Lessons Learned from the 2009 H1N1 Influenza Pandemic
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1 Lessons Learned from the 2009 H1N1 Influenza Pandemic Ruben Donis Influenza Division, CDC, DHHS FAO/OIE/WHO Joint Scientific Consultation On Influenza And Other Emerging Infectious Diseases At The Human-animal Interface Verona, April 27-29, 2010 Those who do not remember the past are condemned to repeat it. George Santayana ( ) 1918 H1N1 Pandemic 1957 H2N2 Pandemic 1968 H3N2 Pandemic 1976 Swine flu USA 1977 H1N1 re-entry 1997 H5N1 Outbreak 1
2 Other Zoonotic Influenza Infections Swine ~ 60 zoonotic H1N1 swine influenza cases reported since 1958 Classical swine lineage viruses Eurasian swine lineage viruses triple reassortant North American viruses Swine influenza lacked human-to-human transmissibility Seals and poultry H7N7 and H7Nx in Europe and North America Pandemic Preparedness Plans: Assumptions 2
3 Main Assumptions for Pandemic Planning H5N1 greatest concern, H2 and H9 possible Population immunity it to H1N1 and H3N2 preclude subtype H1 and H3 emergence Avian virus genes to reassort with human virus Asia leading epicenter for emergence Naïve population require two doses of vaccine Slow initial spread of avian-origin virus Preparedness for H5N1 would be portable to other subtypes Predictions Capua I, et al PLoS Pathog 5(6): e June 2009 Volume 5 Issue 6 e the assumption that antibodies to human influenza viruses of the H1 and H3 subtypes are cross-reactive towards contemporary avian H1 and H3 viruses of Eurasian lineage is incorrect. 3
4 CDC Pandemic Preparedness: Before April 2009 Diagnostics Rapid, Point of care Differentiate human seasonal from other influenza viruses Laboratory Dx capacity Clinical trials: FDA approval Surveillance Focus on Asia Strengthened public health lab capacity (atypical flu) Vaccines H5N1, H7N7, H9N2, etc. Antigenic drift monitoring Vaccine candidate development Vaccine stockpiles Antiviral drugs Detect resistant strains Stockpile First Detection of 2009 H1N1 in the U.S. 24 April 22 May 4
5 26 April U.S. declares National Public Health Emergency Regulatory changes EUA Diagnostics and Vaccines Authorize funding Response to 2009 H1N1 by CDC Detection Surveillance: Epidemiology, diagnostics, etc. Domestic and global Intervention Pharmacologic Antiviral drugs and Vaccines Non-pharmacologic Community mitigation (e.g. school closure) Travel restrictions, border controls, etc. Hospital infection control, laboratory biosafety, etc. 5
6 ORIGIN OF THE 2009 PANDEMIC H1N1 VIRUS North American triple reassortant H1N1 (swine/avian/human) Eurasian swine H1N1 ( avian like ) PB2 PB1 PA HA NP NA MP NS PB2 PB1 PA HA NP NA MP NS 2009 H1N1 Lesson #1 PB2 PB1 PA HA NP NA MP NS Classical Swine N. American Lineage Avian N. American Birds Seasonal H3N2 Eurasian Swine Lineage Gaps in Surveillance Lesson #1 No recent ancestors known ~9-17 years evolving without detection Escaped virologic surveillance NA gene Long branch H1N1pdm 6
7 Lesson # Pandemic H1N1 Virus Broke the Rules Pre-existing immunity to seasonal H1N1 in humans did not preclude emergence of 2009 H1N1 virus Household secondary attack rates are lower than previous pandemics: 2009 H1N1 is less transmissible No recent avian or human virus reassortment 2009 H1N1 virus probably emerged with pandemic properties in Mexico Ressortment time, place, host remain unknown Secondary Attack Rates: 10-13% Cauchemez S. et al; N Engl J Med, 2009; 361:
8 Lesson #2 Diagnostic Preparedness Global pandemic preparedness for a H5N1 facilitated rapid an effective response to 2009 H1N1 Additional networks and institutional partnerships allowed a more coordinated and measured global response Rapid publication of CDC sequence data allowed rapid development of molecular tests More sensitive and inexpensive tests are needed Diagnostics tests that inform on subtype in clinical settings may detect pandemic viruses earlier CDC Virologic Surveillance Influenza Seasons As of April 3, Number of Positive Specimens >600,000 Specimens Tested 2.5 fold increase over prior season Percent Positiv ve Week Number B A(Subtyping not performed) A(H1) A(H3) A(Unable to Subtype) A(2009 H1N1) Percent Positive www cdc gov/h1n1flu 8
9 Timeline From Virus Seed to Vaccine APRIL MAY JUNE JULY AUG SEPT OCT Week Prepare high growth reassortant 25 APRIL Working seed 26 MAY Prepare monovalent pilot lot Production monovalent vaccine Potency testing FDA release Formulate & Fill Distribution 5 OCTOBER Decision to Place Order For Vaccines for US population July: Spring Wave H1N1 Down in US Jan 1, 2009 May Jun Jul 9
