[inaudible conversations]

>> good morning everyone. we want to get started here. we've got three days of very interesting and exciting and informational presentations to behole and so what i want to do first is get some of the housekeeping things in order. first of all, i would hope everyone has found the nutritionist warning refreshing, and we're going to get started. what i want to share with you, first of all, on a little house keeping matter is in your conference programs, please look at the very, very back of those programs and then you'll see your breakout sessions for day one and day two. it has all the rooms and the times and the speakers there, so please look there for when you want to know where the next session is going to be that you intend to participate in. we'd like to also go ahead and thank our sponsors, major

sponsors, thank them very much for supporting this conference for us today and making it very possible for all of us who are here today. i'm going to make my speech very short, because i really am excited about the lineup that we have for you for the next several days. i think we have some of the experts without a doubt, and if we were doing the -- some type of awards ceremony, i probably would have a black tie on and everything and introducing them, because i think we have the cast for you that will be to present i think the message thaw want to hear and deliver the information you need in terms of what you're doing for the business at hand. i would like to acknowledge and welcome all the individuals, agencies and countries who are participating in today's international swine flu conference. the outcome of this important conference will truly be realized from your thoughtful

engagement through the various breakout sessions and the critically important information that will be shared by my new found colleagues today, with you being here, and the esteemed speakers and guests from around the world. this important work couldn't be possible, of course, without the dedicated staff of newfield's incorporated and i definitely would say that i am very humbled that we were able to allow me to speak here with you. i have spoken at several of their conferences as chair, to be here with you as well. without that staff, we would not be able to have this conference here today. i appreciate newfield's for taking up this necessary calling once again for a meaningful conversation and dialogue, they do so much around the world. through a myriad of topics, as it relates to an appropriate response to the worldwide health threat. joining in the coming weeks and

months will no doubt be daunting as the world awaits answers to the knowns and unknowns, regarding the treatment of the h1n1 virus. the various experts in their field of study, practice, research, will be assembling here over the next two to three days to share cutting edge knowledge and science with each of you as we seek direction and instructions for those answers. however, even upped these siegely uncertain times, i remain hopeful, there cysts a plethora of opportunities as we gaze through collective efforts regarding how we can begin to explore the possibility of facilitating meaningful dialogue partnerships. this, ladies and gentlemen, can only occur when leadership

within government, health, education, the broader community, businesses such as newfield and the corporations that are here can access better practices and the latest research to improve the preparedness and response efforts. as a world community, we must challenge ourself and our community members in evaluating and fostering wrap-around service and supports that will create aecium bee hot particular relationship that will yield a healthier community here in the united states and abroad. i'm going to conclude by saying, it is my sincere hope that each of you draw from the knowledge of the representatives here an one another to take the advantage of the meaning opportunities and network and share your unique experiences for the betterment of humanity. and that kind of encapsulates my

closing to you, because i really wants to open up the opportunity as we present our speakers for this morning. now what i would like to do is a little bit of a surprise for think morning. i wanted to bring up one of my special colleagues who i have been working with in many conferences, he's going to get you -- kind of get you excited about what we're getting ready thetough topic that we're about to address, so if you can give me a round of applause for a good associate of mine and let him do his introduction himself, please give a round of applause for >> ok. here we go. dr. steve, welcome you here. you know what the conference is about, it's about crisis response, the prevention, preparedness, recovery and response.

you know i read that wrong, but i'm also telling you i'm adhd and dyslexic, ok? but we have challenges here. communication, coordination, and cooperation. if we can't pull those three c's together, things are not going to work. as i stand here today, our only real weapon right now is education. against h1n1. you have the power, one, to make a difference. so would everybody please stand up. i'm here today to make you realize how important you are in the world today. repeat after me. [inaudible] >> i am the power of one. >> my body. i am the power of one.

with everything you've got. my body. my voice. i'm the power of one. >> have a seat. thank you. >> i go out after students that have been killed, i go out and deal with crisis. i have to convince everyone here that you are far more important than you think you are to make a difference. and i'm here to tell you, if you can't deliver your job with passion, people aren't going to believe you. because if you don't get to a heart, you don't get to the head. i go into crisis where people don't want to hear what i have to say. how many of you are physicians? as the physicians out here today, how many of you think, what percent of physicians get their immunizations for flu every year? you know what the figure is? less than 50%.

so we've got a job out there, trying to convince people to do things. on top of this, we have a fear going around in the country today. you show this picture in communities, and people go, oh, what's going on here. let me ask you a question. because the kids ask me this. could there be transmission possibly there? there could be. ok? well, we're going to be back to school pretty soon and that's one of our biggest challenges, who this new kid in the classroom here today. we have a crisis. as i go and talk around the country right now, people in schools and parents and administrators and teachers, their plate is full. school is starting up and this thing called h1n1, it's on the radar, but it's way, way back there. i hope that approach to crisis deals with you. i see dealing with disease prevention is like a chair.

there are four legs, one is a students, one is a school, one is the parent, one is the community. you take one leg away, it falls over. we can't do it alone. now, my message today, it's not about all that. it's about you. never doubt that a small group of softball commissions can change the world. it can. you only need a single moment before starting to improve the word, but here's the solution, you can't solve the problem with the same thinking that started the problem. today, prevention needs creativity. you've all seen this little design where you take nine dots and try to connect with four straight lines. it's a great way to talk about thinking outside the box. sometimes you have to be creative. in a school, we have a situation where you might have heard about where girls were kissing the mirror every single day in the bathroom and leaving their lipstick and the principal and the parents and everybody got upset, the school nurse, you have to stop this, not a good idea to kiss a mirror, you're

leaving lipstick there. they tried all these things, tried to scare the students. it didn't work. they knew it was the eighth grade girls, they locked the girls in with the custodian, they said look, you're leaving the lipstick marks, you have to clean the mirror. they asked the custodian, how do you clean the mirror. he took a mop, stuck it in the toilet and cleaned the mirror. they never kissed the mirror again. who remembers the stars shake? who remembers the sars shake? let me ask my body here. we went around -- we told people not to make contact, the sars shake became -- remember that. ok. it's almost like something else, but sometimes -- thank you.

you just have to get creative like with the sars shake. my sob today when i go out is personal responsibility. as i travel the world in many countries, people take responsibility. in the u.s., i'm a lawyer. we have to make a difference. that's what the power of one is about. little things you can make a difference with. didn't wash hands. could it be that simple? maybe it could be. see, change is inevitable. growth is optional. people respond to people, not programs. when i go out and deal in crisis, it's the face-to-face that makes the difference today. unfortunately, many people don't want to hear your message. they often have their head in the sands, what do they need to know and many just say, it's not my job. it's not my job to go a little bit further out there and make that difference. well, i want you to be all ears

here, because i think this is very important. h1n1 prevention an learning, it's about relationships. it's about putting a human face on this disease. because if you don't come out with a pestage, that reflects caring, communication, a community, and a culture, it's not going to work. i work on indian reservations. the four c abc it's not going to work at all. you don't get to the head unless you get to the heart. that's basic psychology. that's basic mental health. let me ask you this. anyone here having a bad day so far? are you having a bad day? are you having a bad day? anybody having a bad day? are you having a bad day? i keep picking on you. you're having a bad day, i just saw you getting your speech together. come up here i want to make a point. darnell, would you like this $20 bill? >> no. >> you don't want it?

>> then i can't work this, man. here's what i want to do. darnell, would you like this 20. now i'm going to crumple it up, you still want it. it's on the floor, do you still want it. i'm stomping it on the floor? you still want it. this 20 darce bill, even though it got crumpled up and stomped, it never lost its value. and brother, when you get crumpled up and stomped on, you never lost your value. that's it. a lot of times when i go out to speak, ok, who has a bad day now. well, you know, i go out and speak a lot of times and i use this little power of one thing and i often give this to people. by the way, you can't buy it. it's not for sale. some things in life should never be sold and this power of one wrist band will never be sold but you can earn it and it's yours, and sometimes, times we have to deliver a message that's

far too valuable to try to sell, but we have to figure out, how do we get that inside of someone so they can make a difference. see, we've got to give messages out there in a way that's going to work for our reluctant population who doesn't want to hear it. reach, teach and protect. timing is everything. school starts up in a week or two. what are your kids going to be doing. what's going to happen before the vaccine kicks in. how are we going to message out, that you know, you don't sneeze or cough on someone. how do we get a message out that you've got to keep your hands clean? how do we get a message out that if you're sick, you don't go to school. how do we teach people to be a germ stopper? one of the problems i have when i go out to speak is one of stress. people always say, man, i can't deal with all this stress, what can i do? we have a pentagonal health person here an one of the finest tools you can have when you deal with crisis, somebody is acting crazy, go over and just go --

three times. and then you can talk again. very simple, it's very effective if a crisis. sometimes helps blow your problems away. i do a lot of work with native americans. one time, one native american told me, dock, you have warrior aura. when a keefe goes down, a warrior steps up and they follow l. i said that's cool. they said not cool. you could lead people the wrong way, just like hitler did. and i started to say let's go and he put his hand up to my face and said hey, remember the great creator has given you two creators, one mouth. a great message with you go back to your community. if that stuff i told you is hogwash, there's the research right there. how are you going to get your message out, why should people believe it. you have the power of one. you can make a difference. you learn all you can, knowledge is power, you take care of one

another and at times of crisis, we need to support one another and you tell the people that you love, you love them. you have a choice of having a nice day. unless you decide otherwise. see, you have the power of one to make a difference. i have the power of one in my pocket right here. could this turn a disease around? could this turn a disease around? this little hand sanitizer? could it be that simple? it could be. perhaps the answer is in your hands. would you repeat after me one more time. my body, my choice, i'm not your choice, i'm the power of one. and you are and please remember this in the next three days. thank you, david, my friend. [applause] >> ok. i wanted to get you a little bit

excited this morning. i see some heads nodding. good. good. dr. sroka and i go back a number years and it's always great to have him with us at our first presentations. we're going to move forward, because we have a list of individuals i think will be presenting to you this morning, that is a must here. so i'm going to bring up the first speaker. he will be speaking in terms of state and local perspectives and strategies for pandemic influenza and planning. and i'm going to take the moment to introduce him a little bit so i can kind of get you prepared for his presentation, darrell darnell. darrell is the director of the district of columbia homeland security, and emergency management agency. he has appropriately aid the position by the mayor, adrian fenti in march, 2007.

