circulating influenza viruses especially those in birds and share some of those behavioral features with some of the pandemic pre-pandemic viruses like h7 that dr fauci alluded to so i think the most important thing is not to just understand 1918 as a historical phenomenon but as an example of what could happen in the future and to use this information to help us gear for how to prepare predict how bird viruses could adapt to humans what mutations would correlate with this kind of high virulence and then ultimately what we could do to prevent it thanks cecile so as an epidemiologist you spent significant effort in studying how pathogens like 1918 influenza spread in the human population could you tell us about what your investigations into this pandemic has taught us about the spread of 1918 influenza in the human population and whether it was really different from what we've seen with other pandemics or in fact what we see with seasonal influenza yeah so i think what made this pandemic really unique was the the severity of it and it's been commended by the previous speaker but we've now looked at uh historical epidemiological data from countries around the world some involved in world war one some not and we see that the severity the the mortality rate was uh unusual and about tenfold higher than when we seen for epidemics surrounding that period so it's not just because people didn't have access to treatment uh it was just something really unique about this train and this population that was hit by the strain the uh other distinguished distinctive feature is the age pattern of death or the the the fraction of the population at highest risk of mortality and we see this very unique peak of mortality at around age 28 years of um of age all around the world um and that's very difficult to explain we think it's a it's a combination of increased severity in young age group and protection in older age group that have seen some of a related strain earlier on in childhood but exactly the mechanisms that are involved are pretty unclear uh and that that's that's very unique to this pandemic um we've also now looked at uh historical pandemics from 1889 to 1918 1957 and 68 2009 and they're all different they're all a little different like their share features they come at odd times they come in in the summer they come in autumn um and they affect more of the younger population but they're all quite different and so that means that for the future we just need to have systems that are in place to have real-time epidemiological information on what this pandemic will look like it will it be more like 1918 or 57 2009 okay david so you know in 1918 there were no pharmaceutical infections available at all to help stem the pandemic we now have both antivirals and vaccines though as tony mentioned their efficacy is not as high as we'd like them to be could you talk a little bit about influenza vaccine history and where you see the field going sort of in the near future to try to improve those tools that we have to deal with the pandemic yeah sure i i think back in 1918 as jeff just pointed out they were already working on vaccines mistakenly working on a vaccine for a bacteria hemophilus influenzae it wasn't until 1931 that it was definitively shown that influenza was caused by a virus 1933 we were able to grow in the laboratory and by 1945 there was the first licensed vaccine in the united states so there have been some improvements since 1945 there have been improvements in the the manufacturing process the 1945 vaccine was a bivalent vaccine for one influenza type a component and one influenza type b component we're now moving to four valent vaccines in 1945 we used ambernated hen eggs to grow the virus now we still use headaches to grow the virus for most of our vaccines but as dr fauci pointed out some companies are moving to cell culture to grow the virus and some are largely bypassing the growth of the virus in a sense in that they're using recombinant technology to express the proteins from the surface of the virus to to make the vaccine we have improved vaccines for older adults by virtue of higher doses or by using adjuvants and i think importantly we're using the vaccines more since 2010 there's been a recommendation for universal use of the of the vaccine for all of us from six months of age and older to get it each year still as dr fauci pointed out our current vaccines need some work there's much more that we can do and they're they're different from other vaccines first of all the disease we're trying to prevent is very prevalent up to 20 percent of us will have an influenza infection during the course of a year secondly the viruses keep changing that's why we need a new vaccine each year and also the efficacy is lower than for other vaccines but on dr fauci's slide that showed the different efficacy estimates uh 2014-2015 the efficacy was just 19 but cdc tells us that year that vaccine prevented 1.6 million cases of influenza despite relatively low use of the vaccine and a low efficacy so increased use particularly in pregnant women we heard from john berry about pregnant women being a particularly susceptible group for severe disease so this this all helps looking forward i think there's at least two ways we're moving to improve things dr fauci covered the idea of universal influenza vaccines if we're successful there then we have a vaccine for any influenza virus past present or future human swine derived avian derived were set and this is the kind of vaccine that who is looking for for developing countries most influenza deaths occur in developing countries and very few vaccinations occur there the second approach is to advance these new rapid response platforms gsk has a few such platforms one of them for example was used to make a vaccine for h7n9 virus it took eight days to make that vaccine from the time the chinese posted the sequence information for the virus until it was injected into cell culture and into mice and in talking to the scientists that did that work they tell us tell me they could have done it four days because there were two uh snail snail mail steps uh in in the process so i mean once we have these sorts of platforms that are working it then becomes quality control release of product and the regulatory steps that are on the critical path so i think there's much to look forward to we just need the time and resources to make it happen so i'll encourage anyone in the audience to ask questions uh if you have a question just raise your hand try to get my attention um and we'll try to acknowledge you and get you uh involved in the discussion while we're waiting for that though um a couple of follow-up questions so maybe we'll start with jeff so um let me put you on the spot do you think influenza is the most likely virus uh to cause next pandemic or are there other microorganisms out there that pose an equal or a greater that threat to the human population well i think the future for influence and pandemics is always a good strong bet for what a pandemic would be there were certainly other viruses that we would think about there are some other respiratory viruses and animals for example the family of viruses that led to sars and mers something that's concerning there are paramyxivors measles like viruses like nepa and hendra that certainly could be concerning um there are arbor viruses of course we've had the the insect-borne viruses like zika that that are concerning but i think that influenza really is always the way to bet of something that's the most concerning you have an enormous diversity of influenza viruses in an incredible number of animal species both birds and mammals in in wild birds wild mammals and in domestic birds and mammals and these viruses mutate like mad and can adapt and move between species in a really unpredictable way and so that is what i think gives us the greatest fear is that despite 100 years of studying the virus we really have no way to accurately predict what strains will emerge how they will adapt from one animal to another uh and how virulent they will be and that that's the huge challenge yeah and i think to add to that i think influenza and its natural vectors is such a very different disease doesn't really cause that much illness these animals can be infected shed virus for long periods of time and go on migration patterns that take them hundreds if not thousands of miles away to be introduced into new reservoirs so i think the diversity out there and how those viruses move around the world is really mind-boggling all right well cecile so you've been doing a lot of work on understanding and modeling how pathogens spread in human populations so this has been particularly fascinating to me as we work as my center is working towards looking at seasonal understanding seasonal influenza more carefully could you speak to how modeling efforts can perhaps inform our public health responses to the next pandemic and sort of help us come up with interventions or ways to at least minimize spread of viruses yeah so i think modeling is it's very useful to run what-if scenarios so if for instance if in the context of a new pandemic you have the option of closing schools when should you should you close school for how long and that might you know gain your time before until new vaccines becomes available and models are very powerful to do that there was also a lot of questions around uh closing borders in the context of epandemics and there all of the models agree that it's no use to school to close borders the the disease is just too fast so the they're very useful for that and and there's more and more effort to embed modeling teams within the policy context and that's been done for 2009 for the ebola outbreak for sales etc um there's also a really active area of modeling around forecasting and there we are really decades ahead of the weather uh forecast but we're really beginning and and putting a lot of effort into that uh from short term uh projections of the outbreak trajectory and how high is the peak going to be every season uh two projection of three to six months ahead of which strain is gonna become dominant uh and so and i think that you know it's gonna progress um and and that's uh quite exciting um and then david so you mentioned um briefly in your in your answer to the first question so gsk has started some initiatives recently uh really aimed at shortening in time to generate new vaccines to emerging pathogens including ones with global pandemic potential there's a relatively new facility opening up nearby here in rockville maryland devoted to those efforts can you maybe tell us a little bit about how that company is sort of approaching this idea of making vaccines to pandemics or potential pandemic organisms you know gsk has been working with the u.s government specifically the biomedical advanced research and development authority or barta since barda's inception in 2006 to develop and to produce preparedness products so in our case that's h5n1 vaccine h7 at nine vaccine uh we have monoclonal antibody for anthrax uh for a treatment for for influenza and also antimicrobial resistance which would be a great topic for another johns hopkins smithsonian symposium barda obviously is working with other companies and i understand that to date they have 21 products in the strategic national stockpile ready for use this is great but it's not really sustainable we need more and more products and the products we have reach the end of their shelf life and need to be replaced so gsk and others are interested to move more to the rapid response platforms gsk was partially motivated by the the 2014 uh epidemic of ebola in west africa we responded to that outbreak with our primary scientific partners at nih and went from the start of a phase one clinical trial to the start of a phase three clinical trial in five months rather than usual five years or even longer but it was too late and so we we need to be able to react faster so again gsk many other groups are working towards these these platforms in in the ideal we would have continue to have or even improve our surveillance we'd identify a pandemic threat it would be sequenced posted to the cloud research laboratories would download it create a vaccine mainly in a computer identify the gene segments that are needed for that load it back up to the cloud and then it would come down to different manufacturing facilities that are using that platform using it every day for a standard vaccine say influenza many parts of the world but then when the pandemic threatens they interrupt their routine manufacture start making pandemic vaccine within weeks and months we have millions or billions of doses that's the ideal i glossed considerably there but i think those are sort of things we can hope to look forward to now i think that's an excellent point to make i know that some of the work that we've been doing using seasonal influenza virus as the model system for trying to set