Safety and Efficacy of Extended-Duration Antiviral Chemoprophylaxis Against Pandemic and Seasonal Influenza
Background: Neuraminidase inhibitors (NAIs) are stockpiled internationally for extended use in an influenza pandemic.
Purpose: To evaluate the safety and efficacy of extended-duration (>4 weeks) NAI chemoprophylaxis against influenza.
Data Sources: Studies published in any language through 11 June 2009 identified by searching 10 electronic databases and 3 trial registries.
Study Selection: Randomized, placebo-controlled, double-blinded human trials of extended-duration NAI chemoprophylaxis that reported outcomes of laboratory-confirmed influenza or adverse events.
Data Extraction: 2 reviewers independently assessed study quality and abstracted information from eligible studies.
Data Synthesis: Of 1876 potentially relevant citations, 7 trials involving 7021 unique participants met inclusion criteria. Data were pooled by using random-effects models. NAI chemoprophylaxis decreased the frequency of symptomatic influenza (relative risk [RR], 0.26 [95% CI, 0.18 to 0.37]; risk difference [RD], –3.9 percentage points [CI, –5.8 to –1.9 percentage points]) but not asymptomatic influenza (RR, 1.03 [CI, 0.81 to 1.30]; RD, –0.4 percentage point [CI, –1.6 to 0.9 percentage point). Adverse effects were not increased overall among NAI recipients (RR, 1.01 [CI, 0.94 to 1.08]; RD, 0.1 percentage point [CI, –0.2 to 0.4 percentage point), but nausea and vomiting were more common among those who took oseltamivir (RR, 1.48 [CI, 1.86 to 2.33]; RD, 1.7 percentage points [CI, 0.6 to 2.9 percentage points]). Prevention of influenza did not statistically significantly differ between zanamivir and oseltamivir.
Limitations: All trials were industry-sponsored. No study was powered to detect rare adverse events, and none included diverse racial groups, children, immunocompromised patients, or individuals who received live attenuated influenza virus vaccine.
Conclusion: Extended-duration zanamivir and oseltamivir chemoprophylaxis appears to be highly efficacious for preventing symptomatic influenza among immunocompetent white and Japanese adults. Extended-duration oseltamivir is associated with increased nausea and vomiting. Safety and efficacy in several subpopulations that might receive extended-duration influenza chemoprophylaxis are unknown.
Options for European Ballistic Missile Defenses
This talk will address alternative options for European ballistic missile defense, including the now cancelled Polish-Czech option and the recently announced Obama plan for a phased deployment of Standard Missile 3 interceptors in and around Europe. This talk will also address recent Iranian progress in developing medium-range ballistic missiles and possible missile defense cooperation with Russia.
Dean Wilkening is a Senior Research Scientist at the Center for International Security and Cooperation at Stanford University. He holds a Ph.D. in physics from Harvard University and worked at the RAND Corporation prior to coming to Stanford. His major research interests include nuclear strategy and policy, arms control, the proliferation of nuclear and biological weapons, bioterrorism, ballistic missile defense, and energy and security. His most recent research focuses on the broad strategic and political implications of ballistic missile defense deployments in Northeast Asia, South Asia and Europe. Prior work focused on the technical feasibility of boost-phase ballistic missile defense interceptors. His recent work on bioterrorism focuses on understanding the scientific and technical uncertainties associated with predicting the outcome of hypothetical airborne biological attacks and the human effects of inhalation anthrax, with the aim of devising more effective civil defenses. He has participated in, and briefed, several US National Academy of Science committees on biological terrorism and consults for several US national laboratories and government agencies.
Reuben W. Hills Conference Room
Global Welfare Regimes: A Cluster Analysis
This paper tests the claim that a small number of distinct „welfare regimes,
combining institutional patterns and social welfare outcomes, can be identified
across the developing world. It develops a methodology for clustering a large
number of developing countries, identifying and ranking their welfare regimes,
assessing their stability over the decade 1990-2000, and relating these to important
structural variables. It identifies three meta-welfare regimes: proto-welfare state
regimes, informal security regimes and insecurity regimes (distinguishing illiterateinsecurity
and morbidity-insecurity regimes). Membership of these is „sticky over
time, but has been modified by two global trends: the HIV-AIDS pandemic in Africa
and the growing role of remittances in some countries.