darrell was urban director and exercising programs at i.m. in louisiana, based national disaster and homeland security consulting company and i'm going to let darrell come up and share with you a lot more about his personal background. ladies and gentlemen, please welcome darrell darnell. [applause] >> thank you, david, for that introduction, and you know, steve clearly is a morning person. and i clearly am not. so it's a tough act to follow here, but i thought that some of the themes that he hit on were very, very appropriate for this conference and what we're dealing with with h1n1, particularly the terms of about communication, the power of one, those different types of things, and that if we're really going to address h1n1 and the potential of a pandemic

influenza this fall, you know, it really starts with, you know, not only the health measures that we have to take, but individual responsibility and i hope to kind of touch on those themes in my remarks for you this morning. i'd like to kind of start by saying first of all, i know many of you are health professionals, doctors and so on, public health officials. i am not. so i'm really not going to talk to you from that type of perspective. my background is in emergency management, homeland security, and those different types of things, and some would say, well, what does this have to do with homeland security and emergency management. well, it has a lot to do with it. it has a lot to do with it, bass as you all well know, if we experience an emergency pandemic influenza, it would influence our continuity of operations, our continuity of government, due to the potential of high absenteeism rates and those types of things, so it's all interconnected and i want to just take a few minutes to share some of my thoughts on this issue, how we plan on dealing with it as a district government

and quite honestly, how we think some of the other state and local jurisdictions around the country are dealing with this as well. it's been the topic of intense conversation and discussions among my colleagues over the last several months and certainly the last couple weeks. i'd like to just start by saying, you know, in the district of columbia, school starts next week, august 24. and clearly, from what we saw in the spring, lots of discussion and thought going around, do we close schools, do we keep schools open, what are the triggers that make us make those decisions and those different types things and again, one of the things that steve had on really, this is a communication, education effort, information sharing. and one of the things that i've learned in this position is is that some things may be inevitable. we probably can't stop the spread of h1n1, but we can mitigate the consequences of it. and a lot of it starts with simple messaging, simple

communication, information sharing. and i don't know how many of you listen to -- how many of you are local here? listen to wtop this morning? did anybody happen to hear our ad this morning that came on at 7:48 a.m. this morning on wtop? ok. not one hand. that's not good. that's not good. it comes back on at 5:15 p.m. today this afternoon. but the point is, we initiated some ads that tell people three really simple things. one, school starts august 24, please make sure your kids get their basic required immunizations. secondly, prepare for h1n1, and the best way to do that is cover your cough, wash your hands, if you're sick, stay ahome. if you have questions, call 311 and we'll put you in touch with our public health officials and what we're trying to do here is get the message out. one, keep it simple. not simple in the literal sense, but simple so that it can be quickly understood very quickly

by large masses of people. secondly, give them information that we hope is useable information. what we found through studies is it it's great to give people in the, but if it's not something that they can use or perceive that they can use, they tune it out. we think it's pretty, usable information. cover your cough, wash your hands, stay at home if you're sick. get your immunizations. so again, 5:15 p.m., wtop, 104 something on your dial. so if you listen to my remarks, i really want to talk a little bit about state perspectives and strategies. our strategie strategies for pac influenza. the emergence of this in the spring of 2009, led us to sort of a reality check in terms of what our response efforts were going to be for this resurgence of an unpredictable resurgence of the virus this fall. and really coming up with more integrated planning efforts at the state and local level. and as we saw h1n1 manifest itself in the spring, there are

many questions that we -- you know, that were left unanswered. i talked about the schools a little bit, talked about how we continue central government services, how will mass immunizations be implemented, how we will communicate to individuals, families and communities and i think that's important and i think steve alluded to this. this can't be some esoteric exercise. we have to be able to communicate to people on an individual level, on a community level and if you think about it, people aren't going to help themselves until they feel like they can help -- they're not going to help their community and the city at large unless one, they think they're protected individually. two, they think they're protected as a family. and then they think, three, their community, the communities are neighborhoods that they live in, their businesses, their schools, and those different types of things. and i use the analogy of riding on an airplane, when you get your safety briefing from a flight attendant and the theirs thing that they tell you is that the oxygen mask goes down, don't

put it on your child first, put it on you first and then put it on your child and this is the same type of thing. we can't protect our families, our communities, until we protect ourselves first, so we're going to spend a lot of our messaging, starting with individuals, the families and the community to try to drive that point home. these and other questions require needed answers. state and local governments have recognized that effective pandemic influenza planning requires a comprehensive government response, and not simply a public health and medical response. again, i started off my remarks by saying i'm not a public health official, but i understand that while we have a very good department of health agency here in the district of columbia, headed by a very capable director, this is not simply a public him problem. this is a district government problem and we have to act accordingly as a government and wile the public health agency certainly is the lead for our

planning for this, we have to provide the logistical and all the other type of supports that we need if this is going to be a comprehensive plan that we can present to our community and to the city. and secondly, as many of you know, the impact of h1n1 is not entirely known, but we can make some assumptions based on previous historical patterns based on previous pandemic planning, in particular, h5n1 or the avian flu, where i had the opportunity to engage in some extensive planning when i was with the department of homeland security, back in 2004 and 2005 and certainly there are lessons that we can learn from sars. i think one of the things that we found in this though, as we were doing our h5n1 planning, we were always planning for the worst case scenario and certainly we need to continue to do that, but i think what we saw in the spring, that the worst case planning does not always -- is not always the most effective planning and so we have to have

scalable, flexible plans that are effective for the worst case scenario, but also take into account something less than the worst case scenario. a lot is often -- a lot of statistics are often spewed about in terms of absenteeism rates, that talk about we could have 40% of our work force out sick or caring for the sick and wile that number is dramatic, it could have potential adverse consequences. the fact of the matter is an absenteeism race of 1% or 5% could have just as much as of an adverse effect, so we have to take those varying situations into account and plan accordingly. and then finally, in terms of what i think in my own personal viewpoint, there are three larger strategic goals and i'll get into these in a little bit here as i go through my remarks. and preparing for a -- pandemic influenza, three larger strategic goals and from my

perspective, one is ensuring effective continuity of operations, continuity of government and continuity of business. two, protecting citizens and three, sustaining our critical infrastructure and key resources. as i said, the full impact of h1n1 is not known. and again, we can make some assumptions off of previous planning. again, i talked a little bit about the absenteeism rate, the stress on our public health infrastructure, the need for additional social -- additionally social services and those type things. as a homeland security adviser and emergency manager, we have all types of mutual wait agreements. if we have a fire supporting jurisdictions will come in and support our fire department, so that if we have something, say, for example, three, four, five alarm fire, which takes a significant amount of our resources to fight that, arlington county in virginia, arlington county fire department, for example, would come in and support us and other parts of the city, so that we would not have a decrease in the

level of services we could provide. well, this is a little bit different than that. you know, obviously a fire truck is not going to be indicate i object, mutual -- compatible mutual wait. those would be stretched and other jurisdictions would quite frankly be holding on to those, because they would know if they need them as well. we don't know for example, what the very lens or the impact of h1n1 will be, but we have to plan for the worst case scenario and as we saw in the spring, we have to be able to be flexible for something less than -- less severe than what we experienced earlier this year. as we develop our planning strategies, our plans for pandemic influenza, we want to develop a plan that minimizes the impact of pandemic flu, but we also wants to build resiliency within the community and i think that's important and

i think dr. steve alluded to that in his remarks. we know that we're not going to able to stop the spread of this pandemic. but we can mitigate the effects of it and what we want to say to the community is, yes, there is something that your government can do. yes, your government is doing something. but this is just not a governmental responsibility. we have to manage expectations and we have to tell the public that you are partners in this with us as well. and i think that's critically important, because we have to have a resilient -- we have to have a resilient community, in effect, we have to have a resilient owe site and i think in some respects, we've kind of abrogated that to the community at large and we've said that the government is here for you, the government will take care of you. well, the government's resources are stretched, particularly in these economic times and we need the public to participate in this process and take responsibility in this as well. so a lot of our planning will certainly resolve around what we

can do as a government, but a lot of it, particularly in the communication, education, the information sharing, we'll say here's what you can do, here's what you can do to protect yourself, here's what you can do to protect your family, here's what you can do to help protect your community. s and other overarching goal in this strategy is to maintain a central public service, main tan commerce hand confidence in the community that the district government is doing all it can to protect its citizens, but again to inform them in ways that they can protect themselves so that they can remain resilient in the face of a pandemic influenza. the first strategic goal i talked about, continuity of operations, continuity of government or continuity of business, of business plan. every government agency, every business, and we're working with the private sector through our district of columbia chamber of

commerce, through the greater washington board of trade, and some other business entities to develop business continuity plans and essentially this plan analyzes an agency or a business's mission and determines what are the minimal essential tasks that must be maintained. in short, what we're asking agencies and businesses to do are determine what are essential services that must be maintained and delivered, in spite of a pandemic influenza outbreak or any widespread or long-term emergency and that's very important. for example, sometimes, agencies don't really grasp this. you know, you talk to, for example, i'll pick on him a little bit, our district of columbia human resources agency. what if the folks who cut our paychecks every two weeks, what if 5% of your work force is sick or out caring for the sick? are we going to be able to get paid on time. those different types of things. our office of unified

communications, which manages our 911 and our 311 call centers, what if 2% or 3% of those call center workers can't make it to work? what is the effect of people calling in for essential city services or for emergency services, does that delay a 911 phone call being picked up in 5 seconds? does it go to 10 seconds or 15 seconds? what's the impact on that person getting the services, the emergency services that they require? so again, this continuity of government, what are those minimum essential services that we need to maintain? protecting citizens. again, i talked about our department of health, that largely is their responsibility as a lead agency to do that. protecting citizens. right now, we're in the process of trying to figure out if there is a vaccine, you know, how we would distribute that vaccine,

who are going to be the priorities. we've gotten some guidance from the cdc in terms of who they believe should be the -- what the prioritization should be. we're in the process of working through that right now. we're in the process of developing messages. i talked about the message that we've already developed on wtop. we're developing messages that will be consistent across the federal government -- i mean, across the district government, led by our department of health, that it doesn't matter whether i am speaking or the pair is speaking or agency head or just one of our folks who go out to community meetings on a regular basis. this is a message that we will give to people, hopefully that it will be consistent, that it will be clear. as i said earlier, it will be a simple pestage in terms of being understandable and it will be something that people can use. one of the things that we've been studying is this outbreak in the spring, and some of the messaging that the cdc put out, and my good friend rich besser, who was the acting cdc director

before the current director was confirmed and sworn in, we thought rich did a very good job in risk communication, because he had a consistent message, he had a simple message and he had a message that people could take that information and they saw that they could use it and so there were polls that were done afterwards and at the outbreak of h1n1 in the spring, about 65% to 70% of respondents across the nation said that they didn't know what h1n1 was and they didn't know what they he needed to do to protect themselves. over a two-week period, those numbers actually were flipped, 65% to 70% of the people who were polled said yes they did foe what it was and yes, they knew how they could protect themselves an yes, they knew where they could get information. that's almost unheard of in terms of getting your message out. i think if the president in trying to get health referral reform, if he could get those numbers right now, he would be a happy camper an having a p

better vacation, but that's the type of thing, if you can have a consistent message, a message that people can understand and you can make it usable, then i think that you're well on your way to building what i call that resiliency, and that partnership among individuals and families and communities to combat this. and then finally, the third leg of this three-legged stool if you will, from my point of view, in terms of our strategic goals, the sustaining, supporting critical infrastructure. and this largely is where we're engaged in the private sector, because the government doesn't own the infrastructure, the critical infrastructure that supports everything that we do. the lights that are on here, the communication systems that are on here, are driven by pepco, old dominion, the local power companies in this region. in fact, about 85% to 95% of the

critical infrastructure and i'm talking about our electrical grid, gas, oil, all those different types of things are owned by the private sector. imagine if, for example, again, a significant amount of people could not come to work to make these systems work, what effect would that have on our daily lives? those of you who live in this area, those of you who are visiting here, you flew into all of our various airports at reagan national, you know, dulles, bwi and so on, some of you probably took our metro system and those different types of things. we carry about 800,000 people per day for example on our metro system and that's the transit buses and so on. imagine if 5% of the train operators or the bus operators could not come to work because they were either infected by h1n1 or they had to care for someone who was infected by h1n1. imagine the effect and the ripple effect that that would have on our transportation system, if the people who rely

on that couldn't come to work, now that's people either couldn't get to work if they didn't have cars, which is significant in the district of columbia, because 23% of our population do not have cars. they rely on public transportation. we have over 300,000 people who come into the city every day, just to work. they rely on our public transportation, they rely on the mark rail system in maryland, the virginia rail system in virginia to come into the city. so imagine, let's say, 5% of those train operators, those bus operators, aren't able to come to work on any given day. the pressure that that would put on our already crowded roadways, or people who just simply said you know what, i'm not coming to work or can't come to work because they don't have a car, so those are the types of things that my agency is focused on, and in my role as the director of the district's homeland security and emergency management agency, my focus is

