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Question and Answer with William Raub

by: DemFromCT

Tue Feb 19, 2008 at 07:24:12 AM EST

HHS Secretary Mike Leavitt's science advisor, Dr. William Raub has kindly agreed to an email/blog interview with the Flu Wiki community.

(Open this diary to read the questions and answers.)

DemFromCT :: Question and Answer with William Raub
The following questions were prepared by the online community (see previous post):

William F. Raub, Ph.D.
Science Advisor to the Secretary of Health and Human Services

Q1. Shared responsibility.  In a recent Washington Post article, the Federal preparedness plan was taken to task by local officials as being too oriented toward vaccine and antiviral production infrastructure and not enough for surge capacity and local hospital needs. What can the federal government do in concert with state and local agencies to ensure sufficient food and necessities have been stockpiled locally, and a plan worked out for distribution to the poor and working class families that will allow them to SIP if a pandemic rolls through? How does that schematic help vulnerable families? Also what about a federally mandated moratorium on mortgage payments, credit payments and utilities during a pandemic so that these working poor can afford to stay away from work until it passes? How are vulnerable families going to be supported? And what is happening at the Fed level to assure intra-agency agreement and coordination at the state level (e.g., is the Department of Education pushing state cooperation with public health and homeland security state agencies)?

A1.  The recent Washington Post article dealt primarily with assertions that the federal government has not done enough to help healthcare institutions prepare for the surge in patients that is likely to accompany an influenza pandemic - especially if mitigation efforts are not highly effective. The article did not address directly the points that this question appropriately raises.

Before responding to the latter, I feel compelled to note that many of the critics of the federal government's role in healthcare emergency preparedness overlook or downplay the fact that the Department of Health and Human Services (HHS), in response to directions from the President and the Congress, has provided approximately $2 billion dollars in financial assistance since 2002 to all 50 States and 4 major urban areas to help hospitals and other healthcare entities within their jurisdictions enhance surge capacity.  Whether the federal role should be bigger or smaller is a legitimate subject for debate.  What is disappointing to many of us is that some commentators continue to espouse the unrealistic expectation that the federal government has the fiscal and logistical wherewithal to do everything for everyone.  It does not.  In fact, as Secretary Leavitt has stressed repeatedly in State Summit meetings with Governors and in numerous other fora, preparedness for pandemic influenza must be a shared responsibility among governments at all levels, the private sector, and individuals.  To the extent that potential partners refuse to apply their talents and assets unless the federal government foots the bill, they are abdicating their responsibility and thereby placing their communities at higher risk than need be.

Our citizens have every right to expect that the federal government will continue to play a prominent role in pandemic preparedness; and it will.  In particular, HHS will continue to give highest priority to those tasks that it is best positioned or uniquely able to undertake.  This includes a) stockpiling prepandemic vaccine and antiviral drugs; b) providing financial and technical assistance to States to help them, among other things, create complementary stockpiles of antiviral drugs and develop and test various mitigation strategies, such as school-closing policies and procedures, to slow and limit the spread of infection; c) creating a domestic vaccine production capacity commensurate with the expected requirements of a pandemic; and d) sponsoring advanced development projects toward the next generation of vaccines, therapeutics, and diagnostics.

Turning to the questions above, I begin with the matter of helping poor and working class families gain access to necessities of daily life during an influenza pandemic.  HHS has taken important steps in this regard and will continue to build on those initiatives.  In particular, HHS agencies (primarily the Centers for Disease Control and Prevention and the Office of the Assistant Secretary for Public Affairs) have developed and promulgated a suite of checklists and other guidances to help individuals and organizations prepare for an influenza pandemic. These can be found on the HHS-operated website titled Pandemicflu.gov.

For example, if those individuals who have the means and will to create a multi-week stockpile of food, water, and other necessities do so, local entities such as municipal governments, private emergency response organizations (notably, the Red Cross), faith-based organizations, and community organizations will be able to target their assets and services toward those who cannot afford to undertake this level of personal preparedness.  In a similar vein, if businesses and other organizations develop and implement realistic plans to continue operations in the face of an influenza pandemic, this will do much to ensure that supply chains for critical goods and services do not collapse.  Even degraded supply chains, coupled with well-designed and well-executed local emergency response plans, can do much to help needy citizens maintain access to fundamental goods and services.

With regard to the questions about financial policy interventions such as a moratorium on mortgage payments, I cannot provide definitive answers now.  Such matters fall outside the authority of HHS and thus are best addressed by the Department of the Treasury and perhaps others such as the Department of Commerce.  My colleagues and I will take the liberty to convey these thoughtful queries to our counterparts in the other Departments and subsequently share their response with you.

With regard to coordination at the State level, HHS is deeply involved.  First, since 1999, HHS has provided funding to State and local public health departments to enhance their preparedness for naturally occurring, accidental, or terrorist-induced emergencies.  This has included strengthening relationships with public safety and emergency management agencies.  Second, since 2002, as cited above, HHS has provided States with funding to foster analogous preparation by hospitals and other healthcare entities.

Third, HHS is leading an effort involving 8 Cabinet Departments of the federal government to help States refine their plans for countering pandemic influenza.  The primary focus of our planning guidance, technical assistance, and readiness assessments is help all agencies of State government, not just the health departments, understand what they can do to help mitigate and otherwise counter an influenza pandemic.  To be sure, this involves looking inward to do what is necessary to continue their respective operations.  But it also involves looking outward to establish and test partnerships with other agencies of state government, local governments, and the private sector - including both for-profit and not-for-profit entities.  The doctrine of shared responsibility says that we all are in this together.  State-based partnerships are one of the most promising ways to prepare for pandemic influenza.

Q2. Vaccine allocation.  If health care workers and first responders as well as emergency personnel are 'top of the list', what about funeral directors and other mass casualty personnel? What about their families? When will the priority allocation scheme be announced? Is implementation a state or federal responsibility?

A2. The working group that was tasked to define a priority order for administration of vaccine to counter an influenza pandemic now is weighing the information received from a second round of public consultation and is updating its earlier draft document to accommodate the most persuasive comments and critiques.  The intent is to have a plan suitable for public release within the next several months.  Implementation necessarily would be the joint responsibility of the federal government, States, and local governments.  The challenge will be to achieve as nearly uniform an implementation as practical while accommodating the reality that every State will have particular needs that are special - even unique - to it.

Looking further ahead, please recognize that vaccine prioritization policy must be a work in progress rather than a one-time decision.  Any plan completed and promulgated in the near term necessarily will be subject to reconsideration, revision, and reissuance from time to time as we learn more about the pandemic influenza threat or acquire better means to counter it.

With regard to the relative priority of funeral directors and other mass casualty personnel compared to other occupations or groups of individuals, HHS will not be able to provide a definitive answer until the working group completes its task.  However, I am aware that various commenters have stressed the importance of these occupations for an effective response to and recovery from an influenza pandemic; and I feel confident that the working group is giving them due consideration.

In a similar vein, a definitive response on the prioritization of family members of individuals in various high-risk or otherwise critical roles also must await the working group's completion of its task.  For now, I note that this issue has been on the minds of many of us from the beginning and continues to elicit a considerable diversity of opinions.  Many argue that those who will be protecting and serving the rest of their communities deserve not only immunization for themselves but also the peace of mind that comes from knowing that their loved ones are protected too.  Others argue that the biggest mitigation benefit for the community overall will come from directing the earliest lots of vaccine strictly to members of high-risk and other critical groups - thereby protecting them as quickly as the flow of vaccine allows and then covering their family members in accord with where they fall within lower priority categories.

Closely related to this conundrum are the poignant comments of several senior citizens during the public consultations.  On the basis of experience with seasonal influenza and the three pandemics of the 20th century, medical experts expect that infants, young children, and elderly individuals would be among those facing the highest mortality risk during the next pandemic.  This consideration alone would justify placing elderly individuals within the highest priority strata for immunization.  Yet, several senior citizens stated that they willingly would give up their place in line if that would ensure that their grandchildren were protected first.  Other seniors go further to include the parents of those grandchildren, arguing that to do otherwise is to risk having a generation of pandemic orphans.

Q3. New vaccine technologies.
 The bulk of US expenditure on panflu prep has gone to vaccine R&D to private industry. How many years away are we from bulk vaccine production with novel technologies (such as DNA vaccines)? Has HHS been assured the vaccine will become internationally available to rich and poor nations and not nationalized in an emergency?

A3.  No one can say with certainty when new technologies such as DNA vaccines will take center stage for influenza vaccine manufacturing.  But, from the vantage point of what we know today, I think that most experts would say that it is more than 5 years away.

HHS is committed to accelerating the maturation of DNA vaccines and other emerging technologies.  The National Institutes of Health, an HHS agency, has funded important research on DNA vaccines against influenza viruses.  And the Office of the Assistant Secretary for Preparedness and Response, part of HHS Headquarters, recently solicited and now is reviewing contract proposals for advanced development of a DNA vaccine.  The latter initiative is a critical milestone on the path from the laboratory bench to the manufacturing floor.

HHS also has a strong interest in vaccine adjuvants.  These are chemical substances that, we added to vaccine, increase the magnitude and, sometimes, the scope of the immune response.  Thus, addition of an adjuvant can have a dose-sparing effect - meaning that protective immunity is achieved with smaller quantities of vaccine than if the adjuvant were absent.  Further, addition of an adjuvant may increase cross-protection - meaning that the vaccine elicits an immune response against more strains of influenza virus than if the vaccine were used alone.  HHS is funding a variety of advanced development projects involving adjuvanted influenza vaccines; and several manufacturers are pursuing independent efforts.

