published 09/24/2009

After the quick spread of the SARS virus threatened to cause a pandemic in late 2002 – but didn’t – and the startling ability of the avian flu virus to infect humans caused a near-panic in the fall of 2005 – but didn’t – it’s understandable that governments, organizations and drug companies have stepped up their efforts to create a vaccine for the current pandemic. But so far swine flu virus infections have generally been on the mild side, with a death rate of one percent. So why are scientists concerned? And have they really dismissed the possibility of a new, deadly outbreak of avian flu?

Unless you’ve been traveling in some remote location of the world where your cell phone doesn’t work, you can’t have missed the recent barrage of news reports on swine flu. The media have fueled a public health scare, even though the facts don’t support the notion that we could be in for a deadly pandemic that will rival the 1918 Spanish flu outbreak, which killed upwards of 100 million people.

The viral strain that caused the swine flu outbreak in the spring of 2009 (H1N1) has become so widespread that the World Health Organization (WHO) proclaimed a pandemic in mid-June. However, this strain produced relatively mild symptoms in the beginning – and it continues to do so.

In recent weeks, cutting-edge scientific research has determined that existing drugs for fighting flu are still effective, and the FDA has just approved the use of so-called pandemic flu vaccines made by four different companies. As well, it appears that one single dose of the vaccine (rather than the standard two-dose regimen) is enough to protect just about everyone – assuaging fears that there won’t be enough pandemic vaccine to go around this winter.

Still, researchers and officials agree that things could change, and the swine flu virus could mutate to a more virulent form in coming months. They simply don’t know. But they are anything but complacent, even though they managed to contain two previous viral infestations that could have wreaked real havoc across the globe.

Remember SARS? The virus responsible for severe acute respiratory syndrome caused a near-pandemic between November 2002 and July 2003. It started in China’s Guangdong Province, but in a matter of weeks it had spread to 37 other countries. All told, SARS infected nearly 8,100 individuals and killed 774 of them. Although efforts to control the epidemic were delayed, by May 2006 the WHO and others managed to fully contain the spread of SARS – although it certainly hasn’t been eradicated.

What about bird flu? Caused by influenza A virus subtype H5N1, this disease probably started in Southeast Asia but then spread globally, killing tens of millions of birds. Sixty-five outbreaks worldwide were reported in June 2006, 55 in June 2007, and 11 in June 2008 – largely held in check (but not stopped) by vaccinating domestic poultry. But H5N1 can infect other species, too – including man. It doesn’t infect humans easily, but when it does it can be quite severe, even lethal. Indeed, by the end of September 2005 we were being warned that a global outbreak of bird flu could kill 5 million to 150 million people.

Since then, H5N1 has spread to new areas and it’s still mutating – making it a prime candidate for “going pandemic.” Frighteningly, genetic analysis of this virus has indicated that future mutations can be more lethal than the Spanish flu pandemic of 1918. WHO has been tracking confirmed cases of bird flu (H5N1) since 2003: As of August 31, 2009, WHO had received reports of a total of 440 confirmed cases from 15 countries (mostly in Asia and Africa). Of those, 262 patients (60 percent) died. This is one virulent virus, for sure, but fortunately WHO has still found no evidence of sustained human-to-human transmission.

Selected Experimental Vaccines For Pandemic Avian Flu

Company	Vaccine/Description	Status
Baxter International	H5N1 pandemic flu vaccine; produced in cell culture	EMEA issued positive opinion on mock-up pandemic vaccine (12/08)
Protein Sciences	H5N1 pandemic flu vaccine (PanBlok); consists of purified recombinant hemagglutinin (HA) antigen from H5N1	Vaccine was safe and effective in Phase I/II clinical trial in Japan by licensee UNM Pharma (1/09)
Vaxart	H5N1 pandemic flu vaccine; comprises a chimeric adenovirus-5 vector that expresses avian flu HA and TLR3 ligand as adjuvant	$2.8M, 3-year, Phase II SBIR grant to support development of oral vaccine (9/09)
Vical	H5N1 pandemic flu vaccine; Vaxfectin-formulated DNA vaccine	Vaccine was safe and elicited significant immune responses in Phase I trial (7/08; 10/08)