up those kind of real time diagnostic efforts sequencing efforts identify these pathogens spread the word around see what new variants are coming through again seasonal influenza is a great way to model what you would want to do eventually in a pandemic and so i think some of those efforts that you're talking about are probably not that far uh away at least for organisms where we understand it well like influenza we know what the target should be in terms of the the head of the the surface proteins yeah um do we have a question yet um i know a lot of talk about vaccine obviously that's the most important thing but what about progress on antivirals so i'll repeat the question so john asked um that we've been talking a little bit about vaccines but what about progress on antivirals and potentially their role in terms of a tool on uh encountering pandemics do you want to um well uh there are antivirals against influenza but really only in two classes and uh the problem is that influenza viruses can very often develop mutations to make them resistant to to these drugs and so clearly more more classes newer classes of drugs need to be made clearly there has been a lot of research both government-funded research as well as an industry to try to develop new new uh anti-viral targets with flu but uh as far as i know i don't know how close those are to uh to licensure so we still are faced with the that really uh for many strains the antivirals that are available for a physician to prescribe to a patient are often inadequate because the viruses are already resistant nothing to add except the silver lining the um to the 2009 pandemic the 2008 and earlier viruses were beginning to become resistant to also tamavir but the new h1n1 is susceptible yeah i do think that there's an added realization now that developing one antiviral is great having two or three and then administered as a cocktail is probably the ideal situation because again in those situations as you've seen with hiv and with a hepatitis c virus when you have a group of cocktail of antivirals then the likelihood of resistance coming up really is decreased exponentially and so i think that's something to keep an eye on in the future in terms of these developments yes there are few i know there are a few drugs in the pipeline and i know that there's been one new antiviral drug that's been licensed in japan but certainly i don't think that there is as many antivirals in the pipeline of development as there probably could be or should be so yeah right there yep question my questions i'm learning about the state of science regarding the immune response mechanism for protection against influenza viruses uh tony fauci mentioned antibodies against hemagglutinin however i went to a session in the medical center where his scientists showed a better correlation with antibodies to neuromenidase than the hemagglutinin with protection in a human challenge study fairly small study but i found that a really interesting finding it's a just a fairly recent few years ago i'm wondering whether that's been pursued or whether what i was once told by gordon ada that it's all about ctls well you know they're always people that believe in ctls i don't really have a feeling for what how much is known at this point about what kind of immune response would confer better than let's say the maximum 60 percent which would not pass muster uh these days for approval of any vaccine thanks well i'm not sure i can uh well i'm sure i cannot completely answer that question i don't know that much more than what you've stated in in in your question uh there remain a number of unknowns about influenza and the best way to prevent it it's complicated with um having a series of infection that really complicates so the history is important in terms of how you as an individual respond to a vaccine there are different parts of the viruses yes that can be targeted by different means through antibody uh through through cellular responses uh antibodies to neuraminidase will protect if there's enough of them but the the current standard for better birth is hemoglobin antibody hemagglutination antibody which is acknowledged as perhaps meaningful by regulatory authorities would you like to add and i can speak to the fact that i spent the morning at a meeting at the nih campus where universal flu vaccines were being discussed and one of the first things that came up was uh was to set up studies to better understand immune responses to infection and vaccination outside of the typical anti-ha antibodies and to really get a stronger sense of what the natural course of an infection induces in terms of protecting antibody responses and to no longer sort of fit into that let's look for titers against the h a protein as our one gold standards so i do think there's a much broader sort of thinking now that we need to go back think about any antibodies t cell responses and the immune response in total to seasonal influenza and use that as a way to help us inform universal flu vaccine uh studies going forward at that meeting that you're referring to it became very clear that you know because we had so-called had some success with the universe with the seasonal flu vaccines that we were okay and there wasn't a lot of going back to the basics and it's almost a little bit embarrassing that we have hemoglobin hemagglutination inhibition assays we have micro newts and that's what we use as the correlates of protection when in fact we haven't pursued neuraminidase as much as we should we haven't pursued cytolytic t cells as much as we should so if we're going to get to the universal vaccine that i was referring to we're almost in some respects have to gonna go back to the basics and ask fundamental questions of what the true correlates of immunity and what the scope of the correlates of immunity are and it's very interesting that in 2017 we really don't know as much as we probably should and that was the conclusion of that workshop that you were at yeah absolutely all right uh with that i'm going to close this panel i want to thank my my panelists for the wonderful discussion that we had and thank you very much for your attention [Applause] good afternoon everyone my name is paul spiegel and i'm the director of the center for humanitarian health at johns hopkins bloomberg school of public health so we're going to now talk about preparing for the worst and is the world ready to respond and i'm hoping we're going to get obviously beyond the vaccine to to other areas clearly there won't be a universal vaccine anytime soon and there's going to be a lot of people that are sick and how will the health care systems in different countries respond so we have two speakers and i'm going to introduce the first one dr daniel sosen who is the deputy director and chief medical officer of the public health preparedness and response or phpr at the centers for disease control and prevention and in this role he is the lead science advisor and provides scientific representation for preparedness on behalf of behalf of phpr and cdc he serves as a liaison to the cdc programs and external partners and assures strategy and program coordination for phpr in the medical and public health and preparedness response so daniel welcome thank you paul it's a honor to be here and to represent the cdc scientists and staff who for more than 60 years have worked to address this threat of influenza and to improve the ways that public health responds to health crises you have heard how the 1918 influenza pandemic was an unprecedented public health crisis and nearly 100 years later the world has made major advances in the science of influenza prevention and control influenza viruses however as you have heard continue to pose one of the world's greatest infectious disease challenges and the risk of pandemic influenza remains our vulnerabilities in a pandemic relate to the virus the susceptibility of our population and the environmental factors that favor the spread of disease by definition a pandemic virus is one for which the population lacks immunity and is capable of transmission from person to person and to cause severe disease in addition to our naive immune systems in a pandemic significant numbers of people today are more susceptible to severe infectious diseases because of diseases they have or therapies they take that compromise their immune system the exponential growth of our populations around the world expanded international travel and increased proximity to humans to animal reservoirs increase the risk that a pandemic influenza will emerge with extreme effects in the absence of a vaccine that can eliminate influenza pandemics time will be of the essence and early recognition of person-to-person transmission of a pandemic virus can make all the difference to an effective response this is why ongoing surveillance networks around the world are so important many pathogens can cause similar symptoms to influenza so diagnostic tests that are rapid accurate and feasible for widespread use are critical to rapid understanding of the pandemic conditions and for specific treatment plans non-pharmaceutical interventions such as personal protective equipment respiratory etiquette hand hygiene social distancing can prevent disease transmission even when a specific medical intervention is not available vaccines of course will be an important part of a response even today medical treatments for influenza and secondary infections can save lives if available in the right hands at the right time an effective pandemic response also requires effective communication with the public [Music] and with our health responders so that there is confidence in our recommendations and motivation to follow them in 1918 we were sorely lacking in these capabilities there was no national system of surveillance much less a global surveillance effort viruses as you've heard have not been discovered and there were no laboratory tests there was limited personal protective equipment there was no vaccine there were no antibiotics to treat secondary bacterial infections and no antiviral drugs there was no mechanical ventilation or intensive care units we heard earlier about communication challenges in 1918 which are surely different today with respect to our understanding of effective communication and the variety of tools to share information so what does cdc do to lessen the threat of influenza cdc works with domestic and global public health partners to monitor both human and animal influenza viruses to know what and where viruses are spreading and what kind of illness they're causing cdc supports more than 50 countries to build surveillance and laboratory capacity to find emerging and influenza threats and to respond to them cdc studies more than 6 000 human and animal influenza viruses in the laboratory each year to better understand the characteristics of these viruses cdc develops and distributes tests and supplies materials to laboratories around the world so they can detect and characterize influenza viruses cdc works with state and local government the world health organization and partner countries and pandemic planning efforts cdc evaluates the effectiveness of pharmaceutical and non-pharmaceutical interventions and updates recommendations on these cdc helps global and domestic experts choose which viruses to include in seasonal vaccines and guides prioritization of pandemic vaccine development cdc develops candidate vaccine viruses used by manufacturers to make flu vaccines and cdc monitors influenza vaccine distribution cdc also manages the us strategic national stockpile and supports public health departments across the country to ensure that critical medical supplies are available when and where they are needed cdc also informs healthcare providers and the public about influenza prevention and control measures and cdc works at home and abroad to train staff and establish emergency operation centers that improve the efficiency and interconnectedness of the public health response each emergence of a new virus such as the h7n9 virus in china essentially initiates a new pandemic response as our scientists and partners around the world work to characterize the virus develop and distribute new diagnostic tests and investigate transmission patterns and disease severity okay since the 2009 h1n1 pandemic cdc has reviewed and updated tools for pandemic preparedness including the pandemic influenza preparedness and response framework which can be used as a pandemic planning guide the influenza risk assessment tool which assesses potential pandemic risk posed by influenza viruses that currently currently circulate in animals but not in humans a strain is scored on 10 factors for the likelihood that it will change to infect people and for the potential severity if it does the pandemic severity assessment framework guides public health officials to anticipate the severity of a pandemic once a novel virus is identified and is found to be