But we need not and do not place all our hopes on new vaccine technology.  One of HHS' highest priorities, in concert with an array of leading pharmaceutical companies, is to enhance and expand US-based production capacity to the point that it can generate 600 million doses of an pandemic influenza vaccine (two doses for every American) within 6 months of the time that a reference strain of the actual pandemic virus is developed.  When this initiative began just over two years ago, the US had only a small fraction of this target capacity.  Only two domestic manufacturers of approved influenza vaccine existed; and only one of those had a product that was licensed for use in all appropriate age groups.  Today, six companies, with HHS funding, are in various stages of implementing commercial scale production with cell culture methods and/or expanding capacity for conventional manufacturing using chicken eggs.  The target date for the achieving the 600-million-doses target is 2011.  The work is on schedule.

The driving motivation to build the target production capacity within the United States is to ensure that we can provide pandemic influenza vaccine for every American without having to purchase and import it from foreign manufacturers.  A condition of HHS' funding for the participating companies is that their manufacturing facilities be located within the United States.  At the same time, we hope and expect that these manufacturers, once they have met the needs of the US market, will have opportunities to sell their life-saving products to others around the world.  Our current collaborations with the World Health Organization and other international partners are an important step toward creating the mechanisms that will be needed to combat pandemic influenza in a coordinated manner around the globe.

Q4. Antiviral technologies.  A frequent question about antivirals are their availability. Right now, most state health departments advise against individual stockpiling. Why is that? Whatever the new medicines, will there be enough, and who will allocate the scarce resources? Will the US continue to make this a state 'unfunded mandate'?

A4. Public health officials advise against individual stockpiling of antiviral drugs for a variety of reasons.  The one that I hear most frequently is the concern that many individuals will not hold onto the drugs until an influenza pandemic is upon us but instead will use them for other purposes, probably without contemporaneous direction from a healthcare professional, and probably incorrectly.  For example, individuals could be tempted to break into a household cache of antiviral drugs in response to a cough, sniffles, fever, or other symptoms of influenza-like illness during the winter months.  Yet, insofar as seasonal influenza is concerned, only about one third of those who experience influenza-like illness are likely to have influenza.  Thus, through inappropriate use of the drugs, the individual would incur the adverse-event risks that are associated with the particular pharmaceutical without experiencing an offsetting benefit.  Moreover, widespread misuse of antiviral drugs during the normal influenza season could accelerate the emergence of drug-resistant influenza viruses and thus reduce the effectiveness of drug therapy for the annual epidemics.

Several years ago, public health officials raised essentially identical concerns regarding the prospect of household caches of antibiotic drugs as a modality of personal preparedness for a bioterrorism event - say, an attack involving wide-area outdoor release of the bacterium that causes anthrax.  In response, HHS' Centers for Disease Control and Prevention tested the concept through a field trial in St. Louis.  The study team enrolled over 4,000 households, each of which received in-person counseling and a MedKit containing an appropriate antibiotic for each member.  The study team then revisited the households during the succeeding 2 to 8 months to retrieve the MedKits and interview the householders regarding their experiences with and attitudes about home stockpiling.  The results of the study are strongly encouraging.  They show that, with proper counseling and appropriate packaging of the drugs, well over 90% of the households maintained the package properly and neither misused nor abused the drugs.  Moreover, the vast majority of those interviewed was enthusiastic about this aspect of personal preparedness and expressed inclination to purchase such a MedKit if one were come onto the market.

HHS is following up on this encouraging outcome through two parallel initiatives.  One seeks to encourage commercialization of antibiotic MedKits.  The other seeks to apply the lessons learned with antibiotics to determining how to design an antiviral MedKit and assess its feasibility.  Household stockpiling of pharmaceuticals for use during public health emergencies could be an important modality of personal preparedness if we can develop products and approaches that are affordable; easy to obtain, maintain, and use; and consistent with medical and public health principles.

With regard to availability and allocation of antiviral drugs, the strategy that is being played out is as follows.  In November 2005, the federal government determined that prepandemic stockpiling of antiviral drugs is essential and proposed a national target of 75 million treatment courses - assuming that, during an influenza pandemic, about 25% of the US population would present for treatment.  Further, viewing such stockpiling as appropriate for shared responsibility, the federal government proposed to acquire and stockpile about 60% of the national requirement directly and to look to the States to acquire and stockpile the other 40%.  HHS went on to assist the States both administratively and financially - a) by negotiating master contracts with the two pertinent manufacturers to enable States to purchase the drugs efficiently and at a prices well below those that they could negotiate on their own and b) by providing a 25% subsidy for States' purchases through the HHS contracts.  Most States have availed themselves of this opportunity, with many of them purchasing the fully subsided amount or more.  HHS is hopeful that States will make additional purchases through this mechanism this year.

Each State is responsible for allocating its respective share of the HHS stockpile and its own stockpile, if any.  Therefore, as part of their preparedness planning, States need to identify the hospital entities and other healthcare-associated loci where to drugs are to be prepositioned when an influenza pandemic is judged to be imminent.  States are not responsible for allocation of antiviral drugs that are held outside the national and State stockpiles - e.g., drugs acquired by businesses or not-for-profit entities for their employees and, possibly, the employees' families.  In these instances, allocation is the responsibility of the purchaser.  HHS will continue to encourage States, local governments, and private sector entities to share the responsibility for stockpiling antiviral drugs.

Whether this strategy is tantamount to an "unfunded mandate" upon the States is in the eye of the beholder.  HHS has committed to providing 60% of each States' estimated treatment requirement; and, for those States taking full advantage of the subsidized purchases, HHS is covering an additional 10% (25% of 40%) - yielding a 70% share.  States therefore can provide antiviral drugs for their citizens for 30 cents on the dollar.  Some see the offer as being 30% empty.  I see it as 70% full.

Q5. Community mitigation.  A frequent question that comes up is whether the federal government has doe enough to inform and warn the public about a potential pandemic (H5N1 or other strain). PSAs (public service announcements) have been prepared but rarely shown. How can community mitigation plans locally be supported and implemented without a clear message from the government about the need and the importance of such measures as school student dismissal? What further plans are there for information about pandemics to be given to the public? In this article you suggest low tech plans for home care are good. How will that be supported by HHS and the Federal government (including informing the public of the need)?

A5.  Strong, sustained communication about the threat of pandemic influenza and recommended countermeasures is central to preparedness.  The challenge is more difficult now than 2 years ago because, for many laypersons, the novelty of the topic seems to have worn off and anxiety seems to have diminished.  Nevertheless, the threat remains; and the nation must not let down its guard.  H5N1 avian influenza may not become the trigger for the next human influenza pandemic.  All of us should hope it isn't.  But, if not, history says that, sooner or later, a pandemic influenza virus will spring from some other root.

HHS is committed to continuing its strong role in public communications about seasonal and pandemic influenza.  The website Pandemicflu.gov will remain the lynchpin of our messaging machinery.  But we recognize that we need multiple modalities to promulgate and reinforce preparedness messages; and we constantly are alert to opportunities to try new approaches and strengthen existing ones.  In that regard, we value the new formats and pathways that the Flu Wiki community provides; and we are grateful for the thoughtful recommendations and critiques that have come our way as a result.

I am pleased to see the emphasis on school closing in the question above.  Well-timed and well-executed dismissal of students promises to be one of the most effective means for mitigating an influenza pandemic as it reaches each community.  Yet the action is much easier to describe than to perform and demands thoroughgoing community-wide planning and testing.

HHS has focused special attention on school closing policies and procedures.  Last year, HHS' Center for Disease Control and Prevention provided funding and technical assistance to the States to help them conduct community-level tabletop exercises on this topic.  The objective was to bring together representatives of all the pertinent agencies and organizations, as well as members of the general public, to think through how this instrument of mitigation might be shaped and wielded.  For many communities, the exercise produced more questions than answers; but they are the right questions in that they make clear why planning is important, what needs to be done to get it right, and who needs to do it.  HHS will be alert to future opportunities along this line.

Q6.  International cooperation. New WHO databases for viral sharing have been set up by international agreement, and the idea of open source viral sharing has been endorsed by research scientists and international experts. Does the US (CDC, NIH, NAMRU, etc) make all of their viral sequences open source and freely available? If not, why not?

A6. The science agencies of the HHS and other federal government departments are strongly committed to unrestricted sharing of virus isolates and related biological materials.  The US is an active partner with the World Health Organization and other member nations in promoting this concept and in seeking remedies for those countries who do not believe their interests are served by this practice.  The only instances known to me in which US agencies have not shared samples or sequence information have involved materials restricted by a non-US donor.  For example, from time to time, the HHS Centers for Disease Control and Prevention receives material from outside the US with explicit restrictions that limit or preclude further sharing.

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we'd like to thank Dr. Raub
for taking the time to answer all the questions so thoroughly.

While there's no obligation to agree with all the answers, it is very helpful to know the thinking and philosophy behind the policy.

The community came up with good and thoughtful questions! One that's come up since the questions were submitted is "who's in charge of pandemic response (NRF or PAHPA, DHS or HHS)"? Our short answer is that HHS is lead agency for medical response and DHS is in charge of non-medical response. Shared governance/unified command is not easy, though, and has yet to be tested.

Dr.Raub states

HHS is leading an effort involving 8 Cabinet Departments of the federal government to help States refine their plans for countering pandemic influenza.
We'd hope the Department of Education is going to be more proactive in getting the message down to state Education Depts and school superintendents.

Again, thanks for the effort and interaction!

Dr raub has not committed to commenting here, but the comments will be read.

Yes - thank you Dr. Raub and Dem
While I don't agree with all the positions, I do appreciate the fact that Dr. Raub has taken the time to answer Dem's questions.  Hopefully this is a dialog that can continue.

Well, there you have it folks!
To the extent that potential partners refuse to apply their talents and assets unless the federal government foots the bill, they are abdicating their responsibility and thereby placing their communities at higher risk than need be.

that applies to states, counties and locals
the question then becomes what do we do about it? And what does HHS do to help?

[ Parent ]
Yes Dem That is what I meant
he is telling us exactly what a lot of us are running into.  I don't know what we can do. I am tired of being beaten down for trying to help.  It goes in spurts.

I have asked my regional coordinator twice if we are having a meeting for our regional plan.