making sure we have the integrated and coordinated planning led by the department of health of all of our district government agencies, so we can come up with a comprehensive plan. three major objectives, keep our government open, protect our citizens, maintain our central services and then our critical resources and so on. and again, i think that this is a partnership effort, not only amongst you, the people in this room and the government and again, i can't emphasize it enough, it has to start at the individual level, the family level, the community level, and then he on to the larger city level in society at large. so i want to thank you all for the work that you're doing. unfortunately, i won't unable to stay here and participate in the rest of the conference. i'm actually jumping on a plane to fly out to los angeles here in about a couple hours to participate in another conference that i had overbooked myself to on prior to accepting this engagement, but i want to thank you all for the work that you do. i'm sure you'll have a great

conference. but don't work too hard. if you're not from here, go out, spending money. we need the revenue. and spend your money in district restaurants. not in virginia and maryland. but i love my neighbors. thank you all very much. [applause] >> thank you very much, darrell. there are three points i took to his presentation. one is that we're in process, we're ever learning, we're ever growing, we're ever understanding. the other two is the power of one. i heard steve talk about it, the power of one, having one message when you're actually delivering, and that ties into risk communications. the interesting thing that is -- this is the area that we're going to be dealing with and at some point in our communication, risk communication. how do we reach various

populations in our community and i was on a radio broadcast with one of my colleagues an we were talking about its h1n1 and it was shared with us that the faith-based community in a particular city had come together in coalition so that they can speak it from their synagogues and their mosques and their pool pits, within their churches, so one message was delivered to this wide broad coalition of faith based community leaders, so a very, very important topic. thank you very much, darrell and i think he's already out the door, sprinting his way away. our next speaker will be speaking on pandemic influenza, the response from the perspective of the pan american melt organization. dr. john kim andrus has 25 years experience working in the field of vaccines, immunizations and primary care, in developing countries, he currently serves as the lead technical adviser for the pan american health

organization, and he's its professor and director of the global health program at george washington university. he also has -- holds an adjunct faculty appointments at university of california-san francisco, school of medicine and john hopkins bloomberg school of public health. ladies and gentlemen, please welcome up our next speaker, jon kim andrus. dr. jon kim. [applause] >>

>> good morning. it's a pleasure and an honor to be here. i've been asked to talk about response to the pandemic, looking through the lens of of the pan american health organization, which is the world health organization's regional office for the americas, so we spend a great deal of our work supporting developing countries in latin america and the caribbean. in my presentation, i'm going it cover the his tore cool context -- historical context of the pandemics. i spend most of my time talking about the response an finish up with a discussion of risk factors and future challenges moving forward. i'd like to share a personal reflection first formalized several years ago, i found myself the district medical

officer of malawi. i had done my family medicine training in california, i served in the national health service corps and felt a calling for working overseas in global held. i worked in a hospital where i was the only doctor serving a district with about 12 other peripheral clinics and what i saw was in 1986, was the year the immunization in africa. it was a year where who and unicef got together and formed a coalition to improve immunization coverage among children of africa because it was abysmally low and we had this influx of resources and what i saw was this added support, was an injection of enthusiasm from the health assistants and clinical officers working in the hospital,

probably on less wages than i was as a peace corps volunteer. i saw them get excited about prevention. i had trained three clinical officers to do high risk obstetrics, so i could get involved in public health and i probably at that time could not even spell epidemiology, but that second year i was there, we could focus on this activity of immunization and i always felt coming away that i wanted more of that. i wanted to see the power prevention and the -- coupled with giving support to the network of health workers, because they were seeing children die every day of measles, diptheria and pertussis and what i wanted to do for the rest of my career, i i've been very lucky to work with the pan american health organization.

you're aware of documented shifts of influenza viruses causing the three pandemics that we had last century, and this has been an enormous -- a very beneficial point to reflect on, and compare the current situation, so that people can understand and compare what we're seeing today. but at the same time, we can't forget the fact that we're still dealing with seasonal influenza and we estimate that there are in excess of 250,000 to 500,000 deaths a year globally from seasonal influenza. and more than 90% of those deaths are occurring in developing countries. in addition to this historical con text, about five -- contest, about five years ago, as mentioned by the former

speakers, there was a great deal of attention from what we were observing from the h5n1 situation and so this led at least in the americas, to a partnership that involved the pan american health organization and the centers for disease control in atlanta, georgia, as well as other partners such as health canada, the ministries of health throughout the region. and we gained a lot of experience getting prepared and coupling that preparedness with communication. it's so essential to communicate that preparedness, not only from an organizational standpoint, but down to the individual and family level. what can a family do in the case of their child getting sick, how are they going to plan for care of the child and so on. surveillance has always been an underpinning of this preparation, as well as the response and containment to transmission. so this partnership also

provided opportunities to test certain strategies, laboratory tests, develop surveillance and improve surveillance. but what we found was that the discussion of the h5n1 in the context that it had about a 70% case fatality ratio, that when vaccine becomes available, that there would be a shortage, or we were hearing from the manufacturers, we just don't know the demand. we need to have more accurate demand information so that we can then deliver the vaccine, so back then, we realized that it was important for us to create that demand, so if vaccine became available, it would become accessible, we would have as an underpinning to that access, equity and health for all the countries of the americas. so we did two things.

we accelerated first the policy process. we are fortunate to have received a grant from the gates foundation, to work over the next five years, supporting countries to enhance their policy process. to ground it in evidence-based decisions and help them develop the science and data necessary to take these decisions, so in this project, which we call provac and it stands for promoting the capacity of developing countries to make evidence-based decisions, we've created a framework for which they can work from. and to make pa decision, there should be adequate technical criteria, adequate programmatic criteria, as well as financial as well as what some people have been referring to, social criteria, so technical criteria, knowledge of the vaccine, is the vaccine killed, live, does it

come in a single dose vile, multidose vials. programmatic, if we introduce the virus, will a cochain be able to absorb it. imagine a village nurse getting on her bicycle to vaccinate the children in the next village and she has a vaccine carrier. so in the case of roto virus bacteria, the vaccine comes if a single dose box, about the size of my palm. so if you're introducing that vaccine, imagine what that does to the nurse on her bicycle. does she need one more vaccine carrier, perhaps two or three? can she do it with the bicycle, will she need a motorcycle, will she need a car? all of these have huge implications that we've been working on and of course, the sustainability financial issues.

we also share information, this is a role that we think is critical in paho, this is an example of a study conducted in costa rica, where they found that seasonal vaccination is cost effective and we immediately got the word out to the other countries. we also tapped the political commitment to support our policy. every year, paho holds a directing council meeting where all ministers of health of all countries of the americas come to washington, d.c. and meet to discuss progress of the public health program and what recommendations can be done, and in 2006, we put forward a resolution, that i think is a landmark resolution, which was calling upon countries and urging them to expand their legal and fiscal space for few vaccines, so a new life saving

vaccine, for example, pneumococcol vaccine, where we know in the united states, every two hours, children die of pneumococcal vaccine. but we want to introduce the vaccine so it can be sustained or not handicap another public held program. perhaps aids, perhaps t.b., perhaps adolescent health, so that requires the expansion of the fiscal space that governments have to introduce these vaccines. and influenza was explicitly addressed in this resolution. it also called upon countries to utilize the revolving fund, paho, i'll come back to this. paho is unique in that we also serve as unicef in hour region. so our consultants, when they sit across the table from the

minister of health, talking about the technical data required to consider a policy, we can also talk about what we know and what we've communicated with the manufacturers, because we are the purchasing mechanism for vaccines, so this process is hugely powerful and i think has contributed to our success in eradicating polio, measles and it year i believe we stopped transmission of andemic rubella virus. paho also convenes a technical advisory group. for years and years, it was cared by dr. d. -- chaired by dr. d.a. henderson and with his retirement, it's chaired by dr. cyril and there are very technical doctors that review our work and provide us recommendations.

this is an example of the seasonal influenza policy recommendation that came out of the meeting in 2006 in mexico city. and the revolving fund i mentioned, just to put it in perspective, this is a purchasing mechanism that paho coordinates so that countries en masse can order vaccines. the power of bulk purchasing. so the little countries like el salvador, st. kitts, paraguay, can benefit from the demand created by brazil, larger countries. so this is about pan americanism and getting vaccine back to all communities of poverty. and i think the results speak for themselves. so with this work, i believe it was in 2004, we only had 13 countries that introduced seas seasonal influenza vaccination. and we now have 35.

so the response. y'all remember the 16th of april, which led to the activation of our emergency operations committee. we immediately mobilized scientists from paho as well as from cdc and public held canada to go to mexico, coordinating with our partners. this slide summarizes the events, but beginning back in mid april to the 11th of june, resulting in the declaration by the director general that we were in a pandemic phase six. and i use this slide to reflect back on how we initially responded. you know, this is a new virus, we knew very little to nothing about its transmission, about its severity. we were working very hard on detecting cases at the very on

set and then we could start with our teams going to the field, start collecting and conducting more analytic investigations, that has now led to a period where we're monitoring very carefully, particularly the genetics of this virus, and so that if there was a shift in the genome, we would detect it as early as possible. now, paho, i'm going to spend the rest of my talk talking about vaccine, but i did want to cover some of the other areas of work that i've alerted to this response, the activation and use of the international health regulations that has empowered who to be sure that countries are reporting on this virus. all the work that's gone into strengthening surveillance, i believe that the usual thank you i raised at the beginning of the

talk, h5n1 has led to a situation where surveillance still needs improvement. there are still gaps, there are no doubt, but it's better than it's ever been and i think the response and our capacity response is probably historic as well. clinical management, i'm going to go into more detail about the work we're doing for vaccine development and ensuring that it's accessible to all countries and i'll cover some of the risk communication. and i didn't want to forget veterinary public health, because that was a curve ball thrown at us, that we had to deal with both if mexico and canada and certainly in other parts of the world, you may have heard about what happened in egypt. so as we stand here today, there's a lot that we have learned. i've listed in the slide i think what are key features. we know he that the virus will continue to spread, it spread rapidly. i'm going to share with you some data on how infectious it is.

in a subsequent slide. its attack rates are higher in schools. it may be as high as 33%, for example, in some settings, particularly in school settings, but it's much lower in other settings. perhaps 13%. so there's a variation in attack rates. we believe the clinical picture is mild. we used to keep saying mild to moderate. i think we're backing off and focusing more on a mild clinical picture. post people definitely recover -- most people definitely recover. there is however, a marked shift in the age distribution that you're all aware of, for both cases and deaths. we have no evidence to suggest that the seasonal vaccine provides any cross-protection. but we do -- we're finding out though that people born before

1957 remember the pandemic of 1957, those of us who were born before then, we actually may have some cross-protection. so looking towards the future, we are working, i believe, quite hard on ensuring countries that they can respond to what will be a second wave of cases, so that their health services are able to withstand that jolt and that because in the absence of a vaccine that will be -- even when it becomes available, won't be available for everyone, that the primary measure against defense, or primarily defensive measures or mitigating measures that were mentioned by former speakers. i'm come back to the points about risk communication, the lessons learned that we have

from the pan american held organization. this is an example of some of the communication that's taking place in communities of latin america. these are posters that were -- that are now, i was in columbia few weeks ago and these are in most schools, they were quite visible. :

>> it's important for us to say that. it's important for us to say what we know and what we don't know. the complications currently range around 20%. again probably a large variation there. and although i put a percentage, a question mark next to death, we do know definitely that the case fatality is less than 1% and may vary. particularly countries that have more vulnerable populations. the countries that we serve in the americas. so i would like to talk about the re productive numbers. that is simply a measurement trying to estimate the activity of an agent. it's supposed to calculate in the situation where there's no intervention the average number of people that would be become infected if they were exposed to an index case.