Strategies for Combating Bioterrorism
CISAC now accepting applications for William J. Perry International Security Fellowship
Applications are now being accepted for the %fellowship1%. The fellowship is a visiting position for pre- and post- doctoral researchers that CISAC plans to establish in honor of William J. Perry, the 19th U.S. secretary of defense and former CISAC co-director.
Perry fellows will reside at CISAC for a year of policy-relevant research on international security issues. The will join other distinguished scientists, social scientists, and engineers who work together on security problems that cannot be solved within any single field of study. CISAC researchers address overlapping issues in nuclear weapons policy and nuclear proliferation; regional tensions; biosecurity; homeland security; and effective global engagement.
The deadline for applications is Feb. 1, 2009.
Public Health Preparedness and the Unthinkable: Reflections on Nuclear Terrorism and Pandemic Influenza
Abstract: In this era of catastrophic terrorism and heightened concerns about pandemic influenza and other emerging diseases, unprecedented resources have been allocated to improving medical and public health emergency preparedness. Investments in such preparedness, however, can impose significant opportunity costs, particularly when the investments are focused on improving consequence management capabilities. Enhancing preparedness and response capabilities in economically efficient, proportionate, and politically sustainable ways thus becomes a critical component of any longterm effort to address the threats we face. Dr. Hatchett will speak about the challenges of developing medical countermeasure for CBRN threats and preparing communities for infectious disease emergencies, using these examples to raise more general issues about the relative benefits of specific v. "broad-spectrum" strategies and countermeasures, decision-making under conditions of uncertainty, and our efforts to "get ready" for nuclear terrorism and pandemic influenza.
Dr. Hatchett is Associate Director for Radiation Countermeasures Research and Emergency Preparedness at the National Institute for Allergy and Infectious Disease, overseeing a program that develops drugs and devices to prevent or mitigate the effects of radiation exposure.
In 2005-06, he served as Director for Biodefense Policy at the White House Homeland Security Council, where he was a principal author of the Implementation Plan for the National Strategy for Pandemic Influenza and helped set policy and devise strategies to mitigate the consequences of a pandemic. Dr. Hatchett previously served as Senior Medical Adviser in the U.S. Department of Health and Human Services (HHS) Office of Public Health Emergency Preparedness, where he worked on a wide range of biodefense issues, including the delivery of mass prophylaxis to urban populations, the development of disease containment strategies, and the role of modeling in the formulation of public health policy.
Dr. Hatchett completed his undergraduate and medical educations at Vanderbilt University, an internship and residency in Internal Medicine at New York Hospital - Cornell Medical Center, and a fellowship in Medical Oncology at the Duke University Medical Center.
Reuben W. Hills Conference Room
Transitions 2009 conference to focus on action plan for President-elect Obama
America's standing in the world has been damaged by eight years of unilateralism and it must cooperate with rising powers to tackle emerging transnational threats, according to a major research project to be unveiled Thursday, Nov. 13, at a conference hosted by Stanford's Freeman Spogli Institute for International Studies (FSI).
The directors of "Managing Global Insecurity Project (MGI)" (MGI) from Stanford's Center for International Security and Cooperation (CISAC), New York University and the Brookings Institution will use the conference to present their "plan for action" for the next U.S. president.
"President-elect Obama should take advantage of the current financial crisis and the goodwill engendered by his election to reestablish American leadership, and use it to rebuild international order," said CISAC's Stephen J. Stedman. "Part of that is to recalibrate international institutions to reflect today's distribution of power. If you could find a way for constructive engagement between the G-7 and Russia, China, India, Brazil and South Africa-that reflects the reality of world power today-you could actually animate a lot of cooperation."
Stedman, Bruce Jones from New York University's Center on International Cooperation and Carlos Pascual from Brookings will discuss concrete actions for the incoming administration to restore American credibility, galvanize action against transnational threats ranging from global warming to nuclear proliferation and rejuvenate international institutions such as the United Nations.
"You find in American foreign policy a blanket dismissal of international institutions, especially regarding security," Stedman said. "But if you eliminate them, you don't have a prayer of recreating the kind of cooperation that exists in the U.N. There actually is a pretty good basis of cooperation on which to build."
The nonpartisan project also will be presented Nov. 20 at a high-profile event at the Brookings Institution that will feature leaders such as former Secretary of State Madeleine Albright and Brookings President Strobe Talbott. That in turn will take place on the heels of the upcoming G-20 emergency summit to discuss measures to stave off a global recession and give a greater voice to developing nations. MGI's "plan for action" includes a series of policy papers on hot-button topics such as economic security.
