patrick j. scannon, m.d., ph.d. cso, xoma stanford university, october 2015 technology impact on...
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Biotechnology Advances over Past Ten Years: Faster, Cheaper, Mobile and Global Many biotechnologic advances: Accelerated research technologies: Accelerated development technologies Internet: Methodologies widely published The Impact: Good: Greater innovation, faster and cheaper Bad: Greater innovation, faster and cheaper: non-state roguesTRANSCRIPT
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Patrick J. Scannon, M.D., Ph.D.CSO, XOMAStanford University, October 2015
Technology Impact on Biosecurity Policy and Practice
“D.A. Henderson, Scientist Who Helped Eradicate Smallpox, Says U.S. Is Unprepared For Bioterrorism” Huffington Post , Feb 6, 2012
“California nurses go on strike over lack of Ebola preparedness” Fortune, Nov 11, 2014
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Biosecurity - Technology - Public Policy Biosecurity (adapted from NIH): Taking appropriate
measures to address life sciences research (eg, human, animal, plant) with the potential to be misused to threaten public health or national security.
Technology (adapted from Merriam Webster): the science of the application of knowledge to practical purposes – often building upon prior generations of science and technologies
Public Policy (adapted from study.com): the means by which a government maintains order or addresses the needs of its citizens, through actions defined by its constitution.
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Biotechnology Advances over Past Ten Years: Faster, Cheaper, Mobile and Global
Many biotechnologic advances:• Accelerated research technologies: • Accelerated development technologies• Internet: Methodologies widely published
The Impact:• Good: Greater innovation, faster and cheaper• Bad: Greater innovation, faster and cheaper: non-state
rogues
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Biosecurity: Animals – Plants – Humans
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Recent Biosecurity-Related Topics in Medical News
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Key Biosecurity Public Policy Questions to Ask:
What is/should be the United States’ overarching policy for biosecurity, even if not formally stated? And what role does Technology play?
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Some Desirable Properties of Public Policy Forward looking and strategic guidance, ideally with declared
objectives, from government to its society - guidance has some reasonable/likely life span
Guidance results in enhancing society’s protection or well being Guidance anticipates scope Guidance acknowledges all processes necessary to meet
objectives Guidance should recognize required leadership Fiscally manageable and timely Guidance is directional but also adaptive
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Can’t write Public Policy in a Vacuum
Written Here
Needed Here
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Key Biosecurity Public Policy Concerns Management of concept of near-zero probability X high societal impact:
Many known, and perhaps more unknown, all rare biothreats: what is real and what is “crying wolf”? Fear tactics quickly tachyphylax audiences.
Some factors concerning biothreats: natural vs intentional vs accidental causes, disease toxicity/pathology/mortality, disease speed in affected host, ease of dissemination across populations, impact on health care system – how to prioritize across so many possibilities?
Prevention versus treatment strategies: when is each appropriate? Available resources – how much to allocate? Long lead times and big costs with new drug development – how to allocate
time? Disease boundaries do not respect State boundaries – how encompassing
should public policy be? Country-wide? Global? Role of technologies: often rapidly evolving – how to capture in public
policy?
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Examples of Biothreats
Anthrax: October 2001 Intentional
Flu: 1997, 2005, 2011, 2015 &
ongoing Natural
Ebola: 2015 & Ongoing Natural
Examples of Post Event Comments
REGARDING THE “BIG ONE”
Missed that Bullet…
Hasn’t happened yet…..