and you see based on these diseases there's quite a range. there are at the bottom the 1918 estimates up to measles ranging from 12 to 18 on average that would become infected from one case in the absence of interventions. so measles is the most infectious virus that we know. when i'm with students i asked them to picture standing in your locker and a friend taps you. you turn around. you sneeze, and you happen to have measles. 20 feet on either side of, depending on what direction you are standing, those children would be at risk if they are susceptible. so that's a highly infectious virus. this virus, the pandemic virus

is spread by large droplets. it's impossible to carry the distance that measles would. one or two meters if someone were to sneeze in your direction. and for this virus, we estimate that measures that are somewhere between 1 hadn't 4 and 1.6. i have also included the case fatality ratio from canada and the u.s. and how it varies. just to summarize a publication that came out from cdc that health care providessers are not overrepresented in the cases that are respected. but, however, despite that, health care providers are essential to being able to withstand that second weight that i mentioned. maintaining health services. they are also more likely to be

treating patients on a daily basis, patients that have underlying chronic diseases. so again another reason why we want to be sure that when vaccine becomes available in all countries they can maintain the stability of their country. children are what we're calling amplifiers of infection. there have been studies that have shown the prevention of influenza in children will reduce it in all age groups. closing of schools in certain settings has been acceptful. but this needs to be balanced with a message particularly in our developing countries where there's a large proportion of people living on edge who are poor. if i lose, if i take a day off

work what will that mean to the economic status. that needs to be balanced. that gets back to the messaging and the communication at the family, community level, neighborhood level, what can we do if our children get sick. can we have a plan in place that will allow us to continue to work and perhaps prevent closure of schools? certainly pregnancy is a risk factor. as i'm getting close to the end and covering these risk factors. and the pregnant women will emerge at the top of our priority with health care workers in the americas. i would like to end by discussion on vaccine availability. this map highlights where the various manufacturers in the world are located. and notice those two red circles. those manufacturers are in

europe and north america. and they provide probably at least 0e68% of the world's vaccine supply. and unfortunately a large proportion of that potential vaccine supply is already tied up in preproduction contracts. our work is trying to ensure that all countries have access to this vaccine. to understand the situation better, dr. marie conducted and asked manufacturers who she made certain assumptions where her group in gay five have, w.h.o., given the pandemic virus, the yield will be similar to the yield of a seasonal influenza.

what would be the number of dozes in x, y, and so on. and collect is that information so we will know what do we have to work with? so she sent it out to every potential manufacturer in the world. we got a great response rate. this summarizes the data that we could estimate that per week the global capacity could produce about 94.5 million dozes. and over the year, that would translate to about 4.9 million dozes. we had a set back where we learned that the yield is indeed not the same. it maybe a quarter to a third of seasonal. so if we multiple the figures by a quarter or a third then you become to realize what we have to work with. global planet population of 6.7

billion people, we need to be really thinking about how we prioritize the use of the vaccine. this summarizes some of that work where you see this line graft showing vaccine available in billions of dozes over a period of time. and what we can do to focus on strategies. well, in that first phase, we and work with the manufacturers to ensure that their setting aside a certain percentage of vaccines that will become available to the countries. and this indeed is happening. we can talk to industrialized countries so that countries of europe and north america can set aside and work the developing countries to ensure that simultaneously those two processes will give us something to work with to protect vulnerable populations in our

region. we can also talk about shortening what we call the contracting window, whether it will help. we now have a better yielding constraint. scientists went back to work and now have produced a strain that appeared to be at the same level. so that's excellent. and thirdly, we can work with industry and our partners to transfer technology to the transferors. and this indeed is the case with butonton in brazil and a mexico. i believe that given the technology to the brazilians to make this vaccine. hopefully we can use some proportion of that to neighboring countries as well. when a vaccine becomes

available, it will become available. we know it won't be in the quantity where everybody can be vaccined, we really need to address this question given the limited supply of who we vaccinate and what will be the recommendations? in many countries this virus is replacing the seasonal. but seasonal still has a foothold. so we again do not want to lose sight of that. if it appears we will continue to recommend seasonal vac -- vaccination north of equator. we've had meetings of experts in gay five have in july. our own technical advisor group that i mention is meeting next week in coast that rick coo.

and this will be the first day's discussion. who are we going to priorize in our country for vaccination. and that will be followed up with other meetings. the yearly meeting that selects the seasonal vaccine will be taking place in melborne in september as well. so what we've learned, i believe is important -- i think we're fortunate to recognize at the beginning that it was important to bring together. acknowledging of all that preparatory work helped bring the level of confidence to countries that they could tackle the current challenge. we certainly, i think, in the americas have a level of solidarity that's been very

useful and important in coordination. and we add -- at paho, one of our mission statements is to provide and help for all. in this process we've tried to maintain transparency. we've tried to let the evidence speak to the extent possible, use comparisons so people at the community level, family level, can put this into perspective and understand it more effectively. . honest always. we believe maintaining humility will also contribute to gaining the trust of the media and the public. what we know certainly a lot as i mentioned. i think the virus will continue to spread, and it's probably mild severity, we need to balance this overreaction with complacency.

it's a constant point of discussion. all the viruses isolated are similar. we haven't seen major shifts in mutations. it remains sensitive to -- we have at least six documented cases as of last thursday of the teleconference call of resistance. we had four unofficial, some of the countries that we're talking about are twan, south korea, denmark, u.s., i believe australia. and in most all these cases these resistant strains develop on people put on p -- prophylactic. do not use this for prophylactic. it's very hard to monitor compliance.

that's when the resistance becoming introduced. all this leading to the message about our major defenses being mitigating measures mentioned. and these irony viruses are predictable in their unpredictability. we believe once the vaccines become available we will now how to use this vaccine. these are data, the blue lines shows the cases of measles reported from 1980 to 2008, you can see the major reduction with the measles elimination strategies. our last pandemic case was in november 2002. the elimination of measles unmasked the hid the burden of rue bell will and also rubella

syndrome. we know that countries have a passion, a commitment, and an understanding about the power of vaccines and prevention. and we will use these vaccines when they become available. another message to the producers. here's the example of the urban yellow fever outbreak last year in the capitol. this is the first yellow fever outbreak in 45 years in the americas. we had 10 deaths, as you see located in that community. we were able to mobilize vaccine during a global shortage from donations from countries like bah beau live ya, brazil, and vaccinate 1/3 of population over a month. over a situation which led to

the toppling of the government and great instability. we are aware of the adverse consequences. we're trying to mitigate those. so many summary, the last five years has benefited us by being better prepared, perhaps better in history. our revolving fund is very important and playing a critical role. the communication strategy continues to be this balance between overreact and come mr. sen -- complacency. we can't predict the future. but we believe the best scientists in the world are working on that, including our colleagues at cdc and w.h.o.. so we're in a marathon now. before we were sprinting. before the director general declared a phase 6. we realized we were everything for pandemic. so let's take a step back and

reflect and priorize the measures that are going to help protect individuals and their families. i think i'll end there. again, i'd like to thank the organizers for inviting me. [applause] >> we thank him for that. we appreciate all the work we are doing in the survey surveillance of the disease as well as w.h.o. and cdc. i'm going to make a few announcement on change. we're running on the time here. we want to do a coffee break up until about 10:30 is the time we want to do it. we're probably going to get started with our next speaker after that. so we'll give you a break. one of the things i wanted to point off is he said about

putting a face to the infection. if i could everybody in the room right now just a moment of silence to the sick and the fallen to the fatal. we want to take a few seconds, just a moment of silence for that in our country and locally. thank you very much. if you can go ahead and take your coffee break and we're going to meet back here and present with our next speaker. we look forward to see you in just a few more minutes. [hushed conversations] >> about a 10-minute break in the conference on swine flu. we're hearing from local and national health officials on

efforts to propair for -- prepare for the virus, the h1n1 virus also known as swine flu. just a note, live on noon today on c-span, it's a state department briefing on refugee issues. noon on c-span. also on c-span at 1:30 p.m. we'll take you to the white house with press secretary robert gibbs. while we wait for the swine flu conference to presume, some today's news and your phone calls. >> host: here is the article that we refer to the new york times. giving harden republican opposition to congressional health care proposals, democrats now say they see little chance for the majority's cooperation in approving any overhaul and are increasingly focused on

drawing. -- against >> a little bit more from the "new york times" article. >> 202-737-0001. 0002 for democrats, 0003 for independent. the twitter address is

c-spanwj. our first call comes from georgia. >> caller: hey, joe calling. i just wanted to call and say i'm against the bipartisan bill. we have outstanding congressman and state senators and representatives leading the fight to stop this health care plan. i think all of it has been -- it's just awful. and we're -- i'm down here in georgia. a lot of people down here, everybody i talked to down here is against it. we feel like there's too much government. i think obama has to be stopped. i'm proud of people like congressman les that's standing up. we're fired up and increasized to stop this health care bill. we think it needs to be stopped, because it's just socialized medicine, rob. i think the majority of the taxpayer, if all the polls show are against it, it needs to be

stopped. >> host: joe, give me one thing you think is evidence of medicine? >> caller: i think the public option, obama himself used the post office as an example. i graduated in '62 and got my mail at 8:30 and now i'm getting it 10:30 and paying 10 times as much. anything you turn over to government is inefficient. and it costs too much. and the whole public option is something that i think that scares american taxpayers like myself. just about everybody, we're all scared to death about it. just about so the public option is the thing. anything that has to do with adding more government, and that's pretty much all of obama's plans. see i'm a small businessman, and i'm a small businessman in georgia in 1975. i'll tell you, the 27 million small businesses are against this for the most part are

against this health care plan plus all the additional spending by the obama administration. >> host: joe, we're going to leave it there. >> host: in this morning's "philadelphia inquirer." now to our line for democrats. >> caller: yes, i'd like to say that it'd be nice to have a bipartisan bill between the democrats and republicans.

but the republican line stated -- republicans keep saying they won't vote for it. if that will happen, democrats need to do this themselves. that's why they were elected. >> host: how important to you that the bill be bipartisan? >> caller: it's -- i'd like it to be that way both sides take responsibility for the passage of the bill. and they are saying they had a part in taking part in it. that would be fair to all. because we didn't have that option the last eight years. but i would like it to be -- it needs to be done for the country. and these people who are saying that socialized medicine are not -- they wouldn't go through medicare, and that's socialized medicine. there's people out there that are hurting that are working hard too. i just believe it would be the right thing to do with the country? >> host: do you think the bipartisan bill is going to make

a better quality bill? >> caller: it could be. if the republicans would work with them and get some good legislation in there with the democrats, it could be a good bill for everybody. but if they are refusing to do it and they just want to say no and throw it off to the side, then they are just burying it. >> host: on our line for independents. >> caller: yes, i do believe. stephen had a great point. i don't believe in medicare being a socialized program. i had a situation and this obama bill will help out tremendously. and that is the sharing of information between doctors. my mother was just released from the hospital on sunday with a broken arm in three places. and now because she wasn't directed into a rehab center from the hospital, we're going to hack to try to get her into a rehab so she can get her arm

taken care of. i think mr. obama's bill will take care a lot of things. let's sit back and relax. republicans and democrats have never gotten along in the entire time we've ever had them. so bipartisan bill would be great. but i don't think it's ever going to happen. >> more from the "new york times" article. the democrats may not make producing a final bill much easier. the party must still reconcile the views worried about the cost and scope of the legislation with those of more liberal lawmakers determined to win a government-run insurance option to compete with private ensurers. back to the phone, pennsylvania on the line for the republicans. >> caller: yes, good morning. thank you to c-span. i do not believe a bipartisan bill is necessary. i think we need to get health care passed because if -- in the past 30 years there's been a lot of people left out of the

profits. there's a lot of people that are hurting, a lot of people with medicare and securities are the first one to say we do not need -- are that we do not need socialized medicine. however, i think with the people out there that are hurting that need it, any medicine is medicine. we need to stand -- i'm a republican, but i voted for president obama because i feel that we do need a change. and i didn't like extreme change of the republicans. >> host: hold on a second. let me get your reaction to this in the "new york times" article. >> host: what do you think about that? >> caller: i think the democrats need to stand behind their president. the american people voted for

president obama for a reason. with an overwhelming majority. i think he's doing a good job, and i also think that we do not give him enough credit. i feel he has given the republicans enough rope to hang itself. >> host: on the line for democrats. is a bipartisan bill important to you on health care? >> caller: good morning. it is absolutely not. because number one it is never going to pass bipartisan. the republicans, since obama got in, bless his heart, they are not going to vote for anything that has anything to do with him. and i still say it comes down to the fact he is black. they are in their intercore, they are basically racist. they listen three hours a day to their leader, drug-addicted rush limbaugh. i'm very concerned hearding they show up at the meetings with

ak-47s because that's quote unquote is their right. they want this president not only hurt, but gone. if you know what gone means, you get my drift. because they are never going to give him any leeway. the republicans that call before me, there are very few and far between. as far as joe that georgia, he calls all the time. he's one of the radicals. why are they taking -- what they they lost with him in the white house? please have them call in and tell me. >> >> host: molly, hold on. the headline white house backs right to arms outside obama events.