If that does happen, we are in serious trouble. Precisely because bird flu viruses infect humans only rarely, we have no immune protection against them – so a pandemic would be disastrous. It’s that scenario that lit a fuse under public and private research efforts to develop new vaccines to protect against the H5N1 virus back in 2005, and those programs are still active. (Officially, these are called pre-pandemic vaccines because they are intended to be used proactively, before a pandemic strikes, and are based on currently circulating viral strains. A true pandemic vaccine, on the other hand, is based on the viral strain specific to the pandemic and can’t be produced until a pandemic is declared. )

For instance, pharmaceutical giant GlaxoSmithKline plc (GSK) developed an H5N1 split antigen pre-pandemic vaccine that incorporated the company’s adjuvant. Because the adjuvant helps to boost the immune response, the vaccine will require less antigen than normal. In a pandemic, this strategy will allow the production of more doses for mass vaccinations. The European Commission approved GSK’s H5N1 vaccine, Prepandrix, in May 2008; it is recommended for use in individuals between the ages of 18 and 60.

Swiss pharma Novartis AG created a dose-sparing adjuvanted H5N1 vaccine, as well. In September 2008, researchers presented data showing that individuals immunized six years earlier with an MF59 adjuvanted H5N3 vaccine exhibited an immune response seven days after receiving one booster shot of Novartis’ H5N1 adjuvanted pre-pandemic vaccine Aflunov. The immune response was cross-reactive against various strains of avian flu, suggesting that it may be possible for people to get a pre-pandemic flu shot years before an actual pandemic – at which time they would get one shot to boost their immunity.

In April 2009, additional data on Aflunov were published in the Proceedings of the National Academy of Sciences. As before, they showed that the pre-pandemic avian flu vaccine can elicit an immune response covering all known H5N1 antigen variants. As well, new data showed that the vaccine is effective in children aged six months to 17 years.

GSK and Novartis aren’t the only companies developing vaccines for this deadly virus. Among others, Vical Inc. and Sinovac Biotech Ltd. have tested bird flu vaccines in humans. And more are sure to come. The swine flu may have taken center stage this year, but avian flu is still a very serious threat. The WHO certainly thinks so: In May 2009, the organization announced that researchers at the WHO influenza collaborating center within the CDC had developed a new recombinant H5N1 vaccine virus, which it made available to companies, institutions and other organizations that want to develop a pandemic bird flu vaccine.

Meanwhile, we’re in the midst of a swine flu (H1N1) pandemic. The particular H1N1 strain now circulating is entirely new to humans, the WHO said, and could eventually infect two billion people. It has been spreading easily from one person to another and one country to another. As of September 13, 2009, more than 296,471 cases of pandemic H1N1 had been confirmed in 80 countries. Of those at least 3,486 people, or slightly more than one percent, died.

By August 28, the H1N1 pandemic virus had become the dominant flu strain in most parts of the world, according to the WHO. Importantly, there are no signs yet that the virus has mutated to a more virulent or lethal form, the WHO said, and the illness is still mild in most patients. As well, the pandemic virus is still sensitive to the antiviral drugs Tamiflu and Relenza – although labs around the world are reporting sporadic instances of Tamiflu-resistant virus.

The CDC’s latest findings mirror those of the WHO: For the week ended September 12, “almost all of the influenza viruses were 2009 H1N1 influenza A viruses,” reported the CDC. “These 2009 H1N1 viruses remain similar to the viruses chosen for the 2009 H1N1 vaccine, and remain susceptible to antiviral drugs (Tamiflu and Relenza) with rare exception.”

When the swine flu virus first struck in April 2009, there were no vaccines to combat it. But now there are – and the 2009 H1N1 vaccine is on the way. On September 15, the FDA approved supplements to existing vaccine licenses (initially approved for seasonal flu) for four different companies making H1N1 vaccines. These include CSL Ltd., Novartis Vaccines, Sanofi Pasteur, and MedImmune Inc. (now part of AstraZeneca plc.) Reportedly, a fifth manufacturer (probably GlaxoSmithKline) will get the nod soon. In all, the U.S. government has ordered 195 million doses of the swine flu vaccine, but could get more if there’s enough demand.

That’s questionable, given the fact that the swine flu is still a relatively mild infection. As well, since the swine flu vaccine is directed against a different viral strain that any of those included in the seasonal flu vaccine, people are going to have to get two different shots if they want to be protected against both. Meanwhile, vaccine makers are still hard at work testing and perfecting their swine flu vaccines – including those companies that have been tapped by the FDA to supply the 2009 H1N1 vaccine.

