The Public Health Vision Michael T. Osterholm, PhD, MPH Director, Center for Infectious Disease Research & Policy Director, Minnesota Center of Excellence for Influenza Research and Surveillance Professor, Division of Environmental Health Sciences, School of Public Health Adjunct Professor, Medical School University of Minnesota

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

Making Sense of Influenza Pandemics Assessment of the novel H1N1 pandemic and this meeting: –“We are fortunate that this was a mild pandemic.” –“If this virus had been deadly….” –“This pandemic was really just a dry run.” –“This pandemic was regarded as not severe.” –The 2009 pandemic….largely a huge relief and a practice run.” Our current “mild, moderate and severe” measurement system (i.e. number of deaths) is outdated Death is a difficult topic to discuss, particularly when it’s about ourselves

Viboud C, Miller M, Olson D, Osterholm M, Simonsen L. March 20,2010 Preliminary Estimates of Mortality and Years of Life Lost Associated With the 2009 A/H1N1 Pandemic In the US and Comparison With Past Influenza Seasons

Estimates of Number of Deaths, Mean Age of Deaths, and Years of Life Lost Attributable to the 2009 Pandemic In the US. Number of deaths (adjusted to 2000 pop.) Mean age of deaths (yrs) Years of life lost (adjusted to 2000 pop.) 2009 Pandemic 7,500-44,100 * ,000-1,973,000 12,000 (8, ) **463,300 (328,900 – 680,300) 1968 Pandemic86,000 ***62.21,693, Pandemic150,600 ***64.62,698, Pandemic1,272,300 ***27.263,718,000 Average A/H3N2 season, ,800 *** ,000 * Range is based on estimates of excess P&I deaths (lower) and all-cause deaths (upper), based on projections from the 122 cities mortality surveillance ** Estimates based on CDC’s probabilistic estimates, using 2009 pandemic survey data (different from CDC’s excess mortality method for measuring seasonal influenza burden) *** Estimates based on excess mortality approach applied to final national vital statistics and adjusted to the 2000 population age structure

Viboud C, Miller M, Olson D, Osterholm M, Simonsen L March 20 Death and Years of Life Lost From Influenza

Mean Age of Death for Influenza Pandemics and Life Expectancy At Birth; United States Life Mean Age of Year Expectancy Death Difference (29.2) (4.5) (8.1) (37.2)

Making Sense of Influenza Pandemics The 2009 novel H1N1 influenza pandemic, together with the experience of the 3 previous pandemics, seasonal influenza and H5N1, reinforces that “flu isn’t simple” Our current “mild, moderate and severe” measurement system (i.e. number of deaths) is outdated We need a new way to measure and describe the impact of pandemic influenza in a modern world –years of life lost –impact on our modern health care system –impact on the “just-in-time” global economy

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

The Anti-Science Movement “Anti-science, in modern terms, refers to largely ideological attacks on the teaching of evolutionary theory, global climate change, various sorts of medical and public health measures and other sciences. This is particularly true when there is conflict with political or religious pseudo-scientific positions.” The anti-science position generally holds that in cases where science and ideology come into conflict, science itself must be flawed. Anti-science based efforts are often well orchestrated and well financed. They also focus on attacking both the science and individual researchers, practitioners and policy leaders.

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

Vaccines and Tomorrow Efficacy and effectiveness Availability Safety Role of adjuvants

Vaccines and Tomorrow Efficacy and effectiveness Availability Safety Role of adjuvants

Current Whole, Split and Live Virus Seasonal Influenza Vaccines Efficacy/effectiveness in the elderly –Only one randomized control trial in 40 years that has adequate follow up and case definition criteria, randomization, allocation concealment and addresses selection bias (927 treated, 911 controls) –VE=59% (26-77%) Efficacy/effectiveness in everybody else –VE=0 to 80% and varies by antigen match, age and underlying health conditions The public has limited understanding of the relative lack of influenza vaccine efficacy/effectiveness compared to other immunizations

Vaccines For Preventing Influenza In The Elderly Cochrane Review, 2010 Jefferson T, Di Pietrantonj C, Al-Ansary LA, Ferroni E, Thorning S, Thomas RE “The available evidence is of poor quality and provides no guidance regarding the safety, efficacy or effectiveness of influenza vaccines for people aged 65 years or older. To resolve the uncertainty, an adequately powered publicly- funded randomised, placebo-controlled trial run over several seasons should be undertaken.”

Vaccines and Tomorrow Efficacy and effectiveness Availability Safety Role of adjuvants

Source: CDC ILI and Vaccine Distribution Data Percentage of Visits for ILI and H1N1 Vaccine Distribution, Sept 2009 – May 2010

Vaccines and Tomorrow Efficacy and effectiveness Availability Safety Role of adjuvants

Vaccines and Tomorrow Efficacy and effectiveness Availability Safety Role of adjuvants

Vaccines and Tomorrow The influenza research and public health communities must confront the issue of the relative lack of efficacy/effectiveness of our current whole, spilt and live attenuated influenza vaccines We have an urgent need to change our “gradual migration approach” from a 1950s-based influenza vaccine technology to 21 st century universal-based vaccines; we need a game-changer approach The anti-science movement is already seizing on this issue; we owe it to the world to address it head on!

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

“The Government are very keen on amassing statistics - they collect them, add them, raise them to the nth power, take the cube root and prepare wonderful diagrams. But you must never forget that every one of these figures comes in the first instance from the village watchman, who just puts down what he damn pleases.” Sir Josiah Stamp

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

Pandemic Arrival Timeline (Years) ???

The Public Health Vision Describing and understanding influenza pandemics Public health under attack Vaccines and tomorrow Modeling as a tool The next pandemic landfall

“It’s no use saying, ‘We’re doing our best.’ You have got to succeed in doing what is necessary.” Sir Winston Churchill