spreading person to person in a sustained manner available measures of clinical severity and transmission are used to guide decisions about which actions public health authorities recommend and community mitigation guidelines provide the latest scientific evidence available on the use of non-pharmaceutical interventions to slow the transmission of a pandemic virus so what progress have we made due to global investments in pandemic preparedness there is a global influenza surveillance and response system with mechanisms to quickly share laboratory and surveillance information laboratory capacity has shown exponential improvement in recent years we can now sequence a full influenza virus genome in a single day and there are greatly improved tests to detect novel influenza viruses and these are shared with more than 140 labs around the world there is personal protective equipment to prevent transmission particularly in health care settings there are vaccines available and selected vaccines are stockpiled for pandemic use vaccine manufacturing capacity has expanded in the past decade including development of new vaccine technologies there are three recommended antiviral drugs to treat infection and there are many antibiotics to treat secondary bacterial infections there are mechanical ventilators and intensive care units to care for patients in respiratory failure there's a one health initiative to increase interaction and cooperation between human and animal health authorities and we are now experienced in presenting pandemic information through a variety of media channels to support life-saving actions while tremendous advances have been made there are still much to be done to improve pandemic preparedness only about one-third of the 196 countries that signed on to the international health regulations in 2005 currently report having the ability to assess detect and respond to public health emergencies to improve we need to fill the surveillance gaps there are geographic gaps in global surveillance including parts of africa and the southern hemisphere we need better surveillance of influenza viruses circulating and birds and pigs and the ability to share physical virus specimens needs to be improved better diagnostics are needed including over-the-counter and point-of-care tests vaccines as you've heard must be more effective more broadly immunogenic and available more quickly global infrastructure to produce and distribute vaccines needs to be improved better personal protective equipment is needed and needed in large supplies better less costly influenza treatments are needed and there are large parts of the world that don't have the medical infrastructure and equipment to treat severely ill patients and they must be supported and even in this country we need creative approaches to manage the demand on health care so in conclusion much progress has been made but we remain vulnerable to an extreme pandemic influenza viruses are constantly changing requiring sustained efforts to anticipate detect and respond the number of novel viruses detected is increasing requiring ongoing laboratory and epidemiology work and a weak link in global preparedness is a threat to all countries so achieving global health security must remain a priority to tr to lessen the threat of pandemics thank you [Applause] okay thank you dan the next speaker is dr cyril ugarte from the pat pajo who the pan american health organization world health organization he began his career in peru working in general practice in the highlands of cusco and in 1987 he was appointed as regional director and late and later deputy director general of the national institute of occupational health he served as the director general of the national defense and disaster relief office in the ministry of health in peru dr ugarte joined paho as a short-term consultant in honduras where he also serves as united nations disaster task force coordinator for this country he presently serves as the regional advisor for emergency preparedness and disaster relief at paho here in washington dc cyril [Applause] hello how are you doing very good i'm pleased to be here because i engaged very well with a previous presentation on how is the world prepared for a for the next pandemic and the presentation that i will give you is regarding the international response to a potential pandemic so one of the conclusions of the international response is that it should be to improve the coordination of international response they have to be complementary to the national capacity so each nation who is able to early detect and share that information and begin the response meanwhile the international support is coming is crucial for that so how the world is performing on that it has it is related to the international health regulations capacity but it was approved in in 2005 and began into force in 2007 but you see that the countries are not there yet most of them have requested an extension to reach those capacities and the last extension was provided in 2014 so in the americas for example only 13 of the 35 countries have reached that level on a self-assessment aspect so they say that they are there but how are they performing in terms of of those capacities you see here how the countries have been performing one year to another and you see for example the first year is 2011 and then we go to 2016. in each of these areas and we see that the capacities are increasing in legislation coordination and national focal points etc so notice events are coming above 90 now and the you see that the chemical uh capacity and radiological emergencies are also increasing and the first for the first time more than 60 percent of the countries are now able to reach those capacities and then we see that the status of those capacities also in terms of which are the regions of the regions in the americas that are better prepared we see that the caribbean region is still lagging a lot on that so 12 out of 15 80 of the countries have reported that we see that in certain capacities like radiation emergencies or chemical events are very low but we see also that central and south america are very high in terms of most of the infectious diseases related capacities and how are they doing in terms of their contact with paho and who we test those contacts and you see across among the years that the contacts in the connectivity test by email for example is uh above 90 and the first 24 hours of that and the connectivity test by telephone in the next hour of that is more than 90 percent so we do have the connectivity with most of the member states and they are reporting to to paco and how are we doing on the points of entry we're moving from the certified ports and airports two rounds of consultation with uh state parties state parties are the ones who signed the international health regulations and we have a draft procedures the final report is not there yet but we have you see here 64 parts in 31 of 35 states are certified at 78 airports 22 grand crossings and then we are moving around 500 authorized ports in 27 state parties in the region so we are moving towards the points of entry we are not there yet we are moving towards that and most of the countries now are eager to do that in a couple of weeks i'm going to to chile to do the third exercise in a row in terms of points of entry and they are not only in terms of airports and ports but also in terms of those type of ports that do have entries through tourism for example like easter islands and others and this is uh these are the events that are being reported by uh who is reporting on on that you see the national focal points is the yellow dark yellow or maybe orange and you see more or less 40 percent of the source in 2017 are coming from the national so it's official and it's official also through the government but you see that there is a large amount of events that are no report not reported by the governments so how can we say that they do have an outbreak if the government or the national focal point is not sharing that information so we are seeing that in terms of also of what is the type of of events that are reported and most of them are infectious but still there are some issues on food safety animal health and all this and these are the differences between all the years how we are we're going through this is this report that was being officially up to 13th of july this year and how is this system or reporting going in other regions we see here for example that the afro ambro is dark dark blue euro ambrose yarrow and wipro we see the huge difference in the reporting in the americas why you know why because we work with the governments with the countries and we're convincing we're convincing them along with several partners in religion that they do have to report and they are reporting so overwhelmingly in 2016 for example most of the reports come from the americas and it is not uh also in in comparison with all the other regions we see that the amro region and then afro euro emerald sierra and southeast asia and west pacific region so clearly the americas is overwhelmingly the best let's say prepared region in terms of alerting on the events is that uh is the capacity in place well let's see how what's happening in surveillance you see all the countries that are with surveillance and countries without surveillance so we have few countries that are without surveillance well the countries that are not reporting actively okay so it is you know it is as we saw previously this the official reporting and unofficial reporting and how are we doing in terms of reporting on biological data and we see here that 75 or greater reporting in several countries but the the light blue is more than between 50 and 74 and there are other countries still important countries that are reporting less than that biological data so what are the the differences for example we're following also tracking how many samples are being tested or sent to cdc for example the who collaborating center for for a pandemic influenza so in 2014 we had up to six ship shipments two or more shipments and you see in 2016. so the tendency is going forward we are doing much more reporting on that and this is the number of samples that are tested by the national influenza center so you see the number of tests are in the tens of thousands seven nearly 70 000 in 2016. yes we are moving on that but is this uh enough we do have tools who surveillance tools we do have power surveillance tools that are also being applied on top of of the whole tools and we have the capacity to deal with pandemics but once the pandemic influenza comes we will most probably know you and we through the media so it will be extremely difficult to see sorry to to control the pandemic once it begins it happened in in in the case of mexico city we had huge challenges to control that and the biggest poor problem will be in security and economic impact rather than health impact so it is a huge political thing so what happened after the 2009 pandemic influenza there were united nations were important partners gold missions coordinated by power were useful but also u.n agencies not only reduced reduced their participation but they became victims we have to provide support to the u.n agencies in in the affected country and some gourd members the global outbreak and response network uh maintain their institutional objectives rather than the overall control of the epidemic so we do have issues there and we still we have an interagency work we work a lot with all those those partners and the global outbreak but the problem is that each of those institutions have their own mandates their own interests and then when we come the biggest challenge is the coordination why because everybody wants to coordinate but nobody wants to be coordinated so it's a it's a difficult task to do that so we need to politically endorse the documents ensure coordination among established organizations but also establish operational coordination procedures we are working on that 24 countries send their delegates this week to pajo to coordinate in this alert and response to pandemic influenza so we need also with those partners time consuming crisis meetings without operational impact yes we have to unproductive duplication competition we do have that we see that even inside the countries and in this emphasis on visibility rather than excellence we want to be in the photo and convenience rather than effectiveness and ambitions not supported by available resources so we dream a lot we don't sleep enough and the final goal to enhance national international capacity to respond to strengthening and completing the local response capacity and improving the quality of external assistance thank you so much [Applause] um okay thank you very much uh cyril very very enlightening um we will be taking some questions i will start off a bit and it's hard to see with the lights here but um i hope that you from the audience will um will