>> caller: but did they do it before inform this is a side to president obama. they want to intimidate him. it's a prop for that. and i heard that they take these guns. : it is in them and giving a sign, we are in power and we got the guns and i tell you if they don't get a handle on the radical right wing with this bitch real hatred of our president of the united states -- vitriolic hatred. host: is a bipartisan health bill and poor? donnell on the line for independence -- dawna on the nice if everybody on the line played fair but, unfortunately, a lot of these right winged radical" k people are not playi fair and i personally think anybody who is against

healthcare -- against healthcare reform obviously have their nice probably incurred a major health issue because if you have ever been in my situation where i health insurance because i'm self-employed -- i mean, when i had health insurance, you know, as soon as you get sick they kick you off it. that's my personal experience and the experience of a lot of people that i know. so anybody who's against healthcare reform have obviously not had to sit and self-evaluate because if you go to the hospital, you're going to be bombarded with all of these bills that you cannot afford and god forbid if something serious were to happen and you end up in the hospital. i mean, a lot of people are now bankrupt and losing, you know -- losing their homes and pensions and all kinds of things because of healthcare. it's the number one reason for bankruptcy in this country. and people out there protesting so violently, they obviously -- either they're set and they

really don't care about anything else or it's just ignorance. that's my opinion on that matter. we elected barack obama on a platform of healthcare reform. i encourage him to push forward and i encourage everybody to support him and be more vocal and step out and not be so quiet and silent about it. >> victor in silver spring, maryland, a republican. >> caller: i can't believe these last two callers. obama is dangerous. he's a marxist and people around him want to bring this country to the east germany of 1957. and i'm going to speak out. it's my freedom to speak out. and i'm sick and tired of these liberals who get on there and don't want anybody else to talk. molly brought up the fact there may be a race war, fine, bring it on. >> host: new york city, adrian

on our line for democrats. you're next on the "washington journal." >> caller: hi. >> host: what do you think of a bipartisan bill being important? is it important to you? >> caller: i think it's incredibly important. i think we have rising unemployment rates. we have a significant portion of our population that are poor who can't afford health insurance whose employees won't pay for them and some of them are getting some sort of emergency care when something traumatic happens and our premiums go up to pay for that. so i don't think it makes sense -- i don't think the arguments on the opposite end that most of these republicans have in terms of defeating the bill make a whole lot of sense given the fact we're probably paying a lot of these services that these people are receiving in terms of primary care and other sorts of emergency care anyway. and given the fact that i think everybody at this point is sympathetic to the fact that the fact we have a 10% unemployment rate in this country and those people need insurance and there should be some sort of security

net for people. >> host: in the u.s. news section of the wall street journal this morning this headline white house rethinks how it sells health overall, more emotional appeal may surface as obama backers criticize him for focusing on regulatory details instead of lofty themes. jonathan weissman writes this article. in it he writes the president is expected to present a more emotional appeal during a conference call wednesday with liberal h a liberal religious groups. the message will be tailored group' moral his is, although h oned the president' age to igious groups may not hold a broader shift i >> host: back to the phones. middletown, connecticut, john on our line for independents. how important is it for you that the healthcare bill be bipartisanly. >> caller: i don't think with the independents -- as the independents think we look at both sides of the story.

and i just don't think that the democrats or the republicans are going to work together. barack obama -- your past callers -- all they do is class warfare. republicans go against the democrats, the democrats go against the republicans. and all they do is call everybody names. you've on the programs where the republicans would call the democrats names. democrats are calling republicans names. barack obama was elected -- >> we'll leave this recorded portion of today's "washington journal" to take you back now to a conference on the h1n1 flu also known as swine flu. we're hearing from local and national health officials to prepare for the virus today. live coverage continues now on c-span2. >> we want to thank you for sharing your time with us. we want to give a great appreciation for our sponsors, and let me make sure i get their names and i want to make sure i

say them correctly. that is inter-jack is also, ecolab. we want to appreciate them for their support as well. and while everyone is filing in, i want to go ahead and at least going to read the bio or the information of our next speaker who will be speaking. as we prepare our next round after that, there will be a panel discussion with three esteemed guests after this, our next speaker. our next speaker is going to be speaking on the advanced warning of influenza outbreak. his name is dr. samuel bogash. he's a faculty of the harvard medical school, and he is now the boston university school of medicine. dr. bogoch is a founder and chairman of the foundation for

research on nervous systems and he's a chairman of enco lab, inc. i'm going to allow dr. bogoch to come up and join me here because i'm excited about what he is engaged in. i think there's a lot of scientific information that he's going to share with us on this disease that we see. and so, ladies and gentlemen, if you could please give me a warm welcome for dr. samuel bogoch, please. [applause]

>> the technology now exists to tackle one of the most vexing problems facing viralologists and public health officials, how to correctly predict if, when and where a particular strain of the influenza virus will break out and how long it will last, how severe it will be and when it will go away. dr. andrus mentioned that the world health organization was alerted in april of 2009 to the present h1n1 outbreak which became pandemic. april, 2009, was just a few months ago. in april, 2008, we published a

warning that the h1n1 outbreak was coming. this was not noticed too much until recently, but this was done not by any occult methods but by the first methods that we have to examine quantitatively the genome of the virus and to measure quantitatively a group of new peptides that we discovered some years ago that relate quantitatively to rapid replication of the virus and to outbreaks of the virus. we did this in 2006 when we measured the increase in the

thadoly in h5n1 and it's occurrence first in indonesia. my friend said we don't mind if you tell us if it's increasing but please don't tell us the exact spot where it's going to hit first. well, we did publish in 2006, and it did occur that there was an increase in the thadoly in 2007 in humans and it did occur that it hit first and worst in indonesia. slightly encouraged by this but thinking that it might still be a peculiarity of the data, we noticed when we and everybody else was paying attention to h5n1 that, in fact, the other

surveillance we were doing with our computer system indicated that h1n1 was increasing markedly. and when it reached the level -- what we call the count of these peptides that it was at in 1918, we thought we were obliged to take notice of this and published that on april 7th, 2008. now, as public health officials which i think most of us are here, i think it's worthwhile to think whether it would be useful to have a year's extra time, please, to organize our public health response and a year extra time to begin to produce our vaccines so we didn't have this awful crunch of days and weeks

at the -- as the fall approaches, not having enough vaccine produced. i think the answer's clear, both from a public health point of view and from a vaccine protection point of view that it would be useful to have an early warning. now the history of early warning is worth a moment of note. you know that there is providence in the fall of a sparrow, and you know who said that? that was shakespeare in hamlet. and he was probably talking about some -- something other than the h1 viruses but we don't know. there's at least some association with something that said beforehand and something which was to come. the next thing we note that paul

revere got on his horse and rode furiously to warn that the british are coming. in history, therefore, of early warning, this was sort of the next milestone. the next milestone, i guess, was in the use of pigeons to take messages in europe about the wars they were having to good effect with advanced notice. the next milestone was in the war, second world war, when the german bombers that were approaching britain were constantly surprised that the spitfires were up there waiting for them. how did they know that they were coming? they knew because of this new fangled invention called radar. and in honor of that, we've called our effort bioradar

because we are -- as far as we know the first quantitative measure biologically of what was coming, what is coming in virus technology to bother us. the next major event was in 1960. you know that when hurricanes came before that time -- if you had a day or two warning, you were pretty lucky. but with the satellite up there, we got days and weeks of warning. we could watch the storm forming. we could watch its path. we could estimate its target. this is a huge change, scientifically, to be able to measure what was coming. just because nature is about to take a punch at us doesn't mean we have to stay in the way to receive it. if we know in advance that it's coming.

the next advance, i think, has occurred with our discovery of a new group of peptides in the genome of influenza virus and of other infectious diseases which tell us quantitatively what's happening. is the virus sleeping? is it rapidly replicating? where is it rapidly replicating geographically? and so the warning published in april of 2008 noted that the replikin of h1 strain of the virus increased its highest level since 1918 of h1n1 pandemic. and while a few people noticed what we were doing for a few years, they paid attention this time because, obviously, how did you do that? and how we did that was the same way we predicted the h5n1 a

couple of years ago was coming. so we have some assurance that this is a method that could be useful in both getting early warning and in tracking. the current h1n1 virus appears to be rapidly replicating. it may exceed h5n1 as the leading candidate for the next overdue pandemic. this was in our april 7th, 2008 release. i wish we had known the doctor because we would have run to him, look, what we've got here. let's get moving a year ahead of time. and he probably would have said, well, i'm not sure. we'll take it to committee. maybe not. maybe he would have said, yes, we have to start paying attention to this. in june 11th of 2009, w.h.o.

declared the swine flu pandemic. what is a replikin count and how can it forecast the onset of a influenza outbreak? replikins are a new group of peptides and viruses and other infectious organisms and cancer proteins where they were first found by us related to rapid replication. replikins is the number of replikins per 100 amino acids. increasing the replikin count is associated with rapid replication and has been known for many decades -- rapid replication of the virus is associated with virus outbreaks. what do they tell us about the prospect of a influenza outbreak? a strong correlation between high replikin count and major disease outbreaks has been shown and we'll show you some of this. replikin peptide count

quantities increase before strains-specific flu outbreaks. and they decrease to signal the outbreak is over. this is the first virus chemistry which correlates with influenza, epidemics and pandemics the chemistry of rapid replication. this is what we search. we look at all of the published data and here's an example of what we see in influenza virus, for instance, you'll see that there are several genes listed, pb2, pb1, et cetera. each of these genes is examined for the accession numbers which is shown in blue, and those accession numbers are detailed sequences, protein and dna sequences, of that particular strain of influenza, which is actually isolated from a nasal swab or elsewhere in body secretions and the sequence is

published and this is terribly important. i want to emphasize this now and at the end. very important for the governmental organizations and public health organizations to get those sequences out. there are people now who can read them. and tell you back what's coming. this is the kind of sequence that one sees. this is an example of the hemogluin in the gene. and for those of you who are not familiar of amino acids in peptide sequences and protein sequences and you see there's just a row of these things and how would you know what this message is, what is the message? what is the language? we had no language up until now to decipher this. we didn't understand this. this is a language which was

obscured. the replikins were identified as particular units within this long strain which permits you to translate. here is what it looked like for about 40 years. [laughter] >> to the computer that was trying -- the best computers to take this problem and said we've got to find something that will give us some warning from the sequences. and this is what we saw until the stone was dug up which translated these hieroglyphics in three different languages and then it was obvious. now everybody can read hieroglyphics. we believe we've gotten the language for one particular aspect, which is rapid replication. and we've identified -- i'm sure there are thousands of languages but we have been lucky enough to discover the language of rapid

replication and so what we see -- and this is the first case we've seen it in cancer sales. rapid replication in cancer cells. there's a piece of that long sequence which had several groups, 1h and we thought what a strange-looking beast that is to biochemical industrieses in the audience and when we went looking for relatives of it they were all over the place. they were wherever rapid replication occurred. they were in tomato mosaic virus. perhaps you've never seen of it. i've never heard of it before which destroys -- massive destroys tomato crops all over the world. they were in corn and maze viruses. they were in hiv. they were in malaria. and they were in influenza. the cdc was very helpful and sent us is all of their tapes from 1918 forward on the epidemiological aspects, the

outbreaks of particular years and which particular strains were responsible for those outbreaks. and we tried to correlate the information we were getting from our computer search for such beasts with the outbreaks. we thought we'd be lucky if there was a vague correlation since nothing -- no correlation has been shown in the past with any other method of examining the structures. we were quite surprised and pleased to find that there was literally point to point correlation. what the computer does is it -- we've told it a series of criteria that it must use to count, to identify first and count replikins which are lysines which are 6 to 10 amino acids apart that have one group away. that has a greater than 6% lysine. a catechism so to speak of what must be fulfilled for a replikin to be identified.