The Memorandum that my town and the other 19 towns in my region  signed for pan flu dollars with my state say that there will be a meeting in each town before develpment of the plan and after for input.

I know we did not have a meeting before since I would notice something like that and the plan was completed at teh end of last year so I doubt we are having a meeting.

So I have emailed her twice, no answer.

I have emailed my em, he doesn't know the answer.

I also asked a question about the mrc grant money. He said I would have to ask them and cc'd the mrc director. So do ya think she got back to me.

No one wants to answer questions.

I fin dit very frustrating at times.

Thanks Dr Raub for answering the questions!

[ Parent ]
yesterday's Buffalo, NY article
The issue of who is respinsible for what was touched on in the news article yesterday out of Buffalo NY.  (How experience with Hepatitis vaccine showed problems giving out pandemic flu vaccine)


Erie County this week stretched its resources to inject 10,153 people over five days in a hepatitis A scare that offered a real-world test of the community's readiness for a far more serious disaster.

It left an uncomfortable illustration of the nightmarish scenario confronting even the best-run health department if pandemic flu strikes, and many scientists believe it is only a matter of time before that happens.

The county pandemic flu plan, put together under federal guidelines, calls for vaccinating 950,000 people in less than a week if a new, deadly strain of influenza spreads around the globe. The goal is overwhelming.

"We've been sending messages back up the chain to the federal government that the plan is not realistic. What we just experienced proves our point," said Dr. Anthony Billittier IV, the county health commissioner.

The question remains, though -- who IS going to pay for whatever preparations are needed?   Soudns like the federal government is saying, states and counties need to do this, and the states and counties are saying, we need money from the feds.

Meanwhile, the average citizen doesn't think a pandemic is going to happen.   So they just ignore all of this.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
Being just on the other
side of Syracuse, we've never heard about this hepatitis out break, which concerns me because many people could be infected, therefore traveling all over New York state, spreading this infection. We have not been made aware of this situation. It could be possible that more people need the injection. Why is this not news for the people who live in New York state? Why am I the last to know? (well, I'm not, but it sure feels that way.)

I shutter to think that this is how something major will play out. They simply don't want to panic the people, and when they do say something, it's too late!!

(sorry, rant over ;-)

United we stand: Divided we fall

[ Parent ]
I think that the concern of possible hepatitis exposure was confined to a particular grocery store in the Buffalo area as a food borne illness from one employee.   The article said that the store had made great efforts to notify all people who had shopped at that particular store.   Sine the disease primarily would spread through food, i.e. no from person to person vis air, on the bus, etc.  anyone not in the area really shouldn't be considered at risk in this particular case, especially not someone in a different city.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
Dr Raub,
Can you tell me why my local government is not doing any public education to it's 13,000 plus citizen on pandemic preparedness when all it really takes is a few community forums? Cost $0

Why do they not have information on our local government website? Cost $0

Why they do not send out information in their twice yearly tax bills? Cost $0

Why they do not tap the resources of my community for volunteers to help educate people in town? Cost $0

Why do they not want to release their pandemic plan, which is actually an all hazards plan, to the community? Cost $0

Why do my local leaders not send out letters to the over 500 medical professionals in my town and ask them for their assistance in a public health emergency? Cost $210.00

Cost of educating my community $0.00 - $210.00
Cost of not educating my community
2% CFR - 104 deaths
10% CFR - 522 deaths
30% CFR - 1,566 deaths

Dr Raub, the information is free as to what citizens need to do to be prepared. Why are my local government officials not telling me, my neighbors and my community?

Why are my community leaders putting their communities at higher risk if it costs them next to zero dollars?

I have been a pan flu preparedness advocate for approximately 3 years. My emergency manager "doesn't need my help", yet he does nothing to educate my community.  I have started with a friend of mine a Community Awareness and Preparedness Organization that tops cost us $100.00. We have give classes and we hand out information at community events. We have been told that we are providing a great service to our community. The problem lies with the fact that we have only educated about 30 people. You see pandemic influenza is not coming to my town of 13,000 because no one in authority has ever told them.

When will the US government tell local community leaders that it IS their job to educate and prepare thier community?

[ Parent ]
Good points,
Katie Bird,

  Love your ideas. How does one say no to FREE ??  

  Why is there this fear to say "watch out" ??  

  Why do municipalities want un prepared people, particualy if it might increase their legal exposure.

   Why not now? My citites pandemic plan is marked "DRAFT" so now is the time to get citizen input before the plans are carved in stone. Get people invloved now before the plan needs to be re-written. Yes I do say re-written with a clean mind and sober breath.

    Things are rarly done correctly the first time. We get better with practice.

 Katie Bird, two thumbs up.

[ Parent ]
society organizations
Like the way you thinking. Instead of complaining, which usually see, You give concrete solutions. It is a shame that instead of civil society organizations, The government will choose the shortcut, which populist slogans and actions. We live in a world where statistics (surveys Election) mean more than people

plastic surgery prices pictures before and after

[ Parent ]
I have to take a shower now.

Tell the truth

All excellent answers...wow!
We may not agree with all of the above answers, but in the very least, Dr. Raub seems to be as open and honest as he can be within the constraints of his position.

Obviously, he can't divulge every little nuance of PanFlu plans, simply because they don't all exist yet, and inter-Department communication within the Gov't just isn't what it needs to be...

Reading through this, I'd be willing to bet that, off the record, some of his answers are much deeper and much more concise...!

from Mike Costan at avian flu diary

There might be some pertinent comments there, too.

Decent Reply from Raub.

About what we would expect to hear - it's really the job of Local, County, and State Emergency Management/Response authorities to plan and to communicate necessary steps to prepare.  Agree with Bronco Bill - Raub gave us realistic reply, summarizing the general concern themes and addressing them in a carefully crafted, honest response.

The Feds allocated funding years ago; more than half of States have not used their funding (reported about a year ago in the press).

While WHO has emphatically called for preparations to be made by nations, risk seen has been assigned low-to-medium probability by the citizenry at large and public officials in many parts of the world.  That despite the clear nearly linear trend of the spread of H5N1 across Asia, Europe, and parts of Africa and the South Pacific.

This dangerous avian infection will continue to spread - there is no logical reason to suppose that it will be magically geographically constrained.  Facts of species-boundary crossing ability and lethality in it's host vector should stand on their merit as causing severe concern among those who job is to assess potential danger to public health.  Couple that with apparent plasticity in mammalian influenza strains (that have also jumped species) - and your warning antenna should be vibrating with urgency.  Throw in a handful of other overt indicators, and you should be frankly alarmed.

But that won't happen, because those who survived the worst pandemic known in modern times - they have passed on. Public recollection of that monumental public heath threat has dimmed.  More recent notable influenza pandemics have been relatively mild in comparison.

Public confidence is also conditioned by generations of confidence in vaccine and drug intervention to ward off the worst of pandemic influenza and complications.  This confidence will prove to be cold comfort in the face of grim pandemic reality. There will be no general vaccine for the public - any that is available will be dispensed to a select few. All but one anti-viral in use at present, have been shown to be ineffective by means of increasingly common viral genetic rearrangements.  Plus we have a plethora of community-acquired multi-drug antibiotic resistant strains that are carried quietly within the populace.

More worrisome is the espoused logic of Federal dependence on the Red Cross and County/State social welfare services.  The former is in debt and massively downsizing; the latter's resources are stretched thin under a slowly evolving economic recession and progressive budget cuts.

Difficult decisions will be made, regarding who gets and who does not. As many as 3.5 million people experience homelessness in a given year (1% of the entire population or 10% of its poor). That number is rising.  What do think will happen when pandemic hits, and many of the poor and middle class are unable to pay bills in an economic crunch?

There are no emergency legal provisions that will require utilities not to cut off services, that will stop banks and credit lenders from punitive action, nor landlords not to eject tenants - ballooning the number of homeless at critical time.

For those of you cringing at an objective statement of fact, be comforted by your mindset of material preparation - an important step to limit collateral damage from a major pandemic.  Social preparation by neighborhood groups that link to form a prepared response among local community are still possible in the future.  Missing here are discussion of psychosocial and personal health preparations that stand equally as a triparte strategy for interconnected individual and group proactive planning and action.  

The Federal government has given us it's version of planning and response and defined it's role in shared responsibility.

It's time to stop wringing our hands and asking who will "pay for it".  You have been given your answer.

I appreciate Dr. Raub's attention to our questions.
HHS is committed to continuing its strong role in public communications about seasonal and pandemic influenza.  The website Pandemicflu.gov will remain the lynchpin of our messaging machinery.  But we recognize that we need multiple modalities to promulgate and reinforce preparedness messages; and we constantly are alert to opportunities to try new approaches and strengthen existing ones.

This is sad, though.  Does anyone think this is adequate:  "continue its strong role" and the Pandemicflu.gov website as "lynchpin"?  When will any government agency ramp up the message delivery so that everyone hears that schools will be closed and stores won't be stocked as usual??  (Not to mention that the power grid and water/sewage systems are not guaranteed to keep working.)  IMO if a strong message went out, there would be a percentage of people who would attend to it and a smaller percentage (people who are now clueless about a pandemic) who would start pushing for more preparations in their communities.  (BTW, there are local organizations promulgating community gardens, connections to local farmers, and shopping for locally-grown food, as well as other groups for bicycle commuters, peak oilers, mothers groups, Boy Scouts, campers, etc. who have a head start on prepping but probably don't know it.)

IMO it isn't enough to be "alert for opportunities" to communicate.  HHS  (or DHS or someone) has to create opportunities.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

Official portal

 It is an official portal. I wish Pandemicflu was more uptodate and had more.

 Look at why people make Yahoo their web page - daily updats! Feed people, make them feel engaged. Do not make them work for the message.

 This is why we come to Fluwiki - right?

 I agree with you. I feel Pandemicflu.gov webisite is broken.

  How do we fix it. How do we make it better to attract new people.