have some questions too to our colleagues dan i wanted to start with you and you've mentioned many of the key responses that would occur beyond just a when when an epidemic occurs beyond just the vaccinations one question i had is if you could compare what happened what did happen or did not happen in 1918 compared to what you believe would happen now and from everything from ventilation from the antibiotics but also talk about the capacity even here within the united states to be able to respond yeah so i i had a list of a variety of uh of capabilities that we have today that we didn't have in 1918 um and a lot depends on how severe the virus is and how transmissible the virus is obviously there are limits to what even in the united states our healthcare capacity is and our ability to provide antiviral medications ventilator respiratory support all those have their limits so i don't have direct numbers and perhaps dr barry you do on modeling today's therapeutic interventions and public health interventions um on the population then but it's clear um even with our more modern pandemics in the in the past few decades that we have much greater capacity to respond and we would expect to respond more effectively to a 1918 like virus but we could have one more transmissible and more severe so that's why all this work across the spectrum including universal vaccine or better vaccines are so critical thank you and to cyril one question i have is even within the americas we see the the disparity amongst many countries in america can you talk a little bit about the differences that you may see let's say in in some of the more responsive countries you don't have to name them and the differences that may occur in terms of both preparedness but in particular in response and maybe you can use mexico as one example but what the question really is to try to talk try to get at the differences and the capabilities of various countries even within the americas never mind in africa or other areas that i'm more familiar with the most important aspect of the country's capacity to alert and to share information is that the national focal point of ihr or the national offices health officers that have to report that they are empowered to do that and most of the cases they have to filter the sharing of the information through the political channels and you know immediately when it reaches that level it is the economic impact that is facing so even in pandemic influence in 2009 we saw that many countries that did have the capacity to uh let's say detect they were not reporting because the economic impact would be huge and that's some of the aspects that do happen in the americas most of them are able to detect not necessarily the specifics of it but they can report and in some countries we do have that delay not necessarily only the countries that we saw in the picture they did not do not have a surveillance capacity but most of them they lag on that mexico showed by example that they were able to report almost immediately when they discovered that there was something new different and they declare emergency the response happened almost immediately they welcomed many partners uh i was there coordinating who's response for the first two months and we saw that the capacity was there but some of the officers that were in charge of pandemic influenza were moved out of their offices a couple of weeks ago before that because of the reorganization and because of political reasons they were not brought into that it happened also in 2008 in the yellow fever outbreak in paraguay i had to convince the minister of health to appoint the person who knew more about yellow fever that was at the opposition so those are the political and economic aspects are the ones who will make the difference in my opinion it is not and security and safety and not necessarily the health aspects very interesting opening up for questions please raise your hand yes we have one at the back please they're coming to you right now and please introduce yourself hi i'm terry monmoney from smithsonian magazine um a question for dr sosen please and that would be if you could comment on the impact if any of the current white house administration on the ability of the cdc to respond to future or near future influenza pandemic sure um pretty much everything i talked about uh the type of work we're doing um continues to be supported um there are many potential changes coming the future that i can't uh predict myself much less a pandemic um so i feel that the kind of work the areas of work that we are working on continue today as they did um two three four years ago with the same sense of urgency that we have that that this is really important work and by hook or by crook we're going to figure out how to keep doing it so i i can't speak to political changes which may come in future budgets i just hope and pray that we get the resources we need to continue to do the work we do and if those resources change we'll figure out how to adjust and do the best we can with resources we do have are there any other questions from the audience before john do you have yeah please the two questions i i'll name one of the countries that was slow to report and that was brazil i know for a fact that there was a back channel feeding information from epidemiologists in brazil to the white house during 2009 and the white house was telling the source that they were getting information two weeks faster than from the government uh but my question actually and i want to applaud you for you certainly did tell the truth really appreciate your presentation my question is it seemed to me that mexico also told the truth and got punished for it internationally and i'm wondering if uh from your perspective things have improved at all thank you for those two questions very important questions uh brazil though after that problem requested paajo to do an external evaluation of the h1n1 2009 response and we found that brazil recognized community transmission 12 weeks later than it actually happened and it caused brazil the southern states of brazil to be the high to have the highest lethality of h1n1 2009 in the world so they modified their their their procedures and up to the last three or four years they improved a lot on those things okay yes mexico was punished but mexico was punished paraguay was punished haiti was punished peru my country was punished after cholera outbreak that we reported on time it was the second day and we were punished what was the punishment punishment punishment is economic punishment pandemic influence in mexico irrational exactly because of the fear fear causes all these decisions to be made in a fearless i mean in extremely fear related decisions closing borders stopping all all the importations of products that are not related with that stopping tourism and entertainment et cetera just as a relation mexico spend more or less 180 million dollars to respond on the health response to pandemic influenza the overall cost just on the first wave of 2009 pandemic influence in mexico was 9 billion you make the math and who was sharing who has coordinated the response to h1n1 the ministry of health it's nonsense so the preparedness it is multi-sexual preparedness it is the security sector the tourism sector the transportation entertainment other sectors that have to be there in order to respond we had that on paper but in reality the national emergency management officer in mexico sorry well i will say that because i was there was not allowed to enter to the coronation meetings i had to negotiate with the health officers to let her get in and that was the female like director the chief of fema like so we see those type of things and then we see where the fear is coming from so the thing is yes most of the countries are prepared but not at the level of political willingness to control the economic impact of this ebola for example you see the health impact and you see the economic impact is overwhelmingly large so we are not touching the proper buttons there in terms of preparedness excellent thank you i i will have one more question but i want to make sure that uh because we have a couple more minutes left any other questions from the audience okay my my one point is exactly what what cyril what you were saying is that is the health response is a huge but one component of a much broader and we've seen this consistently you mentioned ebola we've seen what's happened in polio is the political response and the economic response are are essential and one but the other thing and john barry mentioned this is the community response and although i know it's extremely different but what we saw in ebola we learned that the community response was probably just as or more important than others and dan you would mention that you have you have a community mitigation guidelines the the mmwr for cdc so i'd like briefly we have a two minutes left but starting with dan and then cyril to talk a little bit about the community either both your experiences but also how you think you can address the community to make sure that they are supported in a in a decent response as opposed to just fear well i saw jim blumenstock here from the association of state and territorial health officers cdc works domestically to provide assistance support guidance to the health officials who have the authority to do this work at the state and community level so these community mitigation guidance isn't the breadth of work that happens at a community level these are the non-pharmaceutical interventions that could delay or forestall certain aspects of the pandemic prevent some disease and spread it out over time to lessen the burden on the health care system in the public health system and we have more data because of the 2009 pandemic so there are is more confidence in these measures and a little bit more information as to when they might be most effectively applied to give guidance to those state and local health officials to take action at an appropriate time um i i do believe very strongly in the message that john berry gave us about uh communication and officials communicating we know a lot more about effective communication in health crisis and uh working as best we can to get political leadership to follow those principles will will be here here and lastly i just wanted to respond to the the point that that the health leadership kept out the rest of the response emergency response leadership in the united states we've been working for the past 15 years to get public health a seat at the table um and it's been an important uh and and and challenging journey um to get there i don't see us ever having the lead um in uh in a national response of this nature but but having a voice and letting scientists be at the table with the political leadership has been very important community participation is crucial but the first thing to have the community participation is their trust in the authorities that are telling them what to do and if they don't trust the health officers or the government in an everyday basis why will they trust them in a crisis so it is a very complicated aspect so we have to build that and yes telling the truth is important but telling the truth all the time not just in times of emergencies you know so and those things happen and also if we are able to convince persons from different perspectives telling the same message and during the cholera outbreak in peru we managed to have one of the lowest lethality of color because we convinced the academia but also the the college of surgeons and the media to help us and we began first with 12 or 24 or 24 between 12 and 24 recommendations and then we came up to three recommendations knowing that so doing risk communication will only work if we do crisis communications so telling the people that we are taking care of them but telling the truth not expanding that not diminishing the risk and that will will build the community participation the communities are not able to respond to all emergencies that's a dream that's that will not happen that dream that may may transform into a nightmare you know so it is a it is the right crisis communication and also the trust in the governments that will make the difference thank you so you want authorities to tell the truth all the time utopia that's a great you are still a dreamer and you work with powho that's wonderful i want to thank cyril and dan very much for their very insightful comments today and let's grab hello i am tom inglesby and i am the director of the center for health security at the johns hopkins bloomberg school of public health and our center's mission is to study epidemic risks and to work to try to diminish the consequences of those risks and it is my pleasure to introduce our next speaker dr sally phillips who is the deputy assistant secretary for policy at the office of the assistant secretary for preparedness and response at hhs sally is responsible for