Sanofi Pasteur, for example, didn’t start U.S. clinical trials testing the safety and immunogenicity of its influenza A (H1N1) monovalent vaccine until August 6, 2009. The following day, the French pharma submitted a supplemental BLA to the FDA for licensure of this vaccine, which the FDA approved on September 15 – the same day it announced that Sanofi Pasteur would be one of this year’s suppliers. But that doesn’t mean that Sanofi has stopped working on the vaccine. Au contraire. According to the company, the final data from the trials will provide important information regarding the vaccine’s optimal dose, the number of doses required, and the schedule.

On August 24, Australian firm CSL started human trials in the U.S. of its own H1N1 pandemic vaccine, a thimerosal-free formulation of the H1N1 vaccine. The company tested 1,300 adults and 450 children to determine the best dose to use in each patient population. All individuals were to receive two vaccinations, three weeks apart. The previous month, CSL started testing its pandemic vaccine in Australia, using a similar study design. That particular trial, which involved 240 healthy adults, was closely watched because it was the very first one to test a putative swine flu vaccine in people.


Meanwhile, Chinese vaccine specialist Sinovac Biotech was testing its own swine flu vaccine Panflu.1 – and the results were startling. The company started its trials in China on July 22, 2009 and announced top-line results on August 17. A committee of experts concluded that the vaccine (which is non-adjuvanted) demonstrated good safety and immunogenicity profiles after one shot, and can be used in all individuals between the ages of 3 and 60 years.

Initially, not all parties agreed that a one-shot vaccine, especially one that doesn’t contain an adjuvant to boost the immune response, will work very well in producing a long-lasting response to viral attack. In recent weeks, however, that view seems to have changed.

On September 3, Novartis reported that one dose of its experimental, cell-culture-based H1N1 flu vaccine Celtura, boosted with the immune-stimulating adjuvant MF59, elicited a strong, potentially protective immune response in 80 out of 100 volunteers.

On September 11, preliminary data from studies conducted by CSL and the U.S. Department of Health and Human Services (HHS) showed that swine flu vaccine can work in adults with just one shot and that protection occurs in 8-10 days. The one-shot option is important because it means that the vaccine supply can now be stretched to cover twice the number of individuals as first supposed.

CSL, which tested its experimental H1N1 pandemic vaccine in healthy adults, found that a single, 15-microgram dose of the non-adjuvanted vaccine elicited an immune response in 95 percent of the 240 test volunteers in its Australian trial. And HHS reported that in trials sponsored by the NIAID (National Institute of Allergy and Infectious Diseases), one dose of an experimental vaccine triggered a strong antibody response in adults. In people ages 18 to 64 who received one of two different pandemic H1N1 vaccines, 80-96 percent developed a robust immune response 8-10 days after a single 15 microgram dose, according to Anthony Fauci, head of the NIAID.

On September 14, GSK reported the initial results from the first clinical trials of its split-virus H1N1 adjuvanted vaccine. According to the company, “after one dose the candidate vaccine can provide a strong immune response which exceeds the immunogenicity criteria as defined by international licensing authorities for a pandemic influenza vaccine.”

For now, anyway, it seems that one shot of swine flu vaccine will be sufficient to protect adults from infection. The data for children – who may need two shots because they have no protective antibodies – aren’t due for weeks.

All the swine flu vaccines currently approved for use in the U.S. this year are made in chicken eggs – the old-fashioned but tried-and-true manufacturing process for seasonal flu vaccines, among others. But most companies are devising methods to make the vaccines in cell culture, instead – a far quicker way that allows a timely response to the arrival of a virulent pandemic virus. As well, a handful of inventive biotech firms have created entirely unconventional ways to make vaccines and treatments for the flu.

For instance, privately held Protein Sciences Corp., which was nearly pushed into bankruptcy earlier this year, snagged a $35 million contract from HHS in late June to develop a faster way to make pandemic flu vaccines. The contract could be extended up to five years, for a total value of $147 million. The company inserts a hemagglutinin-coding gene from the flu virus into an insect virus (baculovirus), which is then grown in cultured insect cells, thus eliminating potential problems with vaccines made in eggs and those that use live viruses. Moreover, the engineered baculovirus-containing cells can be frozen and stored until a pandemic strikes, after which they can make large quantities of vaccine in short order. In fact, Protein Sciences had started to manufacture an H1N1 swine flu vaccine about a week before it won the HHS contract; in mid-August the vaccine was cleared for clinical trials in the U.S.