10 Lesson # Pandemic H1N1 Vaccine Vaccine purchase decisions have to be made before needed knowledge is available Future course of the 2009 H1N1 outbreak uncertain Transmissibility Virulence in various age groups "I am sure that what any of us do, we will be criticized either for doing too much or for doing too little. If an epidemic does not occur, we will be glad. If it does, then I hope we can say that we have done everything and made every preparation possible to do the best job within the limits of available scientific knowledge and administrative procedure." US Surgeon General Leroy Burney, Meeting of the Association of State and Territorial Health Officers, August 28, 1957 From Seed to Vaccine Vaccine manufacturing need firm orders APRIL MAY JUNE JULY AUG SEPT OCT Week Prepare high growth reassortant Working seed 25 APRIL 26 MAY Prepare monovalent pilot lot Production monovalent vaccine Potency testing FDA release Formulate & Fill Distribution US Gov t Places Orders For Vaccines for US population 5 OCTOBER Shown for Inactivated Vaccine (Live Vaccine Available Earlier) 10
11 HA sequence features H1N1pdm vaccine viruses* Virus Position 222 Position 223 others A/California/04/2009 Vaccination D Q A/California/07/2009 D to G Q to R IDCDC-RG15 D Q to R NYMC X-179A D Q to R K209T NIBRG-121 D to G Q IVR-153 D Q to R IDCDC-RG18 D to G Q IDCDC-RG20 D Q to R The Fall Wave of 2009 H1N1 IDCDC-RG22 D Q S183P NIBRG-122 Dt to G Q A135S, I321V NYMC X181 D Q to R N129D, K209T NYMC X-181A D Q to R N129D, K209T NIBRG-122xp D to G Q K119N CBER-RG2 D Q L191I Sep*H1N1 Oct numbering; Nov all changes relative to A/California/04/2009 Lesson # Pandemic H1N1 Vaccine Pandemic vaccine delivery started within 6 months of emergence per Pandemic Plan Despite production being slower than expected Second wave spread through the US in early Fall ~ 3 months earlier than normal flu season A 4-month timeline for vaccine availability is necessary A 4 month timeline for vaccine availability is necessary for future pandemics 11
12 Revisit Pandemic Planning Assumptions H5N1 greatest concern, H2 and H9 possible Population immunity to H1N1 and H3N2 preclude subtype H1 and H3 emergence Avian virus genes to reassort with human virus Asia leading epicenter for pandemic emergence Naïve population require two doses of vaccine Slow initial spread of avian-origin virus All of the above: not this time Preparedness for H5N1 would be portable to other subtypes Acknowledgements CDC Limei Chen Todd Davis Pierre Rivailler James Stevens Yumi Matsuoka Eddie O Neill WenPin Tzeng Jaber Hossain Laura Zambuto Amanda Balish Cathy Smith John Barnes Becky Garten Sasha Lipatov Michael Shaw Joe Bresee Jacqueline Katz Alexander Klimov Ann Moen Tim Uyeki Dan Jernigan Joe Miller Nancy Cox SRP Core, ARB, IACUC MVVB, VSDB, IPB, Influenza Division Beyond CDC WHO GIP Surveillance Network David Swayne; USDA, ARS, Southeast Poultry Research Laboratory, Athens, GA, USA James Paulson, TSRI Richard Compans, Emory U. Yuelong Shu, China CDC Tung Nguyen, NCVD, Vietnam Ilaria Capua, Padova, Italy Gavin Smith, Singapore Malik Peiris, HK SAR Wilina Lim, HK SAR Ervin Fodor, U Cambridge Richard Webby, S Jude CRH Daniel Perez, UMD Kanta Subbarao, NIH Armen Donabedian, BARDA Michael Perdue, BARDA 12
13 Virus of the Year: The Novel H1N1 Influenza Scientists characterized the new virus and distributed ib t d tests t to detect t it at record speed, sharing findings nearly in real time. SCIENCE VOL DECEMBER 2009 THANK YOU! QUESTIONS? S PB2 PB1 PA HA NP NA MP NS 13
14 Consultation Questions 1. What are the knowledge gaps we should address to further define drivers of emergence and predict emergence? 2. What are the surveillance strategies that we need to develop and that can be implemented where these diseases occur? 3. What control and prevention measures are applicable in different scenarios, particularly different economic situations? 4. For which diseases is research into reservoir(s) or disease ecology critical to develop prevention and control measures? 5. Which tools do we have to differentiate between the occurrence of opportunistic and evolutionary or (co-evolutionary) events? 6. How do we decide when to respond? 2009 H1N1 Vaccine Coverage, U.S. January 2010 U.S. Median: 33% among ACIP Priority groups 24% all persons > 6 months of age 14
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