policy development strategy and overall coordination of activities that we're talking about today within that office which is one of the most important offices of government alongside cdc nih fda and others in the federal family working on these issues before sally was in this role she worked at the department of homeland security at the agency for health quality and research and on the hill prior to that uh for a number of years i think it's fair to say that if you're working on pandemic preparedness in washington you know sally and sally knows you so we're very fortunate to have you sally come on [Applause] he can all relax there are no power points so you have a few moments of rest dr bob cadillac is our assistant secretary for preparedness and response and was um hoping to be here with you today but he sends his regrets and i'm delighted that he's not here because i am so but i did want to share a little bit of his view on his ideas since many of you haven't had an opportunity yet to interact with dr cadlick or to hear some of vasper's perspectives and possible changes as we move into a new era in this ver ever changing threat landscape dr cadlick's view of preparedness and pandemic preparedness particularly articulates a position where strategy implementation and the evaluation of progress should be based on the threat landscape rather than a program base and under doctor catholic's leadership when we say threats we mean any threat to the health of the american people these threats may be naturally occurring infectious diseases extreme weather accidental recent accidents we've had in our some of our bio safety incidents and labs or deliberate cbrn cyber attacks on the health care system we recognize that in order to mount an effective response the systems we put in place must be able to adapt to whatever type threats that we're faced with to achieve this we develop nimble public health and health care response strategies that focus and hone in on federal resources and support to state local tribal territorial stakeholders as they identify risks and develop capabilities to address the known and the emerging threats dr cadlick aims to do this through four key priority areas first to provide strong leadership including clear policy direction improved threat and situation awareness and secure adequate resources second to seek the creation of a national disaster health care system by better leveraging and augmenting existing programs such as the hospital preparedness program and the national disaster medical system and dms to create a more coherent comprehensive and capable system integrated into daily care delivery third support the sustainment of robust and reliable public health security capabilities including an improved ability to detect and diagnose infectious diseases and other threats as well as the capability to rapidly dispense medical countermeasures in an emergency and fourth to cultivate an innovative medical countermeasures enterprise by capitalizing on advanced biotechnology and science to develop and maintain a robust stockpile of safe and efficacious vaccines medicines and supplies to respond to emerging disease outbreaks pandemics and chemical biological nuclear and radiologic incident and attacks our mission within asper is to save lives protect america from 21st century health security risks threats in june of this year hhs released an update on the pandemic influenza plan the update was developed through a collaborative process with our partners at hhs cdc fda and nih and expands on concepts outlined in the original 2000 fine plan acknowledge the advances made in science and research and other outlines for continued improvement across key domains and you heard that some of that from dan these areas cross surveillance epidemiology laboratory activities community mitigation measures development of medical countermeasures health care systems and infrastructure preparedness domestic and international response policy in 2017 the update highlights progress since the original plan we've made progress in addressing many needs for pandemic preparedness and response and we're better prepared now than we were in 2005. specifically hhs supported state and local partners in development of their own pandemic influenza plans we've worked with partners to expand the definition of who can vaccinate and in what settings for example 10 years ago you had to go to the doctor or to the hospital to be vaccinated for seasonal flu now you can go to your local pharmacy with respect to system enhancements for vaccines treatments and diagnostics to allow for wider distribution of medical countermeasures the aspers biomedical advanced research development authority barta has been working with partners with hhs dod and other federal agencies and has developed and licensed new cell-based recombinant adjuvant vaccines for seasonal and pandemic influenza it's important to note that barda was created to bridge the valley of death with flexible nimble authorities and multi-year funding to promote innovation and facilitate partnerships with cutting edge expertise over the last decade barda has successfully built in-house technical expertise developed 34 fda licensed products 14 products to the strategic national stockpile under project bioshield are ready for emergency use and significantly expanded pandemic influenza domestic vaccine production capability we increased in the bulk domestic vaccine production capacity from 60 million to 600 million over the last decade thanks to significant united states investments in both egg and cell-based influenza vaccine manufacturing infrastructure as well as antigen sparing adjuvants barda has also accelerated the antibacterial product development with respect to the healthcare system's preparedness the aspers hospital preparedness program in the past year released new guidance documents for its awareness and healthcare coalitions the funding opportunity announcements for 2017 through 22 cooperative agreements was released and outlines program requirements for both hpp and in jointly with the cdc's public health emergency preparedness program hpp's health care preparedness response capabilities represent the ideal state of readiness for the nation's health care system these streamlined capabilities build and improve upon hpp's capabilities particularly incorporating a greater focus on health care these new capabilities cement the critical role of health care coalitions during pandemics and other emergencies focusing on operational health care coalitions for effective response for example to achieve the refined medical surge capability healthcare organizations must be able to deliver timely and efficient care to patients when demand for health care systems exceeds available supply the medical surge capability also requires healthcare organizations and coalitions to take specific steps towards enhancing their preparedness for infectious disease outbreaks that may overwhelm the health care system the capabilities also emphasize the importance of planning for crisis standards of care which may play an important role during pandemics when demand for health care exceeds availability when the healthcare system planning is incredibly difficult it's critical to have an inclusive planning process including the health departments hospitals ems clinicians legal and experts just to name a few the national ebola training education centers were created after and after action during the 2017-2014 ebola pandemic aspirin cdc partnered together to establish the national ebola training and education center netec through a joint cooperative agreement that began in 2015 and will end in 2020. the netec is a consortium of the three healthcare facilities that safely and successfully treated a confirmed patient with ebola in the u.s during the 2014 outbreak knee tech mission is to increase the competency of the health care and public health workforce to improve the capability of health care facilities to deliver safe efficient and effective care to patients with ebola and other special pathogens between 2015 and 2017 the nica has developed metrics to measure facility and healthcare worker readiness to care for patients with highly infectious diseases they've trained over three thousand participants in special pathogens readiness and completed over thirty peer assessment site and readiness assessments created a suite of educational resources related to exercise exercises and training for the care of patients of ebola and other special pathogens and established a phone line for federal partners to provide emergency consultation with health care facilities requiring assistance with potential cases of infectious disease and lastly they launched the specific pathogens research network in 2016 to create a national platform for the study of special pathogens 2018 marks the 100 year anniversary of the 1918 influenza pandemic there's an increasing milestone and it's important to recognize and celebrate the significant advancements made in preparedness since that time however key gaps and challenges remain in our preparedness we will continue to develop new and better ways to prepare for respond to and recover from not only pandemic influenza outbreaks but also outbreaks of other emerging infectious diseases and release of highly infectious agents rather accidental or intentional thank you [Applause] great so he's on perfect just have time for i think a couple of questions and uh you talked a little bit about the healthcare program that asper is managing in the federal government could you say a little more about what the government what it what do we all learn in the experience of ebola when we try to take care of highly contagious patients because that's so relevant for the pandemic influenza preparedness i think in some ways it caught us a little off guard we deal with infectious patients every day in hospitals we have infection control nurses we have systems in place to monitor and track infectious diseases within our hospital situations but bringing something forward as unique as this put a challenge on to how is it transferable and what are the other levels of care related to infectious diseases when we don't really know the cause or it's something that we've never dealt with has really put really put a challenge and sort of a wake-up call to go back and revisit when i was a nurse in the hospitals many years ago we had continuous education classes almost on a weekly basis of something or another a lot of those programs had not been in place in hospitals where we were bringing people back together and reintegrating their knowledge base on certain things and i think what ebola did was to give us a little wake-up call that you know we needed to put put put an emphasis on infectious disease and um not just the things we were used to doing and the most commonly occurring the challenges of some of the donning and doffing and special pathogens and there's there was fear involved in the health care system to the providers trying to get ready and to do the right job it really placed a new challenge and a new lens i think on education and training for our staff great and for people who are unfamiliar with how hospitals are involved in preparedness programs could you explain is it a grant program a requirement how does how does the federal government interact with hospitals in america yeah the healthcare coalition program is the hvp funding that comes from asper that informs and enhances the ability of communities to build coalitions amongst healthcare provider communities um and it's original inception it was a hospital preparedness program and over the years we recognized that preparedness is a community-based focus so we need to draw in all the other members within that community emergency medical services long-term care the primary care networks trying to build a coalition of people in that community or in that region that when an incident like a pandemic comes up or another disease you're gonna have to pull in resources and share resources to meet the healthcare needs of that community so the hpp program in fact rolls out to those healthcare coalitions around the country is is that a is that related to the program that sends emergency healthcare workers to hurricanes and to responses is a disaster how do they relate that's a national disaster medical system that's a separate program that is short-term employees they are physicians nurses health care administrators pharmacists from all over the country who volunteer to be temporary employees with us during an event the national disaster medical system we have teams that are activated during a response and they go in for a two-week period of time provide care when they are needed and they do a rotating system the last three hurricanes challenged our ability many of those to all the teams i believe were activated and many of them did another tour if not more in order to meet the healthcare needs in a community they