  1) Daily updates.
  2) Highlight towns that are "doing it right", Yes I mean the town not an official. There are very few officials who want to play or get the word out.
  3) Email list of weekly news (I do it)
  4) Prep of the day tip
  5) Ask the experts
  6) Averge Joe answers - person to person
     The list goes on.

  Just because the feds say "come here" dose not mean people will.


[ Parent ]
CIDRAP coverage
HHS advisor fields online pandemic preparedness queries

Stephanie Marshall, HHS director of pandemic communications, said HHS is pleased with the question-and-answer discussion between Raub and the FluWiki community, and that she believes this is the first time HHS has participated in this type of online discussion.

"It's an opportunity to reach a very interested and engaged audience and it's something we're considering doing more of in the future," she told CIDRAP News.


it could be said that another *oportunity* has been *created* (by both parties, in a historical process)
This reminds me of the 60-foot rope hanging from the top of a 100-foot cliff metaphor by crofsblogs' author.

How to make the best of this oportunity, how to create said opportunities in other locations around the world and make the best of existing ones, seems to be, well, up to all parties involved, really.

So maybe it's not just about teachable moments anymore (of which there are quite a few), but conversationable moments and engageable moments too.

It looks like it can be done.  In fact, it is being done, a bit.  We just need much more of it.

Thank you for engaging in this conversation.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
btw, with all respect, a conversation with flubies takes us no-where :-)
i mean, look around the room: who's missing? just about everyone else!

it's them we're talking about


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
with respect
that's not completely true, given the million page views a day and the multiple flu stories placed there.

[ Parent ]
ok, but/and
So far, I see a lot of "flubies to flubies" conversation (with useful yield), and some success in "flubies to non-flubies" (so that non-flubies become flubies, so to speak).

At the same time, I think I'm not alone in the opinion that "feds to flubies" (*more* "fed to flubies", and even different "fed to flubies") is somewhat useful, but it might be a good idea to see more of the "feds to non-flubies" part.

I think that's what I meant, and sorry if it came across as something different.

Of course we're getting "somewhere".

But we could go faster.

Maybe even faster than the next pandemic.

An uncomfortable "maybe".

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
...and that was the thrust of the PSA question. We can help, Lion's Clubs can help, etc, but more needs to be done and faster.

I suspect the problem is that there's no unanimity as to what to say.

[ Parent ]
Public meeting on web
  I see your point. There are alot of people looking and hopefully thinking about what we are saying.

 I undersatnd and agree with lugon that it would feel better to have more officials in the mix. Brining in new people would expand the hive knowledge base.

  I trust the audiance is listening, I pray they are acting.


[ Parent ]
Dr. Raub, Thank you
Dr. Raub,

  Thank you for acknoledging that the novelty of H5N1 has worn off. I was watching Channel 12, a local TV channel in Vieanna VA., last night with Govenor Tim Kains Pandemic message. This is the first time I have seen that message on TV.

 Yes - mortgage payments are outside the relm of HHS to change - but knowing what problems people face, where some of the stress and fear is comming from is vital to working with people.

 I do believe you have said it is "unrealistic expectation that the federal government has the fiscal and logistical wherewithal to do everything for everyone.  It does not."  I have come to that conclusion for many reasons.

 Dr. Raub if local and municipal leaders will not budge on this then pressure needs to be exerted from below. Many of us seem to be just average people. I hope you take some time to read over this web site to see the average people working. There are people listening even if local leaders appear no to.

 How the supply chain may break down is a matter of some debate. People will make due according to their skill and ability.

  Thank you for the time.


I'm sorry, help me out here
Strong, sustained communication about the threat of pandemic influenza and recommended countermeasures is central to preparedness.  The challenge is more difficult now than 2 years ago because, for many laypersons, the novelty of the topic seems to have worn off and anxiety seems to have diminished.

While I acknowledge that the novelty has worn off, this is a challenge to the government's efforts to communicate ONLY IF they are ACTUALLY taking steps to inform the public, and the public refuses to listen.

Are we seeing such activities?
 Is this consistent with observations out there, that the government is taking vigorous steps to inform the public, and that it is the public that is at fault, for being complacent?  

Are we seeing PSAs being played repeatedly on primetime and that people switch channels cos it's no longer 'novel'?  Has the Surgeon General (whose job it is, as far as I understand, to advise the people on matters of health and warn them of hazards) put a letter in every mailbox telling them that the government recommends every family should have 2 weeks of food and other essentials?  Has the head of the CDC or NIH or some such similarly august and respected institution given media interviews about the need for the average citizen to prepare?

HHS is committed to continuing its strong role in public communications about seasonal and pandemic influenza.  The website Pandemicflu.gov will remain the lynchpin of our messaging machinery.

May I ask, with respect, if Dr Raub or anyone from HHS is reading this, WHY the website has to be the lynchpin?  Have they been told by experts that putting something up on a website which is not promoted in the general media is the most effective and efficient way to inform the public about anything?  Is there any evidence that supports that?  Last I checked, pandemicflu.gov appears to have a traffic ranking of 318,437, compared to 855 for Washington Post and 599 for People magazine.

But we recognize that we need multiple modalities to promulgate and reinforce preparedness messages; and we constantly are alert to opportunities to try new approaches and strengthen existing ones.  In that regard, we value the new formats and pathways that the Flu Wiki community provides; and we are grateful for the thoughtful recommendations and critiques that have come our way as a result

Thank you. It's always good to know that we are appreciated.  However, such words begin to ring very hollow indeed if we all here, the Flu Wiki community and other online flu forums, have been repeating the same thoughtful recommendations and critiques over and over again, and all we get is another expression of appreciation.  Since that time when Secy Leavitt chose to ignore the overwhelming requests, recommendations, pleas, on one of his blogs expressing the need to educate the public clearly and unambiguously, has anything changed?

Is it time to say, enough is enough?

I don't know what kind of dynamics is going on inside HHS, inside ASPR, inside CDC, but whatever it is I for one am not willing to waste my time on agency politics.  I'm just wondering if, next time when there is another one of these 'public engagement' exercises, whether it is time to call the government on their own game, to say

Please prove to me, sir, that it is worth our while to spend time talking to you.  Engage with us first, address the issues we already told you repeatedly about, before asking us to engage with you!

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

Jan 4th Coast to Coast radio program with Art Bell, Dr.Gary Ridenour
These are my notes taken from the radio late night program Coast to Coast with Art Bell. The first part is from the Coast to Coast site but following the introduction are my notes taken during the broadcast. The information is truly scary, from a doctor, and should be on all the news.
Avian Flu Pandemic:

Art Bell spoke with practicing Dr. Gary Ridenour about why he believes that avian flu represents the greatest health threat to mankind in the history of the world.

The current strain of avian flu kills about 60% of the people who contract it in as little as eight hours, Ridenour said. In order for it to become a pandemic, he explained, the virus must mutate down to a less lethal but far more infectious form that can be spread from one person to another. Ridenour estimates a one in three chance of an avian flu pandemic in the near future.

Though seemingly counterintuitive, Ridenour said the death rate will be highest among 20 to 40 year olds because they have the best immune systems. This is because the avian flu harnesses the immune system to attack and dissolve the tissue in the lungs. According to health experts, this "cytokine storm" is one of the main reasons so many young and healthy people died during the 1918 flu pandemic -- an outbreak that killed an estimated 50 to 100 million people, Ridenour noted.

He estimates this time up to one billion people could perish during the pandemic, but not solely from the virus' lethal effects. Instead, Ridenour believes many will not survive because of a disastrous infrastructure meltdown caused by the pandemic.

Ridenour noted that Tamiflu and other flu treatment drugs will likely not be an effective defense against the virus. If people can stay secluded indoors for the first 8-10 days of the outbreak, he recommended, there is a good chance they will survive the first wave.

Inevitability & Spread:

Avian flu killing now more than 60% of the people that get it, most often in the area of Southeast Asia but the bird flu itself can now be found in around 90 countries throughout the Asian area and the middle east. The "hope" from CDC etc, is that the avian flu virus will drop to at least 10% death rate, but no guarantees that it will do so.

Most people that currently get it, will have blood and body fluids pouring out of their lungs, and most will be dead within around 8 hours, and the highest death rate are those individuals aged from around age 20 to age 40. The death rates of other ages will happen, but secondary death rates from other things will contribute to their deaths. The most susceptible are those individuals with a great immune system. The better the immune system, the more likely that they will succumb to this.

The current yearly flu vaccine, runs about a year late, and science has to guess what the future flu will be, and just like 2008 flu season, most vaccines were not made for the current strain that is creating havoc in the US. The process of making flu vaccine is over 50 years old, and uses eggs to make a vaccine. The problem with the avian flu is that the virus kills the entire egg, thereby no vaccine can be created.

The Center for Disease Control (CDC) states that the avian flu virus is the "greatest threat in the history of the world for mankind."  A very dire disease that will cripple all modern day conveniences that the developed world enjoys currently.

The Spanish Flu of 1918, was a member of the "bird flu" family and world wide had a death rate of around  5% to 10%, while in the USA the death rate was around 2.5% to 3%, and that death rate at that time brought the country to its knees, and very close to collapsing. Most all commerce stopped, no public meetings, no church, no funerals, etc., but more people at that time were able to take care of their own needs by having animals, growing their own garden, canning. Things were done by hand, like banking, mail, and most people lived on family small farms, or more isolated. Today that is not the case as mega cities has grown up, very few people grow their own food, and modern life in interacted with electrical needs etc. People are now dependent on the modern way of life.

Currently the avian flu kills its host so fast, that it is difficult for it to spread beyond a narrow margin of people, but the CDC says that the virus is mutating down, and that the death rate will drop allowing for the further spread of the virus much quicker and more efficiently.
Precautions & Preparations:

With all the hundreds of people that have died in the southeast Asia area, so far there has only been "2" autopsies of people that have died of the avian flu, due to cultural differences, and time lags. It is estimated that that the bird flu, once it goes pandemic, will be the main strain of flu for the next 15 years in the world, with wave after wave after wave washing over the land, with mutating as it spreads.