What are the odds: won’t happen on my watch…
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NIAID Category A, B, and C Priority PathogensCategory A Priority PathogensBacillus anthracis (anthrax)Clostridium botulinum toxin (botulism))Yersinia pestis (plague))Variola major (smallpox) and other related pox virusesFrancisella tularensis (tularemia))Viral hemorrhagic fevers
Arenaviruses Junin, Machupo, Guanarito, Chapare (new in fiscal year (FY) 14), Lassa, Lujo (new in FY 14)
Bunyaviruses Hantaviruses causing Hanta Pulmonary syndrome, Rift Valley Fever, Crimean Congo Hemorrhagic Fever
FlavirusesDengue
FilovirusesEbolaMarburg
Category B Priority PathogensBurkholderia pseudomallei (melioidosis)Coxiella burnetii (Q fever)Brucella species (brucellosis)Burkholderia mallei (glanders)Chlamydia psittaci (Psittacosis)Ricin toxin (Ricinus communis)Epsilon toxin (Clostridium perfringens)Staphylococcus enterotoxin B (SEB)Typhus fever (Rickettsia prowazekii)Food- and waterborne pathogens
Bacteria Diarrheagenic E.coliiPathogenic VibriosShigella species Salmonella Listeria monocytogenesCampylobacter jejuniYersinia enterocolitica
Viruses CalicivirusesHepatitis A
Protozoa Cryptosporidium parvumCyclospora cayatanensisGiardia lambliaEntamoeba histolyticaToxoplasma gondiiNaegleria fowleri (new in FY 14)Balamuthia mandrillaris (new in FY 14)
Fungi Microsporidia
Mosquito-borne encephalitis viruses West Nile virus (WNV) LaCrosse encephalitis (LACV)California encephalitisVenezuelan equine encephalitis (VEE)Eastern equine encephalitis (EEE)Western equine encephalitis (WEE)Japanese encephalitis virus (JE)St. Louis encephalitis virus (SLEV)
Category C Priority Pathogens
Nipah and Hendra virusesAdditional hantavirusesTickborne hemorrhagic fever viruses
Bunyaviruses Severe Fever with Thrombocytopenia Syndrome virus (SFTSV), Heartland virus
Flaviruses Omsk Hemorrhagic Fever virus, Alkhurma virus, Kyasanur Forest virus
Tickborne encephalitis complex flaviviruses Tickborne encephalitis virusesEuropean subtypeFar Eastern subtypeSiberian subtypePowassan/Deer Tick virus
Yellow fever virusTuberculosis, including drug-resistant TB Influenza virusOther RickettsiasRabies virusPrions Chikungunya virusCoccidioides spp.Severe acute respiratory syndrome associated coronavirus (SARS-CoV), MERS-CoV, and other highly pathogenic human coronaviruses (new in FY 14)Antimicrobial resistance
Pharma will not proceed for rare IDs without USG Funding: NIH, CDC, DoD
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Biothreats From Any Direction
Not just on the NIAID Priority List
+
Global Realities Impacting Bioresponse Strategy
Diseases do not recognize national borders
Multiple Populations: Civilian (children, elders, immunocompromised), Military
Inability to stockpile vaccines/therapies for all possible disease
US Strategic National Stockpile (SNS): STRATEGIC CHALLENGES
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Public Policy Requires Many Inputs for Cohesive Integration and Implementation
TECHNOLOGIES
TIME
DEMAND
INTEGRATION:Public Health Dept
Hospitals1st Responders
…
PRIORITIZATION
EFFECTIVEPUBLIC POLICY
DISEASE(S)
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Possible Barriers to the Inclusion of Transformational Technology into Policy
Only one of many variables which need integration Policy Makers may not recognize what is reasonable to
request Technologies “move too fast” – when is good, good
enough?• Proven “Bird in the Hand” technologies: ready to go• Unproven “Birds in the Bush” – what are risks?
Time/cost to develop and implement new technologies
RESULT: Potential default to existent technologies which MAY not meet Policy Objectives – modify objectives?
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Can or should Technology affect Public Policy? Can or should Public Policy affect Technology?
Consider impact, cost, timing of increasing mfg capacity(10x mfg cGMP capacity), yield (10x vaccine/liter from fermenter), potency (1/10 dose)/person.
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Technologies Encompass the Entire Biosecurity Path Rapid and distributed detection systems
Rapid Discovery of new vaccines (prevention) and therapeutics (treatment)
Development
Manufacturing Clinical Trials
Regulatory
FDA approval
Distribution
Administration to Patients
Technical Impacts at Each Step: Speed, Scale, Safety, Efficacy, Cost
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From Another Angle: Same Need for Technology
Bill Gates, N Eng J Med, 372;15 April 9, 2015
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Getting to Some Answers
What makes a rare biothreat disease “bad” for society?
• Mortality: 0% or 100% for individual, variable % for society• High Morbidity: overwhelming the health care system, eg,
ventilators, isolation units, trained personnel (3 shifts)• Contagiousness: high transmission (plague, smallpox) vs low
transmission (anthrax)• Lack of existent prevention and treatment
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Example 1: Disease Transmission, independent of disease, May Affect Policy
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Example 2: Disease Morbidity, independent of disease, May Affect Policy
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Disease Profiles, independent of disease, May Affect Policy
High transmission x high morbidity
High transmission x low morbidity
Low transmission x high morbidity
Low transmission x low morbidity: probably not a meaningful societal threat
Necessary But Not Sufficient: How are bioresponses affected?