then the computer counts them. it says how many of these are there per 100 amino acids? and then we said are the replikins concentrated throughout the genome? are they in particular places in the genome, concentrated? and this slide is interesting because it shows you the 8 genes of h5n1 and it shows you year by year from '03 to '06. and there was nothing going on in any of these genes in terms of replikin count. how many replikins per 100 amino acids were there? and that was even true for this last one which shows that in 2005 and 2006 it took off. now, we used, in effect, the

counting of these replikins to identify the gene location of the replikins and they wouldn't tell you while they weren't active but when they became active, as you see on the one on the right, not only did the mean, which is the blue, the replikin count in blue, but the red, which is the standard distribution, very important that it get much larger -- you see the red is very small, small percentage of the total. in all of the -- in all of the other genes but when it takes off, the standard deviation of the mean is much larger, which means you have a population of viruses, some of which are still sleepy, some of which are taking off with very rapid replication and high replikin count. so, in effect, the function exposed the structure. and that is a very useful

concept so we isolated the gene by in silicon methods. we know about in vitro. there's one in silicone that is we use the computer to isolate where the gene is. that means it's been simulated. it's not the gene. there's the gene accounts for 2% of the information. 98% is in the epigenetic instructions, get overactive. one is told to stay put. another gene is told. and that's what we're looking at here. we're looking at one gene which has the bulk of the replikins so we call it the replikin peak chain. now if you look to all of those epidemics and pandemics from 1918 to 2007, they're stretched out here for all of the data on public-med which is the public

accession for all the accession numbers, and you will see that the first look that bunch of them are very short and some of them are pretty tall. and that's a replikin, 1918 was up near 20. and the black is h1n1. this is -- this is strain-specific. so the h1n1 was elevated in 1918, and you see the numbers of these increases as we did more and more of these. not we, but as the world did, more and more of these analyses. but if you follow the black, after it sort of rebound epidemic in the '30s for h1n1 which fits exactly with what happened, it didn't do much. it didn't do much. but until 2007. if you look at the dark blue, that was the next pandemic in 1957. and that one is2n2. if you look at the green, that

was the next pandemic. that was 1968. and if you look at the red, you see the trouble with h5n1 acted up in these last couple of years. so that took it up to 2007. a very important controls is the light blue, the sky blue, and it's all through there. they're all short. none of them get up above 5. the replikin count doesn't get up above 5. and influenza b is what that is. influenza b doesn't kill people. yet. and, you know, 40 years or so, in 67 years represented on this graph, it's very low. so it's an important control. that means that when these peaks come up, you're in for it. or already engaged in it. here's an example of human h1n1 virus and we isolated two gene

locations, one for infectivity and one for lethality. the infectivity is more concentrated in the hemoglutto area. the infectivity is in the red and the lethality is in black. you see they don't vary together necessarily. and what i see is that there's a gradual increase -- a creeping up of -- since 2002 of the infectivity. and when that infectivity got to be 7, which was the number it was in h1n1, 1918 pandemic, is when we blew the whistle. well, in 2009 it went up even further as we'll show you. here it is again to show you that that increase in h1n1 in the infectivity and the lack of increase in the black, which is

the lethality is not a universal signal. that's h1n1. if you look to the right, h5n1 is just the reverse. the red stays down, the infectivity stays down and the lethality is increasing. now, that's exactly what we know epidemilogically about h5n1 that it is very lethal but thank goodness it doesn't transmit too well. you have to be a little baby who's got a pet chicken that you take to bed in indonesia with you and then -- and then you get infected. or a mother who's mourning her daughter she just lost from h1n1 -- from h5n1 to get infected. it's just the reverse of what we have in h1n1. in h1n1 we have high infectivity low, lethality, fingers i,cross. let us hope the shifting with

these beasts where you have high infectivity and high lethality. here you have the replikin counts that we're now doing instead of annually. we're doing them every day. and you see the beginning on the left -- how low it was. it was around 4 for infectivity and it gradually went up until it reached 7 and as i say we blew the whistle and then look what happened after that. that was in april of 2008 where we made that announcement. and then may in 2009 it had gone up another 40%. but interestingly the lethality had not gone up at that point. and within that month between may and june, the lethality started to creep up, the black. it's still way out here in the end of july.

it's still up about 25% above its resting levels which we observed back here. .. the replikin count for infect is still 39% above that may of

2009. the lethality is up 65% and it's still 25% above in may of 2009. you remember flu forecast data predicts 6 to 12 months in advance. so what we missed was a slide -- i don't know why but there's a slide of sars virus which showed that when sars virus was just beginning, the replikin count dropped. it had been up. it had been up in the viruses in general, fourfold in 2002. and in 2003, the sars virus hit, but just at that time the replikin count went back to normal in quotes where it had been for 10 years before. and that's what we were hoping for in this picture. we want to see a drop in those two back to these resting levels. we haven't seen it yet. therefore, we cannot be too

optimistic. there's a lot of discussion about how, oh, it's not going to be so bad. it's overhyped, it's overexaggerated. this is the only quantitative data that we know of that indicates exactly what the virus is doing in terms of the isolets that we have and it does not reassure. now, in conclusion, the flu forecast technology is now available to permit accurate quantitative analysis of virus genomic data for the first time and from the analysis to predict the infectivity, lethality and geographic location. of any strain of influenza virus 6 to 12 months in advance. however, not all of genome sequence data from which these predictions are made is rapidly published. when the centers of disease control and w.h.o. and our public health bodies and research institutes determined and published, most important to published viral genome sequences

the flu forecast swear services available to accurately predict the course of the current pandemic and to forewarn of future outbreaks. advanced warning 6 to 12 months before the outbreak or the improvement gives the advantage of time to both public health and vaccine efforts against influenza. thank you very much. [applause] >> thank you very much, dr. bogoch. we're going to go into our panel discussion. and the panel discussion i will introduce our next three esteemed guests. they will introduce the topic of the day of their professional expertise and then we'll try to entertain some questions and answers hopefully within a time frame before lunch. but one of the things i'm hoping

they will definitely stay around for your interface and communications as well. and it looks like i may have to get a third chair here. i'm going to introduce each one of them successively here and then we'll have them to come forth. my first guest in country reports in situation update, dr. george benjamin. he's a director of american public health association. he's well-known in the world of public health as a leader and practitioner and administrator. dr. benjamin has been the executive director of the american public health association, the nation's oldest and largest organization and public health -- public health professionals since december 2002. he came to post from his position as secretary of the maryland department of health and mental health hygiene. i'd like to have him come forth and he will definitely be talking more about his professional career to you and

his presentation as well. he will take the seat here closest to me. our next speaker will be dr. ronnie francois assistant secretary of louisiana health and hospitals. he was appointed to secretary levine as the assistant secretary of the office of public health, board of the louisiana public health and hospitals. he oversees the daily functions of the dhs' office of public health and he also served as a secretary of health for the state of florida. dr. francois. dr. adolly troutman, he's the director of louisiana metro public health and wellness. dr. troutman is the director of louisiana metro public health and wellness in whether or not

you are. and currently serves -- pardon me? [inaudible] >> louisville. i like that. he actually is also currently serves as associate professor of the university of louisville school of public health and previously dr. troutman served as a public health director for the fulton count of public health in atlanta, georgia and later to newark, new jersey. so ladies and gentlemen, please give a round of applause for our panelists please. [applause] >> we'll first start out with -- let's see, dr. benjamin. [inaudible conversations]

>> good morning, everyone. let me say how i'm delighted to be here today. i'm going to try to take this from the national perspective and then my colleagues are going to talk about both the state and local perspective, and i'm going to talk a little bit just what i think our experience has been with h1n1 so far. again, just to remind you i think as many people, it's important to remind you that seasonal influenza is already a challenge for us. it has a significant morbidity and mortality. it has huge economic costs. and clearly, this is something we have to deal with every day. you hear a lot about these

numbers, the number of people who died or a number of hospitalizations. it's important to understand that these are -- these are averages. and that these numbers have huge ranges, you know, from a few thousand deaths in some years to, you know, 50,000 deaths that we had or higher than we had in the 1918 influenza outbreak. so it is really important to understand that these are -- these are average numbers and that's why we do have some seasons which influenza is a bad season, quote-unquote, or some years in which it's not as bad. and, of course, many of us we were all sitting around waiting for the next great pandemic to come and we spent a lot of time and effort beginning to plan for this because we do know pandemics do happen. they happen with some degree of regulator -- regularity and we

don't know when they are going to hit. so while we're sitting around waiting for h5n1 last spring, a novel virus did present in mexico and while mexican authorities were struggling really trying to address this, the united states actually had a couple people in texas and california that we picked up with a new influenza-like illness that ultimately turned out to be the same illness that was occurring in mexico. i just point out that time of year as i look around the room, i want you to think back a couple of years when you were in college, just a couple because i'm trying not to become too old. [laughter] >> and think about the fact that we had that time of year -- if your doing and my children were

doing during spring break and all the people that were in mexico at this time, and then, of course, when they -- they returned home, many of them returned home ill which turned out to be this new h1n1 influenza. and then, of course, this has grown. and as you know, eventually it has already turned out to be a pandemic. now i remind people that the term "pandemic" simply means that it's all over the world. it does not tell you anything about the morbidity. it doesn't tell you anything about the mortality, lethality of this virus. it just tells you where it's at. and how frequent it is and how prevalent it is around the world. this particular influenza functionally looks like influenza with one caveat. there seems to be a heavier dose of gastrointestinal vomiting,

loose stools, there may be some things unique about this virus that cause it not only to attack itself to respiretory but the gastrointestinal event. and i need to point out that it's really not well-known, it may have something to do with the why it's actually living a little longer. as you know influenza goes from the fall and winter and goes away in the summer. yes, that's predictable. we had summer influenza outbreaks but usually it's not prevalent in the hot weather. this is a very famous sneeze photo. fundamentally this is the way people get influenza. you cough or sneeze in the air, whether or not the influenza virus spreads a short distance or a long distance depends on droplet size, wind conditions and things like that.