really come in to supplement and support the medical care needs um during those events maybe one last question on medical countermeasure development so we heard a little bit in from the first or a lot from the first panel about the work on influenza vaccine development what's the role of barda within your office in terms of how does it relate to the nih process fda cdc barta is the later term entry into this process they take the work of nih and fda and roll that into advanced research development bringing it to final manufacturing so in that last stage they are a partner along the chain from the end end-to-end strategy in medical countermeasure development in partnership so nih sort of starts the process fda does the regulatory part as we try to get them out into the field and then barda takes it up towards the end and that's not a fair justice to where to trust me but well summarize all right well thank you very much sally i really appreciate it let me invite uh the next panel up to the stage thanks so much excellent so i'm very happy to be moderating this panel on strengthening pandemic preparedness in the front lines i'm here with two superb and very widely respected people to talk about these issues for a little bit on my immediate right is marissa raphael who's the deputy commissioner of the office of emergency preparedness and response at the new york city department of health and hygiene she directs the programs operations administrations strategy for the department's emergency preparedness and response work including oversight for public health emergencies related to the health care system and so mrsa is basically responsible for directing pandemic preparedness for new york city in a summary you can tell me if i'm wrong about that but i think that's a good summary to her right is jamie joseph who is the program officer for biosecurity and pandemic preparedness at the open philanthropy project which is an organization dedicated to making grants in this area and many other important areas she's been leading the biosecurity program for the past 18 months where she's been giving grants around the country and the world to diminish pandemic risks and those from other biological threats and prior to her work at open philanthropy she worked at the department of defense and on the global health security agenda at hhs and with the federation of american scientists among other institutions so i'm going to turn to them in a moment with questions but i'm just going to start with a couple of observations the first just to kind of place the pandemic in a local context is just worth looking back at what happened during 1918 in baltimore where our institution is in 1918 there were six hundred thousand residents of baltimore over the course of one month one in four people became ill with influenza two percent of those people died so in one month more than three thousand people in baltimore died from influenza every sector of the workforce in the city was affected communications was impaired trade with other parts of the country was impaired ethnic groups were scapegoated it was devastating to the health care system overall it was a major major event in the life of baltimore so it's tempting to think that today we would be able to escape that but a model from our center in terms of particulars concluded that a pandemic of the scale of 1918 at its peak would require seven times the number of ventilators than we have on hand in terms of the number who would require that kind of medical care and then my last point before we turn to questions is that no matter how you slice it how the people on the front lines respond to a pandemic will have enormous consequences we have to talk about the global issues we have to talk about the federal issues that are so important but we also have to focus on the state and local systems the doctors and nurses the public health agencies that are doing so much of the work to prepare our country so uh with that we have someone who's really been focusing so much on that uh to start our discussion and what i want to ask marissa about i want to maybe you could take us through the pandemic efforts at a high level in new york city just explain how they work how's the city preparing overall for pandemic flu sure so i think it's worth starting by saying you know based on we conducted in the recent past uh health and public health hazard vulnerability analysis and pandemic flu ranked number two only after coastal storm thus was sort of on the heels of sandy but i think this is to say that this is a threat that we take very seriously and we feel certainty that this is something that we're gonna see in our lifetime um i think the point was made earlier about the health department or sort of health taking the lead in pandemic flu planning and that's definitely the case in new york city but it is a collaborative effort you know we as the health department can't respond alone this is a city-wide response and so while we take the lead and drive the planning it's very much in partnership with the fire department the police department emergency management as well as the health care system which is so critical we do plan for both mild to moderate as well as to a severe uh scenario and our goal is to really limit impact and spread so we don't assume that you know we're going to prevent it from entering into new york city it's really about how do we limit the spread you know we break it down into seven key objectives everything from surveillance and epi to vaccine management anti-viral distribution health care support non-pharmaceutical interventions mental health and last but certainly not least communication and outreach i think the other key point i wanted to make is that it's very much a living document so really learning from previous events which again was mentioned earlier you know we started writing the initial plan with federal funding in 2006 but a lot has changed since then we learned a lot from h1n1 but we also have learned a lot from ebola from legionnaires from zika all of these responses really inform a lot of the all hazards capabilities that go into a pan-flu response and we also did an exercise in 2013 that also informed our planning and the final point i wanted to make on this question is just that this is very much dependent on cdc public health emergency preparedness funding as well as asper hpp funding again without this funding we wouldn't have the dedicated resources to to um focus on this type of planning great we turn to jamie now you've spent the last 18 months or so and time before that kind of wandering the country and the world looking for the most impactful ways to prepare for pandemics and other biological risks and so you've talked to people in universities laboratories governments what's surprised you the most what have you learned about that and and and what do you think maybe is the least appreciated about the potential for impact for pandemics sure thank you tom um so not much surprises me in this space uh except except for one thing um and that is that we find ourselves in a cycle of panic and neglect and that is not a phrase that i've developed it's borrowed from other colleagues in the field and what that means is that while there is acute and acute response um in in reaction to pandemics like h1n1 or ebola and that it's at the highest level of leadership attention at that time as soon as the acute phase of the emergency passes it doesn't continue to be a sustained priority at the highest levels of leadership and so i think the thing that's surprising to me is how quickly that happened after uh the acute phase of the ebola crisis uh phased away um you know we've seen a number of warning shots in recent years we saw the 2009 h1n1 outbreak that infected more than 25 percent of the global population we saw the 2014 ebola outbreak and now we're dealing with an uh zika outbreak and i would consider all of these warning shots and i think it's really incumbent upon us at the federal level in the us government and other governments to to maintain sustained attention but when i talked to my colleagues in the field a number of them say that we were in the neglect stage of the panic and neglect cycle it's surprising to me that we're finding ourselves in this place given that this is not the first time that we've gone around this merry-go-round we were also very focused on the biological threat after the 2001 anthrax attacks and there was a lot of high-level attention in the u.s government to this risk and a lot of funding but as time went by attention diminished uh pri diminished as a priority and funding diminished and now we're repeating that and so i find that to be very surprising and i'm hoping that we can learn from these warning shots in terms of what's least appreciated about impact certainly it's productive to have a lot of conversations about the direct impact of the the disease on public health um but it's a it's also important to remember that they're going to be secondary and tertiary and higher order effects um especially if you're dealing with an extreme pandemic that's larger than what we've seen in recent years it's going to strain our hospital systems it might strain other systems like food and water supply electric power it could lead potentially to conflict depending on the situation and i um i think that it would be useful to draw lessons from the past about how these secondary effects play out what are the nodes the critical vulnerabilities and how can we really be resilient um not only to the disease itself but also from a critical critical infrastructure perspective great marijuana let me ask you just a couple of questions together and you can just bundle them um so what would you consider at this point new york city's greatest challenges and pandemic preparedness what's the hardest thing that the city has to deal with and as part of that i don't know if this is one of them but in terms of plans to get medicines to people should we be fortunate enough to have medicines available in a pandemic how will that work and what do you think are the things that are most likely to go wrong and how do you deal with that sure so i think for um us as new york city first and foremost it's the um population size and density that really comes into play i think also being a port of entry so we anticipate that this is something that will hit us early and that um it will have dramatic spread um and you know relatedly you know as one of the major strategies being um social distancing i think that's going to be very challenging you know especially with the public that's so dependent on mass transit i've seen statistics that uh five million people ride the subway every day um i think the other big challenge is really um and just getting back to the resource issue again i mentioned uh fepen hpp you know i don't know if people are aware but um the fap award has been cut dramatically since its peak in 2005. it's been at least for new york city a 37 percent cut and then on the hpp side a 38 cut since its peak in 2004 and so i think this is very concerning to us because this is the funding that we really depend on to really get the planning done but as someone mentions it's not just about planning it's training it's exercises and also as i mentioned it's not the health department alone it's really bringing together our colleagues and a lot of what we invest in is really in personnel to make sure that this happens and so when the funding gets cut that's what gets jeopardized and that's very concerning to us and then finally in terms of a general challenge something that we've been looking a lot at as an agency have been issues of equity and health disparities something that you see day to day but certainly that you see in emergencies as well and so when you start talking about scarce resources how will those resources be allocated when chunks of the population may be challenged in having sort of day-to-day access and so that's something that we worry about in terms of how we plan to get medication to the people you know it's a multi-prong strategy certainly we have relationships with city agencies that have medical division so that we can take care of our first responders that's a critical first step relationships with providers and mechanisms to get medication to providers to schools you know during h1n1 we did a massive school-based vaccination and we have a robust point of dispensing plan um in 2014 we did a no notice exercise where we were able to open 30 pods in less than eight hours which we were very excited to see sort of the culmination of pretty much a decade of planning and to really show that we were able to to carry it off the other thing that we are very proud of is we've really built some robust relationships with pharmacies we have many pharmacies in new york city the majority of which are actually mom and pop not the chain pharmacies and so we've been working on getting contact information for all those pharmacies and