The CDC states, that is not a question of  "if the avian flu will be a pandemic on the world, but when." The virus continues to mutate and , it is spreading and not stopping due to seasonal differences, and it is moving with the commerce of the world, most often due to bird smuggling, and movement with meat. Not too long ago, in Louisiana, some farm pigs, contacted the avian flu, and were found infected, but were taken care of before it spread from them. The pig itself is close to the human in terms of medical items, and many times pigs will be a mixing bowl of sort of the virus and will spread from them to humans.

Not too long ago, in Vietnam, a veterinarian was taking care of some livestock, and he came down with the bird flu and died. His brother that had not been around the birds previously, also came down with the bird flu and died. Another brother hopped a plane from New York and visited them before they died, and on his return trip to New York, came down with an illness. He was quarantined in New York and tested, before being released, but this shows how quickly the bird flu will spread once it begins to go pandemic.

It is suspected that once the avian (bird) flu, begins to go pandemic and hits the United States, that within a weeks, all the caskets in the country will be used up and no further caskets will be gotten to use, do to sickness and death of casket makers, and funeral homes.

Tamiflu medication, which is the medicine of choice, will be in extremely short supply and most people will not be able to get.. So for most people, once they are exposed to the avian flu, they can expect to begin to get sick within a day or two at the most, and if they do not get it in the first wave, will be susceptible in the following waves if they expose themselves to other people.

During the 1918 Spanish Flu, there were no funerals, no meeting but those people that isolated themselves in their homes, with zero contact with the outside world, were able best to not get the Spanish flu. At that time it was found out that if a person could sequester themselves in their homes for at least 10+ days, that the wave of the Spanish Flu, basically moved on, but with the next wave coming thru the community, again they would have to stay indoors.

It is estimated that one of the large infrastructure items to fail first, is parts of the electrical grid, and this would begin fairly soon, within a week or so, with rolling blackouts or total failure of the electrical system in area, some sooner than others. Along with this, all communication systems (telephone, internet, etc) will fail fairly rapidly in short order, due to electrical problems and lack of personnel to fix and continue the system.

First responders (fire service, ambulance, police) will succumb fairly soon, due to being exposed and will leave their posts to protect their families. Another problem will be a lack of fuel (gasoline, diesel), for emergency vehicles and many will sit idle not being able to respond even if needed due to lack of fuel. Lately this occurred during the ice storms back in the Midwest, and handpumps were used to get fuel out of underground tanks and taken to emergency vehicles, a slow process and a dangerous one. Aircraft will another problem due to sick pilots, lack of maintenance, and lack of fuel, so the air fleet will be grounded in short order.

With about 80% of all pharmaceuticals coming from overseas, many people that currently take insulin will be without and in dire straights without their medication and most likely will succumb to that. Along with kidney dialysis and many other medications that people rely on, like high blood pressure medication etc. These secondary deaths will number in the 100's of thousands and even if they do not get the avian flu itself will succumb to the effects of the avian flu on the world.

It is expected that at hospitals will quickly run out of beds, as about 90% of all beds are in use even now, and even if most of the patients could be taken out and the beds used only for avian flu victims, that 15 to 20 people would vie for each bed. Not a comforting thought, not even counting the lack of Tamiflu, medications, ventilators, or personnel. A poll was taken of hospital personnel, and 40% said that they would abandon their work, to be at home to take care of family members. Basically with nothing that can be done with people that get the avian flu, only those that are spewing blood for body openings will be allowed into the hospitals, if the personnel are there to assist them. Then the people will be given morphine, as long as supplies last, to let them die in comfort at least, but the morphine will run out very quickly.

In England, the plans are in place currently, and buildings found that will be used to house mortuaries, where the dead will be placed. When the buildings are full, the government is planning to burn the whole building.

The bottom line is that, one must be able to protect themselves by being isolated. A person should be understanding this, and planning what they would do, like covering their windows to make sure that no light escapes from their windows in a blacken city or country side, as that will send a beacon to anyone out there, to come see what I have. Not an encouraging sign.
'Can of Beans' & Survival Tips

Basically what a person should know, is if the power went out right now, what would they need to keep warm, cook food, water supply, etc for the next month. If you can figure that out, then you would have a good chance of making it thru at least the first wave.

It is estimated that most of the infrastructure  will break down and be down for a period of months (a year to 18 months) with very little food, medication, fuel, and electrical available. Planning is essential before hand, not after the pandemic begins, as once it begins it will not only be too late to gather supplies, but one will expose themselves at a high risk, due to being in public and fighting over the remaining cans on the shelf. Does not take much planning to know what a person needs for survival. But planning is needed. There will be no second chance.
The book "Pandemic" can be purchased at the Website www.pandemicdirect.com

[ Parent ]
Thank you Dr Raub
I appreciate you taking the time to answer our questions.


Life is not so short but that there is always time enough for courtesy. Ralph Waldo Emerson

A Very Simple Question
ust posted as a separate diary for visibility but relevant here.

"This question has been sent to Secy of HHS Mike Leavitt, his scientific adviser Dr William Raub,  HHS director of pandemic communications Stephanie Marshall, ASPR RADM Craig Vanderwagen, and CDC Director Dr Julie Gerberding.  It's like firing buckshots at a barn door - I appreciate that senior officials are very busy people and don't often have time to engage with flu bloggers as Dr Raub has been doing recently, but still I hope to get some response/answer from at least a few of these distinguished folks.  ;-D

More here

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

vibrating antenna
searching this long thread for probability, I find:
> and your warning antenna should be vibrating with urgency
> you should be frankly alarmed.

who said this, Raub or oracle ?
How can it be translated into numbers ?

Is there some sort of competition going on to invent ever
more non-expressive formulations concerning the
risk of a pandemic ?

whom to trust ? Find the persons who gives you numbers !

ask experts for their subjective
panflu death expectation values
and report the replies

DC hotel
  This moring I gave the receptionist and manager some OSHA, WHO and fluwiki pandemic papers.

 1) They accepted them without screaming at me.
 2) They where more interested in debaitng teh authenticity of the document than if H5N1 is real or not.
 3) Because they live in DC the idea of "Life at ground Zero" is ingrained. Some do have three weeks of food.
 4) The receptionist is actually studying to be a Nurse so she was really interested. I had to switch between layman and techno talk.

 Dr Raub - these people are the exception. Most do not have a weeks supply of food at home nor at they inerested.

 Please do not use the folks in DC as a guide - they are way ahead of most of the people I know from others states.

Take care,
Spread the word.

?Mutating down?
Dr Raub you said:-

'Currently the avian flu kills its host so fast, that it is difficult for it to spread beyond a narrow margin of people, but the CDC says that the virus is mutating down, and that the death rate will drop allowing for the further spread of the virus much quicker and more efficiently'

Please point me to the source that says the virus is mutating down.

I can find no evidence of that in any of the active virion clades. In fact tracking over a period of time tells you overall CFR is rising but this due to the accumulating effect of the sustained 82% kill rate in Indonesia.

The theory that it kills too quickly and therefore burns out is not born out in the reality of this current disease [average infection to hospitalization time is 4 days]During this average 4 day period, if the victim had a human to human transmissable disease it would be possible to infect many before death.

Once again, the only thing that stops this virus is its limited H2H transmissibility not its fatality rate.


 Man occasionally stumbles over the truth.  Most of the time though, he manages to pick himself up and carry on as if nothing had happened.

Winston S Churchill


[ Parent ]
I think you misquoted ;-)
The mutating down comment was made by Gary not Dr Raub.  


The only comments attributable to Dr Raub on this thread are on the top diary, with the Q&A.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Shortage of Ventilators
The shortage of ventilators in a pandemic always seems to be answered in the same way.

1. We know we will not have enough but they are expensive, so we will only stockpile a few now.  There is just not enough political will or foresight to spend what is actually required.
2. When the pandemic strikes, we will triage people to determine who gets the few available ventilators and so has a chance to live.

There is another alternative that never gets mentioned in the official plans.  Using home made ventilators built from readily available materials when the pandemic strikes.

Home made ventilators were successfully used to save lives during the polio epidemic in the 1940s and 1950s.  These were very primitive by todays standards, but they worked.  Using repurposed modern industrial electronic control systems (PLCs) and ordinary solenoid valves it is possible to build reliable ventilators that can safely do the job.  

At the Pandemic Ventilator Project www.panvent.blogspot.com we are working on 2 prototype designs.

Support the Pandemic Ventilator Project


Vents - alts

 Hi. I believe you are right about the official line of cost and triage. The ventilator triage for New York posted by DemFromCT is the hardest thing I've had to read concerning H5N1 and mostly likely the hardest thing I've ever had to read.

 There are home brew solutions. I am glad they are being published and wish they where being tested. When faced with a dying friend, relitive or even stranger I doubt many will sit back and watch. Engineers and shade tree mechanics just may use air mattress pumps to foot pumps.

 I worry about endorsing the activity as

 1) If a city can sell bonds to build a multimillion dollar road they should be able to buy vents. Else they may just end up foot the bill for a million dollar grave and monument to those who died.

 2) Trained personnel on how to work the vents.

 3) Mass produced vents. Instead of turning out a pickup truck or computer every min, many companies could retool and build vents.

 4) Dr. Leavitt of HHS is funding projects to find alternatives.

  5) College competition - pull a McGuyver and build a iron lung with just duct tape, 55 gallon drum, three washing machine water inlet valves and timer made from a rotaing pie plate on a fan motor. (paint the rim of the pie plate with two alternate rings of paint to control the valves.

 Extra credit: use washing machie drum for the iron lung

 Extra points for re-using float sensor for over/under air pressure sensor and lights for display.

 Advanced credit for seniors only:  do not use duct tape.

  Dreamer, there are always alternatives but TPTB can act now to create easy replilcatable solutions.

Just my opinion.