Cel-Sci Corp. has used its L.E.A.P.S. (ligand epitope antigen presentation system) technology to make experimental flu vaccines – and currently it’s doing pre-clinical work on a version that will be able to target mutated type A flu viruses, which (if they occur) could become much more virulent than the strain circulating now. Cel-Sci’s experimental vaccines focus on the conserved, unchanging epitopes of the different strains, including H1N1, H5N1, and others. These epitopes are known to be associated with immune protection in animal studies. The company has also added highly conserved regions of the virus’ hemagglutinin molecule to the mix.

The L.E.A.P.S. technology is a T-cell modulation platform that allows the company to design and synthesize immunogens for any disease organism for which an antigenic sequence has been identified. The resulting constructs contain the antigenic epitope (a small peptide) for a particular disease organism linked to an immune/T-cell binding ligand.

Cel-Sci’s also developing vaccines against non-mutated versions of the H1N1 virus – and in mid-September it got the nod from the FDA to start clinical studies on hospitalized patients infected with laboratory-confirmed H1N1 pandemic flu virus. The vaccine it will use in these studies actually includes the non-changing regions of H1N1 pandemic flu, H5N1 avian flu, and the Spanish flu, so that the vaccine will invoke specific immune responses, rather than a broad-based response that could trigger a potentially lethal cytokine storm.

Selected Experimental Vaccines For Pandemic Swine Flu

Company	Vaccine/Description	Status
Baxter International	H1N1 pandemic flu vaccine (Celvapan); produced in cell culture	Baxter completed 1st commercial run of Celvapan (7/09); confirmatory clinical trials scheduled to begin 8/09
Cel-Sci	H1N1 pandemic flu vaccine; Based on L.E.A.P.S. technology	Clinical testing about to start (9/09)
GlaxoSmithKline	H1N1 pandemic flu vaccine; split-virus adjuvanted (AS03) vaccine	Initial results from 1st clinical trial showed that 1 dose provides a strong immune response (9/09)
Inovio Biomedical	H1N1 pandemic flu vaccine; DNA-based plasmid encodes flu antigens, delivered via electroporation	Protects pigs and mice against H1N1 (7/09)
Novavax	H1N1 pandemic flu vaccine; VLP vaccine	Protects ferrets against H1N1 (8/09)
Vical	H1N1 pandemic flu vaccine; Vaxfectin-formulated DNA vaccine	Produces robust immune response in mice and rabbits (6/09)

And Vical has yet another approach: It incorporates the swine flu vaccine’s H1 hemagglutinin gene sequence (provided by the CDC for the swine-origin A/California/04/09 pandemic influenza virus) into a closed loop of DNA known as a plasmid, which is then scaled up via conventional fermentation processes. Once purified, that product alone can serve as a vaccine, although Vical adds a lipid-based adjuvant (its Vaxfectin technology).

In early May 2009, Vical signed a CRADA (Cooperative Research and Development Agreement) with the U.S. Navy Medical Research Center intended to expedite the development of a pandemic swine flu (H1N1) vaccine based on its technology. The company had previously completed Phase I clinical trials of its Vaxfectin-formulated DNA vaccine against H5N1 (bird) pandemic flu, so it was already geared up to put together a program for the H1N1 strain. (Vical presented the H5N1 results in February 2009 at the 5^th WHO Meeting on Evaluation of Pandemic Influenza Prototype Vaccines in Clinical Trials, which was held in Geneva.)

Indeed, by the end of June, Vical reported that its H1N1 vaccine candidate “produced robust immune responses well above the accepted protection threshold in 100% of vaccinated mice and rabbits after a standard two-dose vaccine regimen.” With that, the company is “ready to advance directly to large-scale cGMP manufacturing of the vaccine for human clinical trials, subject to securing external funding.” When that happens, the Navy will conduct the clinical trials and Vical will be responsible for regulatory approval.