really thinking through how we can utilize them also not just in a pandemic but in other scenarios as well in terms of challenges you know it's very challenging to staff pods when it's a vaccination scenario because not everyone can vaccinate so that limits our personnel also we found during h1n1 maintenance of cold chain during large-scale vaccination can be challenging but not insurmountable and then really this issue of how to maintain adequate supply levels when resources are scarce and then as was mentioned earlier just concerns about trust of government and people doing what we need them to do and as someone said it so eloquently you know you really need to have those relationships built in advance great so jamie in your view what do you think the preparedness community is doing well and what do you think are the biggest unmet challenges with the organizations that you've been working with um so i think um the number one thing that i would point to in terms of where the pandemic preparedness community is doing well is the global health security agenda so i imagine a number of people in the room are familiar with this that it was an international initiative um that was launched during the obama administration and is continuing under this administration it's really focused on reducing pandemic risks globally whether they're naturally emerging accidentally released or the result of a deliberate attack and um there are a number of things that are exciting about the ghsa one of them is that it was really a focused effort to develop a shared set of goals across countries and across different sectors to prevent detect and respond to these threats um and that these that a number of actionable steps were highlighted and um funding was was uh was committed by the us government and other governments um to to take on those tasks and the intention has always been for these this to constitute measurable progress where um governments and performers can be held accountable for uh for results so um and then i think another aspect of it that's been very productive is that it uh recognized that the ability to detect infectious disease outbreaks and the ability to respond to them um is is largely the same irrespective of whether it is a natural deliberate or accidentally caused outbreak and as such they brought together the public health community and the national security community to work together to identify shared needs and to build one system so those are both really productive aspects of that initiative um it's heartening to see that this uh that at the recent high level ghsa meeting in kampala there's been a renewed commitment to this initiative and so the open question now is whether or not the resources will continue to be there in the next five years great marissa on the health care side i want to just drive drill into that a little bit more uh how do you think or how how do you think any city but in particular new york city's health care system could respond to an event of magnitude like a pandemic what kind of bed and respiratory capacity do we have on hand for pandemics in new york city ventilators from national stockpile would that be part of it how would that work so um i think as is true in all the jurisdictions our emergency support function eight which is run out of our emergency management agency is really the linchpin of all health and medical coordination so that gets stood up in a pandemic flu scenario we have been using our hpp funds as was mentioned before to really build up the preparedness of the health care system the way we look at it in new york city it's really the funds are used to bring all the sectors together to address system-wide gaps build coalitions both within sectors as well as across sectors and then also to provide some support to facilities and so for example we work directly with nursing homes we provide support to the primary care sector and so uh pandemic flu is definitely one of the scenarios that we work with the various um sectors on i think it's worth noting that in 2013 we did an exercise to test medical surge and rapid discharge and we were able to we tested it with all 55 hospitals we were able to show that all the hospitals were able to discharge up to one third of their hospitalized patients now that was for a mass casualty incident but we feel that it has applicability to a pan-flu scenario you know in terms of number of beds and ventilate ventilator capacity you know we have a total number of 22 000 licensed hospital beds and 57 hospitals and as of right now we have 2 000 bedside ventilators that could be used for adults and a thousand that could be used for pediatric patients a few other things i wanted to note we do have an ongoing contingency contract to stand up a nurse triage line which we think would be really important to decrease healthcare utilization for less severe flu cases and also through our ebola money that we received we have been doing a lot of intensive work with the healthcare system on infection control including doing mystery patient drills in every hospital where we bring in a faux patient and we document what the reaction is and they have to do an after-action report and we check to see if they've made changes and just at a high level we're finding that infection control practices could definitely be strengthened especially around hand hygiene and also that even when patients are given a mass there's a delay in when those patients are getting a mask and and our bottom line is that infection control really needs to become more routinized with more um testing of staff given staff turnover to really make sure that it's just part of the way that the hospital is doing their day-to-day business and really to maintain vigilance great jamie in terms of uh the work that you're doing um can you give us a sense of the opportunities for improvement either where you see greatest opportunity for foundations like yours and maybe even focusing on technologies in particular what kinds of technologies are worth investing in in addition to the the science that we've started to talk about today sure so i see um not just for open philanthropy investment but just for the community as a whole there are opportunities to get stronger uh in all three of the prevention detection and response areas on prevention uh in particular because i'm thinking a lot about deliberate misuse risks i think there's an opportunity to get stronger on governance of dual use bioscience we've made a lot of progress in recent years in terms of advancing those policies but i think we have a long way to go and there's a lot of fruitful work to be done there on detection we we have an opportunity to improve our systems for early detection of outbreaks in particular the technology that is rapidly emerging that could be very useful as next generation sequencing technology if there are innovative ways to integrate that both into a clinical setting to to identify unanticipated outbreaks in clinical settings earlier and also to potentially apply that technology in the environmental monitoring setting that could be that could be another way to detect outbreaks very early and enable us to get on top of the situation before it spreads in terms of medical countermeasures i think um i think something we really need to think about is you know we're not we're not sure where the next pandemic is going to come from it's very hard to anticipate that and i think we should be prepared to be adaptable um and so the kind of technologies that i think are most useful in that space are ones that are are very uh disease agnostic so broad spectrum antivirals not only against flu but other potential viruses that could emerge um particularly directed at the uh the host immune response as opposed to the the virus itself uh as well as uh platform technologies what we heard that we heard about from some of the earlier speakers that enable us to rapidly develop uh new medical countermeasures and new vaccines in response to novel pathogens that we hadn't anticipated those are all opportunities to get stronger great i think we have time for maybe one more question each and what i'd like to ask you marissa is how do you think other cities are doing i mean there's in the public health preparedness community we always hear about new york city because it's such a high performer almost a couple of standard deviations above other cities at times at least that's the word on the street so what's your sense interacting with the rest of america do you think other cities are doing as well as you've described today or do you think it's a harder challenge for them and what do you think is the most important thing for the federal government to be doing for cities and states so um i think i actually um did it wasn't naturally fall into the emergency management realm i've sort of come up i started sort of at the beginning of the fep program and as it's grown and something that i've learned along the way is that what's valuable about planning is the process not the document you know the document may lay on a shelf you always hear that the plan getting dusty on the shelf yes you should have tools that people can easily reference but it's really about the process and i think something that we've really learned through pan flu planning there's a lot of policy issues that come up many of which you can work out in advance ideally and not at the time so yes it does require resources and so it has been challenging you know there was dedicated pan flu planning way back when and you know um often times as jamie mentioned sometimes with different scenarios you sort of have a focus on a particular scenario and then it goes away the thing i think that's really important to take away is that it's really about building all hazards capabilities that are flexible nimble it's about building systems that you can leverage for many types of events and that does require continued investment you need to the for the capabilities that we have built they have to be maintained with continued investment for the gaps that we identify that needs investment to then address those gaps and that has become very challenging for other jurisdictions and new york city as well i think we do have more resources than a lot of other places and we do try to share with others whatever it is we develop but i talked to many of my colleagues across the country and they are really struggling to just deliver on the baseline capabilities you asked what it is that we need from the federal government you know i think just continuing to really try to preserve the fedman hpp funding which is so critical for this kind of work is really sort of at the top of the list i think the other thing i'll say is you know sort of better defining the roles of different federal agencies in this type of scenario you know this isn't going to be day-to-day business so understanding what those roles are and communicating it to state and locals we did something really interesting after ebola that i thought was actually a best practice which was we got our federal partners our state partners and our local partners all together in a room and talked about what had gone well what could we improve with a specific focus on communication and coordination i think that's really important to do and then the final point i'll make is that sometimes well in these types of scenarios guidance is coming fast and furious and to the extent that state and locals can be consulted i think that will be really important again it can be done in advance but also at the time because where we found in ebola h1n1 some of the guidance that came out would be sort of not really in sync with urban settings and it created problems for us specifically around public communication great and jamie you started to talk about this a bit already but uh beyond pandemic influenza you also have an interest your organization has an interest you have a personal interest in preparing for the broader range of serious biological threats in the world what else are you worried about just so people are kind of leave thinking a little bit in addition to pandemic flu what should we be thinking about certainly so uh in addition to a pandemic flu we think a lot about uh man-made pathogens engineered pathogens um that could emerge in in the coming decades where um they could be engineered to be more transmissible virulent or resistant to medical countermeasures that's something that we think about because we feel that that could pose a severe pandemic risk and it's highly relevant to our interest in low probability high consequence events that we're particularly concerned with okay great thank you both so much for being with us let me just [Applause] really appreciate it okay i think okay uh good afternoon my name is sabrina schultz and i'm a curator of physical anthropology at the national museum of natural history where you are where we have the wonderful mission of understanding the natural world and the place