[ Parent ]
Polio is not same thing as viral pneumonia, is it?
Maybe I don't know what I'm talking about here.  Or maybe I do have a clue.  Dem from CT, can you comment?

It seems to me that iron lungs or home-made home ventilators for polio patients were needed in order to overcome the lack of muscle activity needed for the mechanical process of breathing.  There was nothing diseased about the lungs themselves, right?  Not necessarily, anyway.

Lungs infected with severe influenza that may be entering the Acute Respiratory Distress state brought on by cytokine storm are already very damaged and extremely fragile tissue. Wouldn't a homemade device be just as likely to cause further harm as to do any good? Especially in untrained hands?

No, if we are going to go the ventilator route, I think we need to come up with the money to buy professional machines and train people how to use them.  By the way, there are exceptionally few cases in China and Southeast Asia in which an H5N1 patient requiring ventilation actually survived.  Nearly all of them die.

[ Parent ]
Efficacy of vents

 Hi. I hope DemFromCt or SusanC do comment. I confess a over abundace of medical ignorace - give me a 327 small block or dual core RAID-10 proliant server over a real person. Severs and cars do not sue :o)

 Your quote statled me
"exceptionally few cases in China and Southeast Asia in which an H5N1 patient requiring ventilation actually survived.  Nearly all of them die."  Eeek! Well onward and upward to "do your best"

 While I agree with "trained personnel" for fragile avioli of the lungs and how it applies to "do no harm", my eyes water at the thought of doing nothing while watching someone die.

 If there are not enough vents and there is nothing to do but "make them comfertable" that is one thing. But this is a case of planned medical scarcity not solutions.

 A pandemic will happen and medical supplies are not being purchased. Hence it is a planned disaster just like leaving port with 1,200 passsengers but only life boats for 300 of them.

 Sadly the penalty for not buying enough vents and causing 100 deaths is the same as causing 1,000 deaths.

  Flutraker, I agree home made vents with no guages, certification nor calibration are hazerdus at best. That is why I do not endorse them as a solution. However when TSHTF I feel, honestly feel, people will try what ever they can to save another. Frankly I would be disapointed if they did not.

 Just my opinion.


[ Parent ]
I'm not a pulmonologist
but let me hazard a non-technical explanation here, from what I understand.

Yes, iron lungs work in polio because it replaces or does the work that the paralyzed muscles were supposed to do, which is to move the chest wall to create the negative pressure needed to suck air in to the airways, basically.  And you are right that the airways and lungs are healthy in polio, so that the pressure needed to inflate the lungs lies within the same range as when the person is breathing on their own.  Thus the lungs are not under more stress than with normal breathing, and the danger of inadvertent lung damage is much lower.

In the case of ARDS, the primary problem does not lie in the muscles, but in the damage to the lungs.  The lungs become stiff and require higher pressures just to inflate.  At the same time, they are also fragile and prone to further damage and rupture.  Ventilation becomes very hazardous because (just from the mechanistic angle) you need higher pressures to overcome the stiffness, but the higher pressures are also likely to cause the stiff tissues to rupture rather than inflate, causing pneumothorax (air escaping into the space between the lungs and the chest wall) and other serious and potentially life-threatening complications.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
there is also the issue of
'end expiratory pressure'.  In layman terms, during normal respiration, when you breathe out, the pressure in the airways drops.  It continues to drop till the very last moment just before you switch to breathing in again.  This is what we call the end expiratory pressure.

For polio, in a healthy lung, all you need to do is get something to do the work of what normally the muscles will do, and the end expiratory pressure needs to be no higher than what one would need in normal respiration.  Iron lungs cannot deliver more end expiratory pressure than normal (which essentially is atmospheric pressure), but that is not the case with diseased lungs and airways.  In these cases, optimally you would want to maintain some degree of positive (in relation to atmospheric pressure) end expiratory pressure just to keep the airways/lungs from collapsing between inspiration and expiration.

Modern ventilators and CPAP machines are able to deliver that.    Not so with iron lungs.  It is a critical component (as far as I understand.  Dem?) of respiratory therapy in such instances.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Iron Lung

 Hmmm. Interesting. I would have thought the paper thin wall of the avioli would be safer with external force than internal force.

 Hmmm (looks around room) there must be somethig I can make a CPAP out of.


[ Parent ]
If you are that interested, Kobie, people sell used CPAPs on E-Bay all the time.  You might want to have a professional check it out and do maintenance if you acquire one this way, though.

I don't recommend it, though.  Just seems to me like it's not going to work, may do more harm than good, and the risk of infection to the caretaker would increase.

Just my 2-cents.  Maybe I don't know what I'm talking about.

[ Parent ]
The goal is...
...to sustain and treat the infected flu patient to prevent or at least moderate cytokine storm and ARDS, isn't it?  We don't want them to get to the point of needing a ventilator.  (When most of them will die anyway.)

That's why we need better antivirals, and we need them like yesterday.

[ Parent ]

  Absolutly - prevenet long before ARDS sets in.

  There is no need, and very little good, in promoting home made vent. The number of things people build right the first time is small.

  There is no supstitute for experiance.

  With that said I doubt all the ARDS cases will be prevented. Though India has not had any human H5N1 cases moved fourteen (? think it was fourteen) extra ventilators into the country a month ago during their outbreak.

  I applaud Dr. Levitt for pushing for new developments in ventlators. College competition often bring out new ideas on a shoe string budget using COTS (consumer off the shelf) parts.

  N.A.S.A. used ot publish their spin off catalog of ideas and products. They went to do a and found B,C,D, and E.

 Anybody heard of Teflon? That is a N.A.S.A. spin off products.

 I think the same would go for vent build compition.

 Lastly, FluTracker I still belive that when someone is taken off a vent the freinds and family will try and save them. I see it in pet owners and parents who must make hard descisions. While the doctor may have seen a hundred cases the parents are seeing it for the first time. In their nieve hope some bad descisions are made.

  Where do we draw the line at making do?

  If there is no vent, we just make the patient  comfertable? we do not try even though we might build and operate one?

  If there is no electricity - do we just make the patient comfertable even though the family could bring in their generator and gas to run the equipment?

  WW-III, MAD, planning of stockpillin morphiine was easier to take because there was nothing that could be done. With ARDS it just may be a lack of equipment. A man made disaster.


[ Parent ]
E-Bay - thanks for the idea. The CPAP filter and my lack of training are holding me back n/t

[ Parent ]
OK, then. Why not spend the $$$ on morphine and N95s?
Thanks for your answer, Susan C.

It sounds like ventilators -- professional models or homemade -- are going to be durn near worthless during a pandemic of severe, virulent influenza.

So...why not spend more money -- LOTS more money -- on morphine for keeping people "comfortable" and PPE for healthcare workers, including the "health care workers" at home(read that as moms, dads, and other family members) who need to protect themselves from infection while giving care?

How about lots more money applied to fast-tracking the promising new antivirals that are out there, to replace the Tamiflu that is clearly going to become rapidly ineffective, if seasonal strains are teaching us anything.

Why are common sense approaches so difficult for government and businesses to pick up on?  Why so slow?

[ Parent ]
yes. I've always been dubious
about spending large amounts of money on vents.  For every person we can put on a ventilator, with all the necessary highly trained staff and all the rest of the expenses required, we can treat a much larger number of serious but not critically ill people, thus reducing the number of people who will be come critically ill in the first place!

I believe we need to spend a lot more on PPE, antivirals, antibiotics, IV, oxygen (and ability to deliver mass oxygen therapy), morphine, etc.  Until we have enough capacity to deliver 'austere' care to large numbers of seriously ill people, we should not be putting money into vents AT ALL.

It's a complex discussion that we've entered into before.  Check out this comment http://www.newfluwiki2.com/sho... and the rest of the related comments on that diary.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
let me especially quote this comment
cross-posted from here http://www.newfluwiki2.com/sho... on

My POV is this option needs to be put on the table, as part of planning.  The big picture reality is that this is about what is the best use of limited resources in a pandemic.

Now, let's back up a little and consider how much it costs to put a patient on a ventilator.  The following is from the journal Critical Care Medicine, showing the relative costs of caring for patients all of whom were in ICU:

Daily cost of an intensive care unit day: The contribution of mechanical ventilation
Mean intensive care unit cost and length of stay were $31,574 +/- 42,570 and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and $12,931 +/- 20,569 and 8.5 days +/- 10.5 for those not requiring mechanical ventilation.

OTOH, let's say simple replacement IV fluid infusion costs maybe $10 per day plus staff and other basic care costs.  Higher if you add antibiotics and what-not, but it's still way less than ventilating one patient.  How many people can you give say 2 days of IV to for each patient on ventilator?  Or how many sets of IV infusions can you buy for the cost of one additional ventilator that they are buying now?  What is the current state of stockpile of such basic items?

Of course, the calculations are a lot more complex than that.  But the fact remains that in a fullblown pandemic, there maybe many hundreds or even thousands of patients who would benefit from simple treatments like IV's, oxygen, and basic respiratory care that cannot be delivered at home and require a small degree of professional supervision.  Remember the photo from John Barry's book?

For a proportion of these patient, having access to such care may make the difference between rapid improvement and deterioration and loss of life. 

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
also this
As TXNurse said on that thread
In my 10 bed ICU unit there are about 22 nurses on staff

If you have 22 trained nurses, would it be better to have them try to save 10 patients, and probably end up maybe saving 3 of them if they are lucky, of whom 1 will have severe permanent disability, in the middle of a pandemic?

Or would it be better to have those 22 nurses caring for 100 patients on IV's and oxygens, of whom let's say 20 for whom this made the difference between life and death or long term severe disability?

Remember, these are highly qualified and competent staff.  Each one of them can, for example, supervise a whole number of other less experienced staff and/or even volunteers.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Please look
Please look...

Your motives are genuinely good, but please look at the differences between polio-caused respiratory failure and that of flu.