As further evidence that Vical’s H1N1 flu vaccine could be a potent and effective treatment, the company reported on September 10 that a two-dose regimen of the vaccine “demonstrated robust immune responses in 100 percent of vaccinated animals against virus strains isolated from recent outbreaks in three distinct geographic locations – California, Texas and Mexico.” The study also showed that the various H1N1 strains currently circulating are still antigenically homogeneous – i.e., a vaccine against one should also work against the others. But that doesn’t mean that one or more of these strains won’t mutate in the future.

Inovio Biomedical Corp. is also developing DNA vaccines, which are delivered by electroporation. In mid-August 2009 the San Diego-based firm signed a collaborative agreement with the NIH’s vaccine research center (VRC) to develop universal flu vaccines as well as vaccines for the current pandemic H1N1 swine flu virus. Initially, the partners will test DNA vaccine plasmids encoding flu antigens in animal models. Successful ones will be developed further. Inovio’s universal flu vaccines are based on influenza HA (hemagglutinin), NA (neuraminidase) and NP (nucleoprotein) proteins from strains H1N1, H2N2, H3N2 and H5N1.Theoretically, such a vaccine could not only protect against seasonal and pandemic flu, but also against mutated and/or unmatched subtypes.

Meanwhile, the Northern Hemisphere has just entered autumn, and with it comes the seasonal flu. As we mentioned previously, protection against seasonal flu will require a different shot than the one for 2009 H1N1 pandemic flu. That’s because they are caused by different viruses and target different age groups: Swine flu infects young people (six months to 24 years) while seasonal flu goes after the elderly (65 and older).

The seasonal flu vaccine actually consists of three strains of flu virus (subtypes A and type B), which experts have identified as those that might cause the most illness in the coming season. These three strains are chosen anew each year; for the 2009-2010 season they include an A/Brisbane/59/2007 (H1N1)-like virus; an A/Brisbane/10/2007 (H3N2)-like virus; and a B/Brisbane/60/2008-like virus.

On July 20, 2009, the FDA approved the following 2009-2010 seasonal flu vaccines: Afluria (manufactured by CSL); Fluarix (GlaxoSmithKline); FluLaval (ID Biomedical Corp., now part of GSK); Fluvirin (Novartis Vaccines and Diagnostics Ltd.); Fluzone (Sanofi Pasteur); and FluMist (MedImmune Vaccines Inc., now part of AstraZeneca).

Not surprisingly, a number of companies are testing new ways to create seasonal flu vaccines. Among them, biotech firm Novavax Inc. is plugging away at its own seasonal flu vaccine candidate. The experimental product, a trivalent virus-like particle (VLP) vaccine, consists of three VLPs (H3N2, H1N1 and B) that were matched to the strains recommended for use in flu vaccines for the 2008-2009 season and created by recombinant cell culture. On September 1, 2009, Novavax announced that this experimental vaccine produced positive results in a second Phase II trial. It was well tolerated and induced robust immune responses against all three flu strains in the vaccine, according to the company.

As we know, the antiviral drugs Tamiflu and Relenza, which are influenza virus neuraminidase inhibitors, have been shown to both treat and prevent all types of flu if given early enough. This year, however, U.S. health officials are stressing that the drugs should only be used to treat flu, not prevent it.

Though both drugs were approved by the FDA about the same time (Relenza was approved in July 1999 and Tamiflu was approved in October 1999), Tamiflu gained the upper hand, and in no time governments and organizations around the world started stockpiling it in preparation for a pandemic outbreak of bird flu. These efforts reached a peak in 2006, when worldwide sales of Tamiflu -- which was developed by Gilead Sciences Inc. and is marketed by Roche -- topped $2.1 billion. Relenza, on the other hand – which was developed by Biota Holdings and is marketed by GlaxoSmithKline -- is just beginning to come into its own.

In late January 2009, GSK signed a contract with the U.K. government covering 10.6 million treatment courses of Relenza, which the government is stockpiling against an influenza pandemic. The government was already stockpiling Tamiflu, and with the additional of Relenza it now has enough to treat about half the British population.

But flu-drug competition still looms: With the help of a $102.6 million, four-year contract with the U.S. Department of Health and Human Services (HSS), BioCryst Pharmaceuticals Inc. has been hard at work developing the neuraminidase inhibitor peramivir for treating influenza. Unlike other flu drugs, peramivir is dosed intravenously and its use – so far, anyway – is restricted to hospitalized patients with the flu. (On September 21, the HHS awarded an additional $77.2 million to BioCryst so it could complete Phase III development of peramivir.)