Possible Profile Categories – each with different impact
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Different Disease Categories Suggest Different Medical (Technical) Responses Concept: Diseases with high transmission and
substantial morbidities affecting large populations, especially where time is critical, may be best addressed by a “bioresponse” prevention plan which includes novel vaccines
Complementary Concept: Diseases with low transmission and substantial morbidities may be more practically approached by a “bioresponse” treatment plan which includes novel therapeutics
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Impact of Technology: Two Scenarios for a highly contagious, high morbidity pathogen
Scenario 1: Previously unknown pathogenNo vaccine or therapy known
Scenario 2Known pathogenExistent vaccine
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The “Simple Case”: Scenario 2 Options
In Place Vaccine but Stores Insufficient 10X10,000 L bioreactors available 1 microgram dose, single vaccine (no booster
required) Availability 1: 100 million doses given by shot
Availability 2: 1 billion doses given by pill
How extensive would the public policy be for each?
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Policy concerns (inversely proportional to number of doses and route of administration)
100,000,000 doses IM Prioritization for
administration (eg, first responders, elderly, children, military)
Availability of 100,000,000 needles, syringes and sufficient cold storage
Availability of hospitals, MDs, technicians….
1 billion doses PO Deliver everywhere
ASAP Make available to ROW
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Conceptual Public Policy Bifurcation for Different Biothreats:
Disease Transmission x Morbidity
Requirement for Rapid Response
High Transmission x High Morbidity
Low Transmission x High Morbidity
Technology Implications:•Identification/Detection•Rapid Vaccine Development•Medical Supportive Care: Quantity + Quality•Distribution/Administration
Technology Implications:•Identification/Detection•Rapid Therapy Development
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Current focus appears to be on categories of diseases (eg, NIAID, CDC, CDC/USDA select agent/toxin listings) and specific diseases within.
Alternatively, “USG bioresponses to disease” driven by disease profile and technology, rather than disease specifics, may beneficially impact USG response, eg, vaccine, therapy and relative funding to support different scenarios.
USG’s Overarching Biosecurity Policy?
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Pathogen
Response in place eg, SNS
No Response in place, eg, new
High Transmission, High Morbidity, eg, pandemic
Low Transmission, High Morbidity, eg, containable
Vaccine Therapy, eg, siRNA, mAb
Technology-Driven Bioresponse to Pathogen Profile Provides Direction
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Key Biosecurity Public Policy Questions to Ask:
What is/should be the United States’ overarching policy for biosecurity, even if not formally stated? And what role does Technology play?
Who is in charge? And do the involved departments know what the other departments’ responsibilities are?
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Multiple Federal Agencies Are Involved: But who should be in charge of biosecurity?
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Key Biosecurity Public Policy Questions to Ask:
What is the United States’ overarching policy for biosecurity? And what role does Technology play?
Who is in charge? And do the involved departments know what the other departments’ responsibilities are?
What does it take to be ready?
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Preparing for unknown biothreats: Where to Start?
First, recognize and accept such biological threats can happen anywhere and anytime: natural, accidental, intentional
Assess our limitations on global scale, and determine which are addressable by investments in technology: • Timely Biothreat identification• Current Bioresponse Capabilities/ Capacities• Public health care and logistical response structures – not made for rapid
and large scale emergencies Develop Overarching Biosecurity Public Policy as broadly as
practical: • Top down leadership with long term commitment• Greater communication nationally and internationally • Large and distributable technology platforms adaptable for rapid
implementation when needed
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Progress into Preparedness
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“An epidemic is one of the few catastrophes that could set the world back drastically in the next few decades. By building a global warning and response system, we can prepare for it and prevent millions of deaths.” Bill Gates, N Eng J Med, 372;15 April 9, 2015
An example of an Overarching Biosecurity Public PolicyStatement
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My Viewpoint
Responses cannot be developed for questions not asked. Biosecurity Public Policy makers should not permit public policy to be driven solely by present day technologies but, rather, must create the needed vision in order to challenge technologists to address biothreats both today and tomorrow.
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An Adaptable Strategy for Addressing Unknown Biothreats on a Global Scale Depends on
Technology Advances and Leadership at Every Step
Cooperative communication network
Early-warning biosurveillance
Public Health response system for pandemics
(Global)Vaccine/Therapy response plan
Response plan for unknown biothreats
International Cooperation of governments, policymakers, public health
systems, industry and academia
Prepared for the Unknown on Global Scale