Dr. David Fedson, Interview-late 2005

Medical Director, Vaccines Division, Sanofi-Aventis (retired)
Fellow, American College of Physicians and the Infectious Diseases Society of America

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Dr. David Fedson, Interview-late 2005

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The following is an edited excerpt from and interview with Dr. David Fedson, conducted in late 2005...
CBC News, Canada
http://www.cbc.ca/fifth/nextpandemic/in ... edson.html

How close are we to this pandemic?

It’s really impossible to say how close we are to the next pandemic. Everyone who is knowledgeable about this will say the pandemic is inevitable; we know the pandemic clock is ticking, we just don’t know what time it is. As each day, week, month goes by we are getting closer to the inevitable next pandemic.

What’s is your hypothesis of how an influenza pandemic would spread in today’s world?

For me one of the important lessons to be learned from the pandemics of the twentieth century is that despite the enormous amount of international travel that we see today, we do not have to assume that the next pandemic virus, once it appears in a human community, is going to spread rapidly around the world and within a matter of a few weeks cause devastating disease world wide. This it not the evolution of the pandemics of the twentieth century.

In 1918 the first wave of infection occurred during the springtime, but the really deadly second wave did not occur until the following fall. If we look at our most recent pandemic in 1968-69 we find that the virus appeared in mid 1968 and caused pandemic disease in many countries including the United States and Canada in the fall of 1968-69. But in fact the excess mortality experience was worse the following year in the U.S., three provinces in Canada, and in France and Germany.

Now why did this virus, which was causing pandemic disease, why did it wait for more than a year to cause its real mortality impact in several countries? We have no idea why the virus behaved that way, but it did.

For me, the lesson that I take from that is that history tends to repeat itself and we should say that despite our international travel capabilities today the virus is not going to depend upon just 747s to move out – it’s going to behave in the way that it has behaved in the past and that means many parts of the world and probably billions of people will have time to prepare and to do things that will help protect themselves and help them to confront the pandemic experience once the virus arrives.
What would happen if there were news of an influenza pandemic outbreak today?

If the pandemic were to start today I think we would have tremendous confusion at the scientific level, at the level of the companies that make vaccines and antivirals and medical supplies. We would have extraordinary confusion at the public health at all levels: local, state, national, and international. Very quickly we would have an international political crisis, the likes of which we have never had to deal with in the past.

Very quickly it became evident to all those participating in this exercise that each country would tend to take care of its own people immediately. When you have a global epidemic and pandemic where people in all countries are involved, there has to be some sort of sharing of resources, sharing of expertise if these communities are to work together and survive. If the tendency politically for these communities is to look out for themselves, then that is going to create tremendous political pain. It’s something we have to anticipate and I don’t know to what extent any of the political institutions at the national or international level have even begun to map out what their behaviour is going to be once the pandemic appears.

I don’t think we have the international mechanism to deal with this. If we take a look at the AIDS epidemic, this is a horrific event that is devastating countries in sub-Sahara Africa and will soon devastate many other countries closer to Western Europe, North America in the developed world. How long has it taken for us to begin to build the international focus of attention and bring the resources to try to control HIV/AIDSs in the area of the world where it’s most devastating?

It’s taken 20 years. Why? What is it that takes people that long to pay attention to these kinds of events? We tend not to have the imagination – and even if we have the imagination, we don’t have the kinds of human institutions that are able to take a global event like this and come up with practical solutions and how to manage it.

What is it about this particular virus that is so severe?

We don’t know what our pandemic virus is going to be. There is a lot of concern about the H5N1 virus in south East Asia now, the bird flu. Is the next pandemic going to be caused by the bird flu virus? We don’t know. Many people think that it’s certainly possible. Other people would say, ‘Well if it is possible, why hasn’t it caused a pandemic when this virus first appeared in 1997? Here we are eight years later, no pandemic. What’s going on?’ I don’t know.

We know that this virus can infect human beings. We know that when people are infected with this virus that many of them become very ill, and that this illness is particularly severe in younger people, and that it carries a high mortality in recognized cases. But the H5N1 virus is not the only virus that we need to think about as having pandemic potential.

There are viruses known as the H9 viruses. There is an H7 virus that caused outbreaks of disease in the Netherlands a couple of years ago. There is the H2 virus that caused the 1957 Asian influenza pandemic – if that were to come back again, two third of the world’s population living today would be totally susceptible to this virus. That’s all you need to have pandemic circumstances and allow this virus to spread worldwide.

H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

What is the worst-case scenario?

We have to believe that something like 1918 could occur again, because it’s occurred in the past. What would we do if we have a pandemic virus like that and it would have the potential to killing 175 to 350 million people? How would we respond in our communities?

I think that any scenario you choose to imagine. We live in a society in which everybody is playing some sort of a role in providing a service. What happens if all the people who supply cash to the cash machines are sick? We can’t go shopping we can’t even buy the little food that is of our shelves of our supermarkets because it’s all been bought and it’s not being delivered anymore. We have some potential for very serious breakdowns in the very fabric of our daily life if a pandemic comes and we have to prepare for that.

What about your own preparations for you and your family?

I have done nothing. It’s a very difficult sort of decision. Some people would say you better go off and buy a supply of antiviral medication, which may help save the lives of your family and yourself, but in a situation like this where you have a stock of antivirals and nobody in your neighbourhood has a stock of antivirals and your neighbours begin to die and their children are dying – what do you do? Do you just lock the door? Do you get out your shotgun to defend yourself?

We are really talking about a situation of human survival and the ethical dimensions of the choices that will be faced are very hard to predict. Do I have a family supply of anti virals? No. It might make me feel safer in one respect, but it might make my life a lot more difficult to live in the face of pandemic moving through my community when I saw what it was doing to other people without antivirals.

What are the goals for developing a vaccine?

You want as much vaccine available as quickly as possible – if you get it there before the first wave and some parts of the world, great, but I think you can be fairly confident there will be more than one wave of the pandemic virus sweeping individual countries. You want to get as much vaccine out there as possible.

The criteria for developing the vaccine should be not to produce a vaccine that is optimally protected for an individual, but one that is acceptably immunogenic or protective for a population. That’s an entirely different perspective that we have had for any of the vaccines that we have produced for any disease up until now. The focus in vaccine production has always been to develop a safe and optimally protective vaccine for individuals. You have got time to produce as many doses of vaccine as can be sold, or purchased by public health authorities or bought by individual families. Here we have an entirely different situation.

We have got to find a formula for the vaccine that will be both safe and acceptably immonogenic so that we can produce the largest amount of doses as quickly as possible.

Do you think there will be security issues around the transport of the vaccine once it’s available?

The issue of vaccine security when supplies are limited would be immense. You will find black-markets developing and people trying to profit from limited supplies of vaccine. Unscrupulous people in some states that were trying to sell bootleg vaccine or false vaccine for 10 times the price it normally would have obtained. We can expect to see activities like this spring up everywhere.

The security issues are going to be immense and I would think that there are a lot of countries that have already thought of the security and have plans for their military and their national guards on what to do. When supplies of vaccines begin to become available, protecting those supplies and distributing them in a coherent way that meets the needs of the population of public health is going to be a very large challenge.
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