This drug is still experimental, and although BioCryst has been lobbying the U.S. government to instate a pre-emergency use authorization (EUA) so that it can provide peramivir in the event of a severe outbreak, it did not make the short list of drugs included in the CDC’s (Centers for Disease Control and Prevention) latest flu treatment guidelines, released September 8, 2009. However, the approved medicines Tamiflu (oseltamivir) and Relenza (zanamivir) did make the cut.

Briefly, the CDC recommends using one of these drugs to treat “all persons with suspected or confirmed influenza requiring hospitalization” as well as high-risk individuals. These guidelines apply to severe outbreaks of seasonal flu as well as flu caused by the pandemic H1N1 viral strain. According to the CDC, “Based on global experience to date, 2009 H1N1 influenza viruses likely will be the most common influenza viruses among those circulating in the coming season, particularly those causing influenza among younger age groups.” The guidelines also state that more than 98 percent of circulating flu viruses in the U.S. are the H1N1 strain, which are still susceptible to Tamiflu and Relenza – but that could change in the coming season.

Selected Experimental Vaccines For Seasonal Flu

Company	Vaccine/Description	Status
Nobilon (Schering-Plough)	Seasonal flu vaccine (live attenuated viruses; intranasal)	Phase I trials initiated (3/09)
Novavax	Trivalent seasonal influenza VLP vaccine	Phase II results were positive (9/09)
Protein Sciences	Seasonal flu vaccine (FluBlok); Consists of purified recombinant HA antigens	Phase III clinical studies have been conducted; BLA submitted (4/08)

More good news arrived on the drug front on September 13: Two new studies on Tamiflu were presented at the Interscience Congress on Antimicrobial Agents & Chemotherapy (ICAAC) conference in San Francisco. The retrospective studies included almost 1,000 individuals divided into two groups: adults and children diagnosed with avian flu (H5N1) and adults hospitalized with seasonal flu. According to Roche, the drug’s maker, patients receiving Tamiflu had significantly higher survival rates than untreated individuals. Of 215 patients from 10 countries diagnosed with H5N1, only 12 percent of the untreated patients survived, while 53 percent of the patients who received at least one dose of Tamiflu within eight days of disease onset lived. And, although the patient cohort was small, 71 percent of infected individuals survived when they got Tamiflu within two days.

In a separate retrospective study, which analyzed 760 patients hospitalized with seasonal flu, the rate of mortality was reduced by 37 percent in patients getting Tamiflu compared to those who were not treated.

As if that wasn’t enough, another study presented at ICAAC on September 13 proved that BioCryst’s experimental flu drug peramivir is at least as good as Tamiflu in fighting seasonal flu: According to the study, a single IV dose of peramivir worked as well as five days of dosing with Tamiflu pills.

Given these encouraging results, it’s surprising that BioCryst still hasn’t been able to line up any ex-U.S. marketing and distribution partnerships. True, the company did announce three ex-U.S. deals almost immediately following its ICAAC presentation (the Neopharm Group for Israel, NT Pharma Group Co. for China, and moksha8 Pharmaceuticals Inc. for Brazil and Mexico), but these turn out to be binding letters of intent, not “done deals.”

And, on September 21 BioCryst announced that it had (finally) received a request for proposal from the HHS for the supply of peramivir for treating flu patients under Emergency Use Authorization (EUA). If the U.S. government does issue an EUA, it will cover 1,000 to 40,000 courses of treatment. It will also require BioCryst to stand ready to make more if required.

Thanks to extensive – some would say excessive – media coverage, everyone is aware of the current swine flu pandemic as well as the drugs and vaccines available to fight it. But the very word pandemic strikes fear in the hearts of many. It evokes images of the extremely deadly Spanish flu pandemic of 1918, which infected a full third of the world’s population and killed 50-100 million people worldwide.

Governments and international organizations like WHO are doing everything they can to prevent a recurrence of that disaster – but people have to comply for the plan to work. Unfortunately, surveys show that many individuals have no intention of getting a flu shot (seasonal or pandemic) this year. Perhaps they think that a virulent variant of the swine flu virus just won’t materialize. Or, if it does, that organizations will be able to contain it – as they did for avian flu and SARS.

We hope they’re right.