of humans within it one of the great privileges of being a scientist in this museum is our connection our service to the public at the smithsonian it's our mandate not only to increase knowledge but to diffuse it and so with our exhibits for example we reach millions of people a year i am the lead curator um on an exhibit there it is um [Music] that serves a critical function um of public communication about pandemic risks and threats it's called outbreak um epidemics in connected world and it opens in may next year outbreak places influenza and other zoonotic viruses ebola zika haunter nipah mers sars and hiv in an ecological context we present human health animal health and environmental health as one health and show how pandemics can result from a failure to recognize and respect that connectedness so we do this with stories that demonstrate the principles of one health where human impacts on animal health or environmental health can be linked to impacts on human health such as in a virus spilling over from wildlife or livestock and causing an outbreak we explain the human drivers the activities that spread disease such as global travel and trade and how they can cause an outbreak anywhere and threaten the health of people everywhere we show the effects of a pandemic on human health and society and the kinds of efforts needed to fight back by science and activism and healthcare and policy we illustrate the importance of the community in breaking the curve of an epidemic and the cultural factors that will always be a part of that effort and last but not least we explain to our visitors the fundamental role of research and vaccines in preparing us for the next pandemic so um outbreak is a new kind of exhibit for us and that's because public health is a new space for us as museum um a place for us to be you know it's um it's a part of our work you know as stewards of natural history as a curator of collections like myself um that is motivating um our exhibits in most cases and while it is true that our collections do have value for infectious disease research um as we show in the table in the back room um that's not the only strength that we're actually using in this in this situation in this place um we have convening power at this museum which i think is demonstrated by this event today and um you know which is also shown by the many free public events they're supporting the outbreak exhibit throughout its three-year run and so we want to raise awareness we want to motivate behavior change and we want to catalyze conversations about pandemic risks in the public and um because pandemics are global a global health threat we are trying to convene a global audience outside the walls of this museum and outside this city outbreak will not only be a new subject for our exhibits in a way but it will be a new model and that's because we designed the second version of the exhibit that will be able to pop up in a community anywhere in the world um using free resources that we'll provide um digitally you know including a guide develop educational programming and template files to customize exhibits because that is the important part you know allowing communities that are vulnerable to epidemics pandemic risks to have those tools to uh communicate and reach their visitors their audiences their you know their their populations um in ways that we can't with the most effective messages in the most appropriate way and so these are messages about epidemics in a connected world outbreak would not be possible um without the generous support of so many partners we've just been really really fortunate our donor partners are listed here just a few of our content partners are shown in that photo and some of our partners are here today and in this room i want to say thank you so much to them and really to all the rest of you um for the good work that you do that you know we try to communicate will hopefully successfully um you know bring to our audiences um and thank you also for your attention so um now i'm going to introduce our final speaker of this program um dr ella mckenzie she is the dean of the johns hopkins bloomberg school public health and a bloomberg distinguished professor with joint appointments in the department of biostatistics and the school of medicine's departments of emergency medicine and physical medicine and rehabilitation in addition to hundreds of publications and numerous honors she was named by the cdc as one of the 20 leaders and visionaries who have had a transformative effect on the field of violence and injury prevention in the past 20 years [Applause] well thanks very much dr schultz on behalf of the bloomberg school of public health i would like to first of all extend my thanks to our panelists and speakers and our collaborators the smithsonian magazine and the national museum of natural history i will confess that i got here a little bit early today and i took the opportunity to wander around the museum and was reminded i hadn't been here for a while and i was reminded how wonderful a place it is and it brought back a lot of great childhood memories and memories of taking my son here and it sounds like based on what you just described you're just taking it to the next level and it's it's fantastic it's really wonderful to see i would also um like to thank our sponsors for this event the bill and melinda gates foundation and the welcome trust and a special thanks to you all for being here in this room and for those of you watching online over the internet as we have heard today public health scientists have made remarkable progress towards identifying and characterizing influenza virus strains that could uh potentially cause a pandemic and these efforts can also help identify other emerging viruses that pose a pandemic threat that are still of some of great concern as we've heard our methods of global and local surveillance and detection have also improved as has our capacity to manufacture and distribute vaccines our speakers reminded us of many other advances but also pointed to the disparities across countries and regions within countries in our ability to prepare respond and recover from a pandemic but clearly more is needed to safeguard the population against another catastrophic pandemic we heard loud and clear from the very beginning that the push to develop a universal influenza vaccine that protects against a wide range of virus strains must be at the top of our priority list especially given that the current seasonal vaccines have limited efficacy but we also heard that we will we may need to go back to the very basics of our understanding the correlates of immunity if we are to get closer to that ultimate goal of creating a universal vaccine we heard many other areas of concern the need for more effective global surveillance in both human and animal populations a decrease in the time to vaccine production faster and more equitable vaccine distribution more research on anti-viral drugs including new classes of drugs and perhaps cocktails of drugs and the use of innovative and exciting new technologies for rapid tech detection and finally the improvement in capacity and readiness of health care systems around the world to respond to a pandemic with a focus on an all hazards approach ongoing continuous improvement our of our local public health infrastructure with an emphasis on forging multi-sectoral links is also critical as we heard in our level of preparedness we also heard again loud and clear that effective communication is critical health officials at all levels need to communicate health threats to the community in a manner that can be understood and acted on in a reasonable way and as john barry admonishes our officials must always tell the truth all the time and they must get out front and stay out front so that's a broad summary of what we heard today i thought i would like to end the symposium today as we began it with some history although i will not pretend to be as great a historian as john berry is but i would like to reflect on the ways that the influenza pandemic influenced the development of our own johns hopkins bloomberg school of public health as a new dean i'm only six or seven weeks into the job i'm particularly interested in our history and i would be remiss if i did not um acknowledge the input from our own historian karen thomas in reminding me of this rich history especially as it relates to van pandemics so in october of 1918 what was then known as the school of hygiene and public health held its first classes just as the great influenza pandemic began to intensify founded by william henry welch and the rockefeller foundation the school made the pandemic the urgent launch point for its work influenza and its worldwide aftermath jump started the school's growth as a leading center of research and training in epidemic disease wade hampton frost the first chair of the department of epidemiology at johns hopkins was already a noted influenza expert when the pandemic hit at that time data were very were extremely difficult to collect much less interpret but as the head of the public health services office of field investigation frost worked with colleagues to conduct house-to-house surveys of a representative sample of communities nationwide these surveys revealed one of the defining characteristics of the 1918 outbreak that we heard about today and that is the that the highest mortality was among young adults under the age of 40. frost then published a chronology of the pandemic spread from the u.s to europe and asia and this chronology became the model for all subsequent efforts to track global pandemics today frost's methods are still used to predict and measure epidemics under frost's influence the school would pioneer the tactic of teaching students shoe leather epidemiology walking from house to house block by block to confirm all cases of a disease in a particularly defined area the pandemic became a primer first johns hopkins students the school's leadership in fighting epidemics intensified after alumnus and former faculty member alexander langmuir founded the epidem epidemic intelligence service or eis at the centers for disease control in 1951. many bloomberg school graduates have gone on to become eis officers and many eis officers in turn have have since joined this the faculty of the school one of those eis officers d.a henderson directed the who's successful campaign to eradicate smallpox he then came to the school as its eighth dean henderson like his mentor alex langemier was also prescient in his pioneer advocacy of biodefense and biosecurity preparedness and went on to establish the center for health security you heard about earlier which is now approaching its 20th anniversary alfred summer and henry mosley two other notable eis eis officers were sent to assess the 1970 cyclone and tidal bore that decimated east bengal now part of bangladesh and they conducted the first epidemiologic survey following a national disaster their goal was to guide long-term relief and recovery planning their eis experience as epidemic fighters was a springboard for outstanding achievements in research training and administration at the bloomberg school dr sommer became our ninth dean and dr mosley chaired the department of population dynamics for over 20 years the school's experience in fighting influenza built the foundation for its rise to international prominence in vaccine development evaluation and policy the faculty have and continue to work on advancing the issues in development testing and policy for vaccines against cholera influenza hpv measles malaria hiv dengue as well as other devastating diseases and they have fully established the power of micronutrients to prevent both nutritional deficiencies and infectious diseases using the public health tools of laboratory investigation biostatistics epidemiology and policy the school has emerged in the 21st century as a thought leader a convener and first-line collaborator for tackling epidemics during our century of existence we are proud to have broadened the scope of public health strengthened its scientific evidence base and trained a global network of public health leaders if together in this room we are unrelenting in our pursuit of new knowledge and application of time-tested public health methods and not neglect the lessons we have learned we will one day hopefully measure death from infectious diseases as a one in million occurrence again let me extend my thanks to all of you for coming and to those of you who are joining us online let's continue the conversation on our social media channels online at the smithsonian magazine hub via the school's global health now website and here at the reception to follow this event again thanks so much for coming and good evening [Applause] this [Music] you

Channel: Smithsonian Magazine

Views: 146,538

Keywords: science, flu, pandemic

Id: Q-jfqpBG9eQ

Length: 154min 34sec (9274 seconds)

Published: Tue Nov 14 2017