Polio paralyzed the muscles we use to breathe-H5N1 destroys the lung tissue itself. The alveoli-the very site where oxygen and carbon dioxide exchange-becomes clogged with plasma, debris, blood cells from the destructive power of ARDS-Acute Respiratory Distress Syndrome.

link: http://www.ards.org/learnabout...

Managing a patient with ARDS takes far, far more than the venilator-the patient must be intubated or have a tracheostomy, the mix of oxygen into the body must be care fully measured, frequent arterial and venous blood tests must be done....there is a long litany of work to be done by a very highly educated team of health care professionals. The patient must be heavily sedated (thru iv medications given with pumps to prevent pulling out all the tubes, daily or more chest xrays must be done. Even today there is an extremely high death rate from ARDS.


Without these support services a ventilator can do far more harm than good.

Please-look into what makes up mechanical venilation past the machine itself. Talk to doctors, nurses, respiratory therapists.............  

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
I agree completely
I don't think home vent training is the answer.

there is a plan to do "just in time" respiratory therapy training (Project Xtreme), and some people might be helped. Also, all patients with panflu might not get ARDS.

So many variables... no easy answers.

[ Parent ]
Homemade Ventilators
Uhhh...where to begin...

Using a ventilator to assist a polio victim is a completely different situation than using one to assist/control an HPAI patient.  

The polio patient was in respiratory distress secondary to paralysis of the muscles of respiration.  The iron lung was a mechanical substitution for those paralyzed muscles.  Those patients that acquired pneumonia as a result of hypoventilation largely died from their infections.  

The HPAI patient presents with a different scenario.  These patients are not merely having problems "breathing", but also oxygenating.  The problem is not merely a mechanical problem, but one of oxygenation.  There are so many secretions, due to hemorrhage, pulmonary edema, etc., that even tho a homemade vent could replicate the mechanics of respiration, the pressure required to oxygenate the patient would be so great, that only a skilled provider could handle it.  

It is true that the potential barotrauma inflicted by such unskilled attempts at "civilian" ventilation could kill the patient just as well as the disease.  There would also have to be a skilled provider to insert an endotracheal tube or a surgical tracheostomy prior to utilizing any mechanical ventilation.  That would require intubation equipment and medications.  Frequent suctioning of the airway would also be a requirement.  

This is not an endeavor for a layman.  IMHO.

again, agree completely n/t

[ Parent ]
Time to replace Tamiflu with something else?
I wish I had seen the earlier thread seeking questions to submit to Dr. Raub.  But, taking the chance that he or one of his staffers is still reading this, I'd like to ask / propose the following.

Isn't it about time to place highest priority on getting some new drug on board to replace Tamiflu?  Doesn't the recent disturbing news about increasing incidence of resistance in seasonal flu strains tell us that Tamiflu is going to be of limited usefulness once pandemic flu breaks out?  It apparently doesn't take many passages through humans (and maybe water birds too, since Tamiflu does not biodegrade in water or sewage systems) for influenza viruses to evolve resistance to Tamiflu's formula.

I myself know of three promising new antivirals (their developers claim they are promising) that are reported to be effective against influenza, including H5N1, both in vivo and in vitro.  They are:

Bavituximab (formerly called Tarvacin).  Peregrine Pharmaceuticals, San Diego, CA.

REP 9C. REPLICor, Inc.  Lavel, Quebec, Canada.

T-705. Toyama Chemical Co., Tokyo.  Fujifilm Corp. recently bought 66% of this firm with the idea of marketing this new drug by 2009.  Bloomberg News Service did a story on this acquisition just a few days ago.

How about the US Dept. of Health and Human Services doing everything it can to fast track the final clinical trials and preparation of these drugs for the marketplace, including FDA approvals of course.  

How about DHHS "jump starting" the initial market for these new antivirals by placing a huge order (as you did with Tamiflu, invite the States into a partnership buying agreement)?

Please don't tell us why this isn't possible.  Find ways to make it happen.

New and better antivirals are going to be needed during the 6 to 12 month time period when the vast majority of the population will go un-vaccinated and illness & death will be rocking our nation.  

they are doing a fair bit on antivirals
and medical countermeasures in general.  The most promising antiviral is Peramivir.

Here are a couple of useful slides from the presentation by Robin Robinson at the National Emergency Management Summit (full slides from link)


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Peramivir has problems
There was a discussion about this at PFI Forum a few days ago.  Pixie had some input there.  Suffice it to say Peramivir is not ready to go.  Not even near it.  They are planning revised trials against seasonal influenza NEXT flu season, not the one we are currently in.

I have continued to ask questions concerning the logistics of Peramivir -- which is being developed as an injectable or an IV-administered drug.  OK, then.  Is the liquid Peramivir going to need constant temperature refrigeration?  How's that going to work out (if it's needed)?  Will just plain folks be able to give the injection, or are we going to have to have licensed nurses or doctors on site to do it for every patient needing it?  Obviously a person must be trained to start and maintain an IV.  Where are all these people going to be available?

The neat thing about a pill or a course of pills is it can be taken home, carried around, administered by anybody who has been properly instructed.  Doesn't need refrigeration (when the power goes out).  Doesn't require another entire set of syringes or IV set-ups.

Does Peramivir have any use as a prophylactic?  For that matter, do any of the anti-virals I noted above have that potential?

I would sure like to see ONE federal official responsible for this line of development coming  here to communicate with us about what specifically is going on.

According to those two slides, DHHS has planned this pandemic effort out through 2012.  OK, then.  Hope we have that long...

[ Parent ]
New stuff?
Stop throwing technology at this thing its too small to see!
Start thinking how do I avoid the problem rather than stepping up and having a bat at it!

Isolation, Isolation, Isolation.

Governments don't want the sensible answer they just want the option that keeps the money coming in.

How smart is it to ignore the unpalatable likely event, in favour of the much more palatable [cheap] but unlikely option?

 Man occasionally stumbles over the truth.  Most of the time though, he manages to pick himself up and carry on as if nothing had happened.

Winston S Churchill


[ Parent ]
All tactics are needed
The social distancing / non-pharmaceutical community mitigation strategies are fine and will be employed.  However, it would be good to educate the entire population about them AHEAD OF TIME and why such measures will be needed.  We'd get better and quicker compliance that way. Don't see that happening.

Even with those measures, some people are going to become infected and ill with pandemic flu.  If some smart scientists in little pharma research firms around the globe are coming up with promising compounds that could replace Tamiflu (which your own UK has recently doubled its order of, by the way, and now it's looking like a useless med), I say let's "float their boats."

We need some way to treat people who get this terrible disease.  It would be great if the same medicine could be taken for prophylaxis, too -- that would keep some health care and vital personnel like police & fire on the job.

Effective medicine is the one thing that could be different from 1918, if things work out.  That and a vaccine, which will take time (it will seem to pass slowly) to make and distribute.  

It's that 6 to 12 months without vaccine that I'm asking the U.S. DHHS to address here.  I see nothing wrong with throwing all possible technology at it for as long as possible.

[ Parent ]
Pixie's concerns don't make peramivir useless
sorry, but the drug remains promising. Nor is tamiflu guaranteed useless.

Is that enough? I agree with you, probably not. But basic research on the science of flu infections, and drug research takes time.

the decision, rightly or wrongly, was made to invest in vaccine infrastructure, R&D and production.

Race for vaccine vs race to mutate.

[ Parent ]
The Glaxo pre-pandemic vaccine?
Thanks, Dem.  Well then what about the Glaxo pre-pandemic vaccine?

Any possibility the USA is going to acquire and use it?  Could someone from DHHS answer that?

[ Parent ]
I hope the thread will continue to be read
by HHS, and that in some fashion (including elsewhere) they address the wondeful questions people ask.

(by the way, i agree with many of Pixie's comments about peramivir being intended for in-hospital use, not so much as a broader net)  ;-)

The pre-pandemic vaccine is, of course, not pandemic vaccine. By then, the virus (whichever) will have changed. I think the plans for pre-pandemic vaccine were always to acquire and store for limited use in case 'other plans' don't reach fruition.

Those other plans have to include cell-based technology to mass produce vaccine in higher amounts currently possible, and even newer technologies such as universal vaccines that work against all flus as well as technologies that allow faster turn-around time. Those are years away, but at least the work has been started.

In the meantime, local health departments practice mass vaccine clinics and mass dispensing clinics even though we all know there ain't no vaccine or antivirals to go around.

someday there might be. it all depends how soon the pandemic is (and no one knows). Frustrating, but I think the state of the art.

[ Parent ]
couple more slides
this one on MCM goals, including prepandemic vaccine

This next is a very good slide that summarizes the whole strategy for mitigation, basically.

Here's the notes that accompany the slide, addressing the gap in countermeasures and medical materiel.  

This gap can be addressed by increasing the supply of these essential goods (by either stockpiling these goods in advance and/or increasing manufacturing before pandemic or increasing surge production capability during the event) and by reshaping the demand for these essential goods by decreasing the need for these goods (by limiting disease transmission and limiting illness and hospitalization).  The most prudent approach is to do both and increase supply while also decreasing demand.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
the concept is
that if they have stockpiles of prepandemic vaccine, which can be given at the very beginning of a pandemic, and if a recombinant vaccine is available (which can be made in 12 weeks or less) then together with community mitigation it may be possible to delay the first wave such that it may be possible to have more vaccines available for everyone before the first wave is over.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Lot of "ifs" there, but I understand
But still...

If there is going to be limited use of pre-pandemic vaccine used at the very beginning of a pandemic, I'd guess those shots will be going to...HCWs, military, police, utility workers (we can hope!).  The rest of the people need to have the rationale for this clearly explained ahead of time.

Same with community mitigation.  Explain and teach now, ahead of time.  Better compliance and better results that way.

[ Parent ]
Weary of delay...
That about describes it.

[ Parent ]
vaccine development
is a very long process, with a lot of products falling off the wayside.

Have a look at this.  From the presentation by Bob Kadlec in Phacilitate 2007.  