but primarily it's still through droplets and the fact that you cough in your hand and you touch something the virus can live on inanimate objects for a while i'm not really for sure what the g.i. tract role is but just something to think about and for those of you who are researchers and scientists, this was an area of research that you may want to begin looking at and see if it has some role because of the high symptomology of gastrointestinal and to point out that we're seeing more and more having a fever is not necessarily indicative of an acute infectious phase. in other words, there's lots of people who are still infectious and are not having a fever so that fever, while certainly a prominent syndrome of influenza isn't necessarily diagnostic by any means. i've always promised that as part of the fact that i like pork and i will support the pork industry to point out the fact

that you can't get this by eating pork, this was a big issue. i also want to point out that it also tell us we have to be a lot more careful as public health practitioners in terms of naming things. this virus actually consists of both human avian and swine virus particles, genes, and while the swine component is predominant in many ways, and that's how it got named, it has had a huge impact on the pork industry. and because people have used it for many reasons to identify a particular food as a risky food and just to point out that is not the case at all with this. and so again risk communications is a very important part what we need to do and i think there's another part of these lessons learned. we had the same thing with the bird flu. we probably didn't learn our

lesson when we tagged h5n1 as the bird flu but it's something for us to think about. now, our mitigation strategy for this outbreak -- because we did not have vaccine was primarily a hand and res pritory gene. and what they can do to cover up their mouth or nose during sneezing and social distancing and i'll come back to that in a bit. antivirals for those at risk or prophylaxis, issues with prophylaxis we certainly can discuss. and to encourage people to be healthy, lead healthier lives and get your chronic diseases under control and pay more attention to your asthma, your diabetes, your heart disease because, obviously, those are the people with chronic diseases who are historically more at any time you have a influenza outbreak. and that was fundamentally our

strategy. normally for influenza, we have a vaccine strategy but we didn't have a vaccine. it was clear that the seasonal vaccine would not protect us at least the one we still had some doses on. this was at the tail end of our usual seasonal flu outbreak so we had the clinical experience of knowing that that vaccine wasn't going to be protective and as you've heard, there's been some evidence that those of us who were born in the early '50s may have some degree of protection depending -- we're not quite sure how much protection but you may have some. now, sociodistancing is social strategy to protect others and we've tried to use that, that strategy a fair amount. by encouraging people if they're sick to stay home at least for a week and if -- at least be symptom-free for 24 hours, certainly whichever is longer.

and the goal has ultimately interrupted the chain of infectious transmissions as we go forward. the ultimate goal of sociodistancing is to take a pandemic like this that has no intervention to move that curve down the line and then to mitigate that curve so that less people get sick over time from the outbreak. it's a very, very important strategy that people use to try to impact the health impact and there is some historical evidence that this was tried in 1918 and 1919. there is some historical evidence that suggests that sociodistancing has a mitigating affect and a slow affect on the outbreak. now, granted, a that's a disease outbreak that has a modest as influenza -- influenza is fairly infectious but it's not measles. but it's important that one thinks about trying to do the

social distancing in a rational, functional way. now, the real science behind how you get infected certainly, the length of the incubation of the period, and how long it takes the virus to incubate, who makes contact with someone who is infectious. the probability of contact and how far the virus particles fly when you sneeze or cough, the probability of someone who gets infected themselves -- of course, they have to get infected and then they have to be able to infect others and the concept to grow which is the real extent of my knowledge is a term to address that. for those of us who are not epidemiologists and try very hard not to be one, the short answer is a ro1 is one who

reproduces itself and a ro less than 1 is transmit the goals and to try to lower the ro as quickly as you can in any way possible. and this is really an example of what it looks like in terms of how infectious and how ro really functions in the real world. now, you know, this is an epidemic and this one is just for discussion purposes has a ro of 2 which is a moderately spread epidemic and is above what it is and it basically shows if you had a person who's infected that person infects two people and each of those people affect two other people and it basically shows an epidemic growth. now the goal is to try to break that cycle anywhere you can. and you do that through a variety of mechanisms, by separating people by vaccinating

people, by getting the immunity so the disease doesn't spread. there's lots of things one can do to break this epidemic cycle but that's the idea behind social distancing and behind vaccinating people and separating folks in such a way that you can ultimately break these cycles as quickly as possible and this isn't rocket science but it is something to think about as we do. this is from the cdc surveillance system looking at influenza-like illness. one of the things that folks need to remember is that we don't -- we don't really count influenza. we do have a national surveillance system which we do have providers who send us specimens to give us an idea of when influenza enters the community and some basic idea which we extrapolate up from as to how many people might be sick

with influenza. and then we count hospitalizations and deaths because those are much more specific and then you have to not only come in with a disease that people think is influenza but you have to then test for it. you have to get a positive culture. and if not all those things are done, then you really don't get an accurate count. so-so our surveillance system to give us an idea when a disease enters the community and some understanding of what's going on. and this gives you an idea of what actually happened for this current bout of influenza-like illness and week one is in january and then it moves on to the years. you can see we're now below our national baseline even though we know we've had some outbreaks in some camps and some other places with this new virus. this also gives you an idea of kind of what the state outlook looked like in the united states. you notice there is no state that was not impacted at some

level. most had some sporatic activity, some had widespread activity doing this last outbreak and this is the last week ending august 8th. and again, once the next influenza season starts again we'll start to count this. this is challenging because we really have two outbreaks that will occur. we expect the seasonal influenza to return and then we, of course, expect h1n1 to return. as we look at what happens so far, we're guessing around a million u.s. cases were estimated for this virus. again, this is a real guess 'cause you don't measure every single case by every means. reportable hospitalizations were over 7,000 and over 400 deaths were -- have been counted, and these are cases that probably confirm culture-positive cases. i should say confirmed cases, they may or may not be

culture-positive or confirmed by some confirmtory test. as we move to the fall and winter we will have a outbreak mitigation strategy. it's really a vaccine strategy. we were hoping to start by effectively vaccinate people by starting with seasonal influenza 'cause we're going to have to do that. the novel h1n1 vaccine and i always remind folks that one of the reasonpgb many folks die is from secondary bacterial infection. at least for those people aged 65 and older we're going to have to give them a pneumonia vaccine. we only give that once. imagine being a 65, 66-year-old senior, now we're going to give you a seasonal influenza shots and a novel h1n1 shots and a pneumonia shot. those of who you know that, the more medication you offer someone and the more shots you have to give them, the less likely they are to take those

shots in the full range of shocks from the vaccination schedule so we are going to have a challenge in terms of vaccinating people this year but we understand what we have to do and it's going to require some work. we're going to promote hand and respiretory hand-washing. and social distancing. we learned a lot from the last outbreak last spring. antivirals for those at risk and certainly those that need to be treated for sure. the prophylaxis area remains to be very complex and in many cases it's not as clear as we would like but we're looking at that very carefully. and again, encourage people to manage their chronic diseases. the healthier they are as they go in this the better off they're going to be. i mentioned the vaccine strategy they're really going to be -- and i shouldn't use the term two strains predominant because, obviously, the seasonal vaccine is multiple strains that vaccine and the h1n1 vaccine, we're

going to actually have to give this series of shots. there are safety and efficacy studies now underway. at the end of those we'll know exactly how many shots we have to give. what will be the spacing of those shots and the shot regiment will come out of those studies. we'll also know -- i mean, you can guess right now it will be somewheres around 4 to 5 weeks from the first shot to the time when you're theoretically fully protected but we won't know all of that until actually these clinical safety and efficacy studies are done. thinking today that you can give the seasonal shot and the h1n1 shot at the same time and again, promoting the need for a numocockal disease. the cdc has come out with its priorities and recommendations

which including pregnant woman who are at risk 16 months to 24 years of age and 25 to 64 who have chronic conditions, cardiovascular disease, kidney disease, cancer, hiv -- any kind of complication will probably be given vaccine first. and also people most likely to spread the flu. so anyone taking care of a very young person under the age of six months -- because we're not going to be vaccinating those people, those children and, therefore, trying to take care of their care workers, family members, et cetera, will be important. healthcare workers because they have to be protected in order to -- even though they are probably not at more increased incidents from the last event they're certainly at increased risk because they're taking care of sick people. note that these recommendations are different from the recommendations for seniors. and for the seasonal influenza. again, that's because of the

experience has shown that seniors are not at great risk compared to others. this is a retroactive look what the infection rates appear to be from the spring event. note again that people age 65 years and older are at much less risk than the people between the age of 5 and 24. let me also point out that, you know, like any wonderful pandemic plan, all these plans will go out the window because normally what we do is we vaccinate and then the disease shows up. we may very well find ourselves in a situation where the disease shows up and then the vaccine shows up. and so our priorities may change and we're going to have to be very agile to rethink these very quickly based on risk. and then, of course, we're going

to have a public demand. you know, the first time someone dies from h1n1 that has now returned and we now have vaccine available and that person is outside one of the normal risk categories, there will be, you know, a demand to rethink that strategy. so we need to have some alternative models already in the can to think about how we will respond to those kinds of things. we also are going to distribute the vaccine a little differently. the seasonal vaccine is going to go through the usual system. meaning providers will simply buy the vaccine as they normally do. the novel flu will be different. it will come through the same process we use for the vaccine for children's program which is through the state and health departments. there's a single distributor. there will certainly be mix use of both public and private sites. ..

>> we still expect to be there. we also, we did expect that by the middle of october 120000000 doses, at least newspaper report said it will be more like 45 million doses. in other words, it will come out of the hopper a lot slower than we thought. but theoretically, this was a

normal influenza season. we should have substantial amount of vaccine by the end of october, and that is a misprint. it should be ended october. not september 1. but we should have a full set of vaccine by the end of that month. we will have some challenges and concerns by the anti-vaccine movement. obviously there are people out there who are not comfortable getting vaccines. they are revved up around a childhood vaccines in particul particular. one needs to recognize that are out there and there is a counter message, so we get the facts out around this issue. we will have some issues around the antiviral agent supplied. there is always porting, always happens. so to extend weekend try to mitigate that that will be very important. and there is or is this risk antiviral resistance that can develop. we do have pockets, small, small

numbers of cultures that have been shown to be resistant to some of the antiviral agents. it is not an issue today, but it could very well become an issue depending on how we use the antiviral agents. we are of course continued with our community mitigation strategy this fall. cdc just came out with their school recommendations. and they have kind of divided them into two boxes. box a. is this outbreak looks like the outbreak we had in the spring. then they are going to encourage people to stay home when they are sick. they encourage schools to simply separate guilt staff and kids if they come to school and you find them say, didn't separate them from the others and send them home. enforcing good hand and respiratory etiquette. clinic, the school's routine, nothing special needed. there are some guidelines that american academy of pediatrics i

think as our schools. dobbies the early treatment of high-risk students and staff. so if you're in school with special needs kids, you will have to have special protocols and procedures in place to figure out how to do with those children. and maybe selective school dismissals. you have children who you know are ill, children with asthma, etc., you have to decide how you will handle those children. i have this picture of kids on the bus. one, to show you that remind you that a bit of the populism of our country are in schools, either the kids at students or people who work in the cafeteria, the maintenance people around the place. plus the people around our schools. kids are often the first to get influenza in the community, and this will take all of you way way back i suspect. and this is what it looks like to be on a school bus. they are in close proximity of one another that they are in a close space and that certainly explains one of the reasons why they get sick. we know that if the event that

we have is worse than we had last spring, they are going to encourage active screening in that school actually looking for kids with fear and doing it and staff. looking at it a couple of times a day. having high risk students and staff to stay home. obviously, if a student has an ill household member, to encourage them to stay home so they don't bring the illness into the school. again, doing some more aggressive distancing of people in the schools. simply moving desks apart, not having school assemblies. may be canceling sporting events. those kinds of things. at the school. and doing school dismissals, both preemptively, meaning that they think there is a lot of influenza in the community so they close cool and pretty much what we did this last spring. and reactively which is also what we did when you had a big outbreak in the school. so we have to look at both of those kind of school dismissals. but this will happen and these

recommendations over if there so much robust outbreak. remind you that all of these decisions are local decisions. the school superintendents guard their authority to open and close their schools with great vigor. i learned that as a state health official. and so that these are really very much a local decisions that are made at the school. so the more that we can give these schools good guidance, and also the more the media cannot compare one community with another, recognizing these things need to be tailored based on the situations in the community will probably be better off. and with that i will stop and pass it over to my colleagues. thank you. [applause]

