1. THE COMMONWEALTH FUND “Science” of Pandemic Influenza Stephen C. Schoenbaum, MD, MPH Executive Vice President for Programs June 15, 2006 www.cmwf.org

2. THE COMMONWEALTH FUND Limitations of Our Knowledge Direct or inferential virologic knowledge only about 1889, 1918, 1957, 1968, 1977 –Direct virus isolation only for the latter 3 –Virus reconstruction for 1918 –Direct pandemic experience with only H1,2,3; N1,2 i.e., 3/16 hemagglutinin types; 2/9 neuraminidase types

3. THE COMMONWEALTH FUND Avian Flu (H5N1) Emerging pandemic among birds –A unique observation (I believe); hence difficult to estimate the probability of its being a prelude to a human pandemic Some, but few, instances of spread to humans –Hopeful, but not an absolute protection –Has occurred with other strains (e.g., H7) Possibly a few instances of spread between humans –Again, a concern; but this has occurred with other strains without causing a pandemic (e.g., Hsw1N1 =H1N1 at Fort Dix, NJ in 1976

4. THE COMMONWEALTH FUND Policy-Relevant Information About Pandemics Pandemics occur irregularly over time –It is likely there will be another some time Pandemics vary in “size” –All are important; but not all have the impact of 1918 Disproportionate effect on younger people than interpandemic epidemics –Policies for control need to be population-wide Can/do cause societal disruption –Need contingency plans for vital societal functions Usually associated with a second, even third, wave

5. THE COMMONWEALTH FUND Policy Options for Preventing or Ameliorating Pandemic Spread Global surveillance for novel strains –Occurring –Leading to control of influenza in flocks of birds –Hard to know if this can have an impact on prevention or amelioration of pandemic spread

6. THE COMMONWEALTH FUND Policy Options for Preventing or Ameliorating Pandemic Spread Developing methods for crash production of vaccines once a pandemic has been detected Stockpiling prototype vaccines for each of the influenza A hemagglutinins Prior immunization with prototypes of the influenza A hemagglutinins Immediate production/use of vaccines to ameliorate second/third waves

7. THE COMMONWEALTH FUND Policy Options for Preventing or Ameliorating Pandemic Spread Stockpiling antivirals and using them with emergence of a new strain Increasing routine use of antivirals Research to develop new antivirals Increased/repeat pneumococcal vaccination at time of emergence of a new influenza A strain Statins - ?other novel/general methods of reducing the lethality of bacteremia or of viral infections

8. THE COMMONWEALTH FUND Policy Options for Preventing or Ameliorating Pandemic Spread “Social Distancing” –1968: school closures (Xmas vacation) –1918: Quarantine of Australia –Bottom line: could buy “some” time Ability to enhance ICU/treatment capacity –Respirators – how many are really needed? –Cross-trained staff – will they show up? –Antibiotics – can we deal with resistance? –Bottom line guess: could probably handle a 1957- size pandemic

9. THE COMMONWEALTH FUND Visit the Fund www.cmwf.org