More details in this diary.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
GSK's press release on Prepandrix
Susan, have you seen this?


Comments?  This is the one I was asking about above.  It looks like Europe may go with this one.  First round of approvals are done, anyway.

[ Parent ]
I know
I'm not impressed.  I have a lot of reservations about adjuvants, and there are huge regulatory and logistical issues in their use.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
What about a "wartime" footing?
Yes, the chart above describes what happens under normal conditions.  

The problem is, killer pandemic influenza on the horizon is not "normal."

Instead it is quite possibly the largest, most vicious national security threat out there.  Who is the woman (Lauri Garrett?) at Council on Foreign Relations who is on record saying and writing that the only thing that equals it in magnitude potential is...international thermonuclear war?

Why has the U.S. government not recognized it as such and declared an all-out effort to get the job(s) done that must be done to face this thing?  I don't care where the answers come from...it should be an all-out international effort.  If an effective treatment comes from a Japanese firm, GREAT!  If a quicker (and safe) vaccine comes from Europe, FINE!

Again...I grow impatient.  We've been looking down the barrel at this virus since at least 1997, and intensely so since 2003.  Would this kind of effort have been enough in 1943?  Where's our Manhattan Project to take on pandemic flu?

[ Parent ]
in their defense
Why has the U.S. government not recognized it as such and declared an all-out effort to get the job(s) done that must be done to face this thing?

On the subject of pandemic vaccine development, I'd say that the US government has done a tremendous amount of work, much more than one can reasonably expect of any government.  It doesn't let them off the hook for any complacency.  But I'm just telling it like it is.  

I was very critical of them a year ago.  I must say that institutional culture has changed a lot, from what I can observe.  I suspect having the new BARDA authorities under ASPR was probably a good opportunity for them to review their processes, etc.

This of course is only my personal opinion, and as usual such opinion can change depending on what happens next... ;-)

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
here's the Draft BARDA Strategic Plan for Medical Countermeasure Research, Development, and Procurement

There's a lot more openness and accountability.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
there's a limit to how much you can hasten research ;-)
If you don't get the results, you don't get the results.  That's the bottomline.  As far as I can see, they are fast-tracking whatever can be fast-tracked.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
re "Laurie Garret, thermonuclear war"

the very first sentence

october 2005

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
I do think we are more prepared in 2008 than 2005
though not anywhere near prepared enough.

it isn;t that nothing';s been done, it's that much is unfinished, partly by the long lag times (e.g. vaccine R&D), and partly by the lack of political will (information to the public).

[ Parent ]
Laurie Garret - Agreed

 Good find - thanks. Sad that no one else takes it seriously.

 Personally, I rank H5N1 just under "Limited global termonuclear war."  MAD (mutualy assured destruction) or typical GTNW has a very low threashold for a global ice age. Why, so much dirt and debree is tossed into the air that a self sustaining nuclear winter is posttible.

 Self sustaining means the process re-enforces itself to where the polar ice caps meet at the equater for years on end. Those who can not live under the ice for hundreds or thousands of years loose out.

 It is how I sleep at night knowing the pandemic will be bad but temporary. We will make it. Things could be far worse. With H5N1 I can see a pre stage, a beginning, a middle, an end, a rebuilding and post pandemic world.

 I would also like to see us prep future generations for their pandemic. To save suceeding gernerations from the virus scurge that has brought so much untold horror and suffering to so many.

 Have a nice day and a latte! (said jokingly to break the tension)


Further reading
2007 study on global nuclear war at http://en.wikipedia.org/wiki/N... What is not mentioned is how the advancing ice increases solar reflection which, according to some modles, enhances the effect. Yes, there is geoligical evidence the planet has frozen solid before. This time it would be self inflicted. Well kinda. They say no humans would be left by the time it happened. I can be optomistic even about this. I think there is a way.  

[ Parent ]
I believe that the decision
to use prepandemic vaccine has not been made.  Nor the decisions about who should receive them.  But the schematic representation is useful to guide vaccine development.

The idea is to encourage companies to make vaccines that can be shown to have prime-boost effect ie 1 dose will prime the recipient such that on receiving a second dose of a vaccine against the same subtype but not necessarily the same clade, there is sufficient immunogenicity to protect the person.

Here's an example of what prime boost looks like, from the study by Treanor on the recombinant vaccine.

There are lots of hurdles to overcome, including the definition of prime-boost response.  Say for example the FDA requires an antibody HI titer of 1:40 with the first dose for a candidate vaccine to be considered, then the manufacturer has to demonstrate that some time later, when the same subject is given a second dose of either the same or different vaccine of the same subtype, the antibody response is higher than can be obtained if the person has not received the first dose (ie primed).

The question then arose (at a recent vaccine meeting that I attended) that what if the first dose did not give the required HI titer, but then subsequently still gives a good prime-boost response?  By only allowing those candidate vaccines that gave an initial 1:40 result, wouldn't they be excluding some perfectly good candidates?

That is just ONE of many issues being discussed (or fought over!) as we speak!  All this is not helped by the fact that attempts to standardize HI test results across labs have been unsuccessful.  AFAIK, there can be as much as 15-fold variations between labs!

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
you're right, of course n/t

[ Parent ]
might try that very promising AIDS vax they recently tested..  that everyone was excited about, and sure would have some benefit.  and it did exactly zip - nada - nothing...

promising isn't enough, certainly not to justify purchasing large quantities..  until the testing actually gets done -- you might have as much luck with snake oil.

not that the options aren't viable -- they may very well be -- but we don't know.  and won't, until they're tested.

[ Parent ]
Agree. So, let's get it done.
It takes leadership as much as anything else.

Susan indicates that things are happening now, during the past year.

OK, we'll see.  I'm from Missouri on this.

[ Parent ]
well, many promises and many hurdles
including issues that potentially compete for attention and resource with pandemic flu.  

That's the current landscape, for the US.  ;-)  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Does DHS get it now, too?
Has any recognized expert suggested that anthrax attack would be as devastating as thermonuculear war?

This line of thinking is ridiculous, and should be exposed as such.

[ Parent ]
What meeting was that?
Where and when did Jeff Runge say that?

That line of thinking is ridiculous.  And everybody right up to Michael Chertoff himself must know that.

Which is not to say that DHS should ignore weaponized anthrax and be preparing for it.  But it's not the biggest threat out there.

[ Parent ]
scroll up from that link
the National Emergency Management Summit.  http://www.emergencymanagement...

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
on the surface, i'd agree...  ask yourself under what circumstance he might come to the conclusions he has - keeping in mind that we have zero real information on the threat we're saying is not as great.  the only way i know to avoid the next pandemic, is if something else kills me first.

[ Parent ]
re Q5. Community mitigation
Sorry, to me he skipped answering that one. Who is going to tell communities ie towns to plan?

It is better to look ahead and prepare than to look back and regret.

Not to mention A #1
I begin with the matter of helping poor and working class families gain access to necessities of daily life during an influenza pandemic.  HHS has taken important steps in this regard and will continue to build on those initiatives.  In particular, HHS agencies (primarily the Centers for Disease Control and Prevention and the Office of the Assistant Secretary for Public Affairs) have developed and promulgated a suite of checklists and other guidances to help individuals and organizations prepare for an influenza pandemic. These can be found on the HHS-operated website titled Pandemicflu.gov.

For example, if those individuals who have the means and will to create a multi-week stockpile of food, water, and other necessities do so, local entities such as municipal governments, private emergency response organizations (notably, the Red Cross), faith-based organizations, and community organizations will be able to target their assets and services toward those who cannot afford to undertake this level of personal preparedness.

(color emphasis added)
But why should anyone (with means, or just scraping by) do this?  People are totally in the dark.  No one has explained the ramifications of a panflu year.  It does not have to be a hysterical message, but it should be dramatic.  Part of the message is that daily life will be different in nearly all aspects.  Pandemic is a high impact event that's going to sneak up on nearly everyone, unless some part of the Federal Government accepts the responsibility to Tell the People.   It takes time to accept and digest the pandemic preparations message (let alone buy the stuff and learn some basic alternative cooking etc. methods)  and we're wasting our "God-given time."

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]
It's the same "hearing with tin ears" over and over again...

Look!  We have a web site with lists!   We can't be held responsible that hardly anyone is using them!  

[ Parent ]
Absolutely right
 'if those individuals who...'

who=? possess psychic abilities? Just happended to meander across the pandemicflu.gov site?

Other than flubies, who points their noses in that direction?

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
See that second paragraph in the boxed quote above?

Now you tell me, when you have food processor giants and commodity traders all nodding their heads (and smiling, no less) at the pronouncement by officials that "we have record food cost increases coming our way)...

How is the working class and poor supposed to stock their larders?  Heck, the middle classes in Mexico and and Indonesia are being priced out of food (see todays BBC News).  In about six months, a significant chunk o' the US population will be joining their ranks..unable to afford any extras, and facing difficult budget trade-offs to keep food on the table.

In other words, with basic fuel and food costs rising, global food banks being rapidly depleted (see todays BBC news), climate-slammed crop failures lining up like dominoes throughout the developing world....all coming on the heels of years of drought and grain shortages, plus biofuels demand sucking up spare grain supply... This has got to be the worst timing possible, to be finally thinking about 'trickle-down' emergency planning.

The charity sector has been making up the deficit for the cash-strapped State and County welfare departments for quite some time. There will be no magical private sector savior to help the working class and retirees, the unemployed, the homeless, and migrant poor.  Those living below poverty number close to 14% and the working poor are 15-18% of the US population.  That doesn't include the homeless nor unemployed.  

[ Parent ]
Maybe it's time to throw cold water on the fuel-from-corn business.
Can any agency face up to it?  Is anyone in charge of prioritizing, or is it just pricing?  Dept. of Agriculture?  Congressmen?   The part of HHS that deals with malnutrition?

Don't forget the bee die-off.  That's going to have an effect on crops this year and maybe into the future.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]

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