>> thank you, doctor benjamin, for the national oversight. please give dr. benjamin another round of applause. [applause] >> that was weak. i want to -- [laughter] >> i want to acknowledge our international visitors, some of them have traveled great distances to be here with us. let's give them a strong round of applause. [applause] and my point is simply that we are in this together. so let me go ahead and start, and i will try to give you the perspective from louisiana. and again, we are going to look at the three pillars of our response. infectious, the laboratory, as well as our antivirals and

vaccines. and this map shows you basically the spread of the disease. the focal point happened to be in region four. and there is no quiz after this. region four is right here. we ended up closing some schools. we are very aggressive because again, when you hear the word new, and it's in a middle school or high school, it gets to be very sensitive. and we certainly responded appropriately. and things could have been much worse. now, here is a snapshot of our epidemiology curve.

i don't like this curve. and if you give me a second, i will show you the way we would like for it to look next time. essentially, we would like to have a low incidence, and buy ourselves some time. some time. the reason for that is that the vaccines are supposed to be here the middle of august, as dr. benjamin mentioned. but we're not going going to have enough for everyone. so therefore, keeping that incidence of low and buying ourselves some time, through what i call the universal hygiene precautions, and social distancing measures, especially in resource poor areas of the

world. these are going to be really the way to go. and again, when we talk about our global family, those approaches are very important. because it only takes a flight or a boat ride, and it is in the next continent for the next country. now, essentially the age group that was most vulnerable in louisiana is between five and 24. and that sort of reflects the national picture. and the key question is what did we, and what did our stakeholders learn from our experience. let me tell you that, i am so glad that we had this pandemic finally happened in a mild way.

because it will return and it may get worse. so the spring, for me, was practice. and hopefully for you all, it gives you an opportunity to take your plans and operationalize them and take this entire pandemic issue seriously. i was in florida back in 2005, and it was very hard to get partners to the table. now i think we have everybody's attention, because again, it is a team sport. it is not a health issue or a doe issue or dhs issue. we have to have a global response. if we are going to be successful. and then what are we going to do differently in the fall is another question. so again, we had a very aggressive approach initially, new virus, scary. we have to develop protocols and

triggers for school closures. but also school events. community events. you know, dance recitals and so on. by week three, if you will remember, we had a paradigm shift, and the approach was scaled back. and of course, the questions never stopped. now, in the spring we were closing schools. in the fall, as you heard from dr. benjamin, the approach is going to be different. but again, we always need to remember that the source of the infection is a person. so, and that is sort of counter to our culture. stay home when you are sick. well, i have been environments, many environments where they say

we don't care if you are on a stretcher, we are going to hang the id over here in the corner and put a laptop on your belly so you can do your work. we have to change that, ladies and gentlemen, because it really takes one infected person to wipe out and decimate your workforce. you really don't want to do that. so again, in the fall, we are going to ask our teachers to be a lot more vigilant in terms of watching the kids. you are not health care providers, but they can certainly identify kids with a lot of, you know, coughing, sneezing and so on. and then sort of try to screen them that way. the media interest i think we'll still be there. and again, dr. benjamin a looted two the regular flu. we lose anywhere on the average of 36000 people. but the media coverage is not

there in terms of -- there is one orlando. there is one in l.a. boom. new orleans. again, that is exactly what we did in new orleans which really raise the anxiety level. the engagement of our response partners, again, is key with respect to security, antiviral deployment. as you heard, whenever there is rationing, what does the public say? i want mine now. people who have never gotten a flu shot, anytime they says there is a little bit of a delay production or delivery, they want theirs. so it's going to get worse because we are going to have priority groups. again, in louisiana we are going to have three forms of surveillance, are central physicians and providers, essentially work with us and submit infectious -- not

infectious, but influenza like illnesses samples from patients to us. and so we can sort of communicate with the cdc in terms of, you know, and over all broad influenza surveillance. we also have the hospital system, and we work with the hospital's. again, every case that is submitted within influenza like illness, will be reported. and the third piece obviously of the schools. we are going to monitor and track absentee is a and dismissals. the laboratory response, and i'm flying to this. by the way, there are some slides that you have that i have taken out just for the purpose of time. so you know that is what happened.

again, in terms of the laboratory, if your state is like my state, i know there are folks who are probably not convinced that, you, public health laboratory, what does that do? well, these are the folks who stood up to 24/7 to respond to this. i mean, they work harder than anybody else. and so again, on a day-to-day basis, they provide ongoing surveillance, as i just mentioned. and that is the basis. the sentinel system is the basis for what happens to the strain, the next vaccine in the following flu season. so that data, from the work that public health laboratories do across the country. again, in the spring, we had a lot of testing. and this fall it is going to be

limited to againfolks who are hospitalized and so on. again, we know that the fda has cleared the first commercially available influenza, and so those things will supplement the work of public health laboratories. and of course, we will be using a cdc developed test. we need to do that, and we will also be using real-time pcr. we have cross train our staff getting ready for the fall. we have bought some additional equipment. but if you like, if we like any other state, there are, you know, hiring freezes and reductions and so on. so again, additional safety cabinets. we have additional automated

extraction equipment, additional real-time pcr. and again, the specimens will not be accepted from everybody. it is going to be just sentinel submitters and hospitalized patients. and of course, we have issues with, you know, people putting the specimens using like a bacterial media and so on. and that is not helpful. so the state epidemiologist will be getting the results along with the submitters. now, the last piece of my talk is about antivirals and vaccines. again, the strategic national stockpile has been working on this for years, and we appreciate the federal support in getting the country ready for this pandemic.

louisiana did purchase its full amount of antivirals, and that varies from state to state, as you know. but thank god for sns that brought in 25 percent cash. and we went ahead and distributed that to tier one, tier two hospitals, nursing homes, and other partners like federal qualified health centers, the apartment of corrections, again, military and tribes. again, with that distribution, you also have to provide guidance. and we are doing that as the data i. in your handout we talk about some assumptions and those

options have to be taken into account. i don't have it here but you can read them at your convenience. but essentially, there are quite a few pieces to pandemic flu activities for the fall. and again, i'm not going to read them to you. i think every state, every local public health entities is going to be doing some of those things as well. and maybe some other activities. again, in terms of prevention, we are not only pushing the regular flu vaccine, but we also as dr. benjamin mentioned, encouraging our elders to get their pneumococcal vaccine. because again, there may be some synergy that obviously if you get the swine flu, the regular flu and pneumonia, it's going to

be tough to get out of that. we are establishing the priority groups. whenever you do that, it causes anxiety and folks who don't fall within those groups. and dr. benjamin went over that. again, talking population. he mentioned those, pregnant women. again, pregnancy is a compromised state. essentially the woman has a baby that is half somebody else. so for her to be able to carry them for nine months, yes, that indian system in every pregnant person is sort of tamed down in order for them to go through the entire pregnancy. but by the same token, it puts them at higher risk for infections. dispensing are going to be done -- is going to be done through traditional outlets and also nontraditional outlets.

vaccine distribution, we're going to be using the louisiana network for kids and added people who are older than kids and make them part of it in order to track not only the vaccines that are being given, but also in order to track the number of vaccines at each site. so this is -- okay. again, it will provide us with real-time, demographics, inventory and so on. okay. the role in our plan implementation will come from obviously our legislature and so on. but please do not forget the last. it is not least. the judiciary, the court system. we need to engage them in that

conversation. you have a very important role in keeping criminals off the street and so on, and so we don't want a dysfunctional judiciary. the plan is absolutely fundamental. it is one of the pillars of a pandemic flu response. they will do follow-up reminders with everyone. we use it judicially. releases, left and right. three languages. we have got information in the minis and spanish and english. we distributed a lot of brochures, and again, i want to thank, the state epidemiologist, the lab director, doctor welch, a flu pandemic medical director

and ms. griffin who put the slide together for me. i want to leave you with a latin quote. dr. benjamin tried to take you back and i am taking you back as well with some latin. that means the safeguard of the people. and the second part says supreme meaning the supreme law of the land. so essentially the safeguard of the people ought to be, should be, is the supreme law of the land. so let's break down those silos. come down together as a global family to tackle pandemic flu. thank you. [applause] >> while i pull out this presentation, i am reminded of the conversation we've had about the perfect storm when it comes to pandemics. on the bottom left hand. right here. okay.

and that is to say that this new virus that -- right here? yes, great. new virus highly lethal, easy transmissible was a perfect storm for a pandemic flu. our perfect storm is that i am the lasting between you and your lunch. [laughter] >> i am the third prisoner and everything that has been said that needs to be said and i have a plane to catch. so enough from new york and i talk fast anyway so let me just get it. so i'm going to talk about is a local response. i run this department in population of 700,000 people. and we are the last line of defense, if you will. we are where the rubber hits the road. as i was sitting listening to the presentations, i reminded of how important everything that has come up to this point in terms of our preparation and our planning has made us, has put us in a position to be as ready as

we can to address this issue. and then on top of that, this past year in metro louisville, we had the evacuees from goosed off from almost 2000 people came to our community that we need to take care of with special shelters and medication etc. we had hurricane ike actually came through medicolegal. and knocked out some 600,000 people in terms of power. we had medical or special needs shelters issues there. and then we had a flood just a couple of weeks ago that has caused us all kinds of problems. so we are tested and ready for anything in metro louisville, i hope. one of the things i wanted to mention very quickly. we did put together a structural change in our organization at the local health department to be able to do with these issues. so we started in office of public health emergency preparednpreparedness a fusion go. i think we have forgotten, maybe, that we've been talking about this ever since 9/11, but also ever since west nile virus. ewing and all the conversation

about the need to communicate and crisis communication and partnerships and collaborations. all that is kind of fertile ground for us to be where we are. this is our mission, invision. i would just mention that the purpose that we would work to prevent disease, injury and disability and ensure conditions that people can be healthy, which is the mantra of our local health department. some of the things that we have done already for pandemic preparation, we follow the all hazards model. and what we are doing for pandemic flu is really an extension of that. we have been focusing on internal readiness and retraining and retraining our staff and changing the structure at the local bubble, multidisciplinary partnerships are key and critical. we have something called the group in metro louisville where everybody who could possibly imagine who has a role sits around the table to many of them was bolted on their ankles. they carry guns, like the fbi and the police. you all don't relate to that? that's all right. [laughter] >> and many other partners that

he did around the table for us to do this work effectively. our collaboration is from city to county to state the region to federal. all at the same time involving themselves and getting ready for what we are facing. we followed the management system that we work on creating center of. we been exercised those scenarios. we evaluate. we we exercise and that is a battery of in falling for the last several years. just an example of some of the people involved. yes, there is a kfc with their, what is it baked chicken? grilled chicken. so even they are coming along in terms of their sense of public health. but you see the sheriff department, targets our community transportation system, the police department, metro sewer system. i want to spend a few minutes going over our effort to see how we could handle mass numbers of vaccinations in our community in a short period of time. and we used last year influenza

preparation to do this. so there are a series of slides i want to go to to show you what we did and try to account is by putting this process in place. so we called ourselves the influence of protection operation at the fairgrounds. kentucky has a huge complex for the state fair, but with the multiple venues. that is where the university of louisville basketball team played their games here consequent, it is a huge parking lot with a ring road that goes all around the operation. and 70 was to drive through to pay your fair into the parking lot. this is a picture of that complex on how extensive it is. we figured we would try to use this. by the way, we've moved to this particular version of access to population after organizing point of dispensing in schools. our first effort was, we have all the schools over the community. we can use the schools as a place to provide medication, vaccines, what have you.

. . to pay tolls. we put together this particular sheet to give us an objective, a directive of what we wanted to do. you can see our goal was to provide 60 vaccinations per booth beginning at 10:00 so we put the word out to the community. we're giving fe