"The big thing we talk about is if you institutionalize cooperation with the existing and rising powers you can hope to build a common understanding of shared long-term interests," Jones said. "If you approach issues only through the lens of the hottest crises, you will find different interests in the very short term on how [problems] are handled."
Transitions 2009
The 20-month-long project, which incorporated feedback and direction from nonpartisan U.S. and international advisory boards, dovetails closely with the theme of FSI's fourth annual conference: "Transitions 2009."
"There has rarely been a moment more fraught with danger and opportunity, as new administrations in the United States and abroad face the interlocking challenges of terrorism, nuclear proliferation, climate change, hunger, soaring food prices, pandemic disease, energy security, an assertive Russia and the grave implications of failed and failing states," FSI Director Coit D. Blacker said. "This conference will examine what we need to do to prepare our own citizens for the formidable challenges we face and America's own evolving role in the world."
Timothy Garton Ash, an Oxford professor and Hoover Institution senior fellow, will deliver the conference's keynote address, titled, "Beyond the West? New Administrations in the United States and Europe Face the Challenge of a Multi-Polar World."
Blacker, who served in the first Clinton administration; Stephen D. Krasner, who worked in the current Bush administration; medical Professor Alan M. Garber; and Stanford President Emeritus Gerhard Casper will open the conference with a reflection on the past and future and the watershed moment presented by Obama's presidency. The conference also will include breakout sessions with FSI faculty such as "Rethinking the War on Terror," led by Martha Crenshaw of CISAC; "Toward Regional Security in Northeast Asia," chaired by former Ambassador Michael J. Armacost, acting director of the Shorenstein Asia-Pacific Research Center; and "Is African Society in Transition?" led by economist Roz Naylor of the Program on Food Security and the Environment.
Long-term security
For MGI project leaders Stedman, Jones and Pascual, the zeitgeist of the moment is America's relationship with the emerging powers. "The good news from an American perspective is, despite the financial crisis, despite everything else, sober leadership in China, India, Brazil and elsewhere understand, in the immediate term, there is no alternative to American leadership, as long as [it] is geared toward cooperation and not 'do as you please-ism,'" Jones said. "On the other side, the financial crisis highlights that U.S. foreign policy has to come to terms with the fact that it does not have the power to dictate outcomes. It has to build cooperation with emerging powers, with international institutions, into the front burner of American foreign policy." More broadly, international cooperation must be built on what Stedman calls the principle of "responsible sovereignty," the notion that sovereignty entails obligations and duties toward other states as well as to one's own citizens.
In addition to MGI's "plan for action," the three men have coauthored Power and Responsibility: International Order in an Era of Transnational Threats, to be published in 2009. The book criticizes both the Bush and Clinton administrations for failing to take advantage of the moment of U.S. dominance after the fall of the Soviet Union to build enduring cooperative structures. "We're in a much tougher position than we were five years ago and 10 years ago," Jones said. "There still is an opportunity, but time is getting away from us."
If revitalizing international cooperation fails, Jones said, transnational threats will gain the upper hand. "We will not be able to come to terms with climate change, transnational terrorism, spreading nuclear proliferation," he said. "U.S. national security and global security will deteriorate. [We] have a moment of opportunity to do this now."
Presidential Leadership, Illness, and Decision Making
Rose McDermott is a Professor of Political Science at Brown University. She is currently a fellow at the Center for Advanced Studies in the Behavioral Sciences at Stanford University. She holds a Ph.D. in Political Science and an M.A. in Experimental Social Psychology, both from Stanford University. She held a National Institute on Drug Abuse Post Doctoral Fellowship in Substance Abuse Treatment Outcome Research at the San Francisco VA through the University of San Francisco Psychiatry Department. Professor McDermott has also held fellowships at the John M. Olin Institute for Strategic Studies and the Women and Public Policy Program, both at Harvard University. Professor McDermott's main area of research concerns political psychology in international relations. She is the author of Risk Taking in International Relations: Prospect Theory in American Foreign Policy (University of Michigan Press, 1998), Political Psychology in International Relations (University of Michigan Press, 2004), and Presidential Illness, Leadership and Decision Making (Cambridge University Press, 2007). She is co-editor of Measuring Identity: A Guide for Social Science Research, with Rawi Abdelal, Yoshiko Herrera, and Alastair Iain Johnson (Cambridge University Press, forthcoming).
She has written numerous articles and book chapters on experimentation, the impact of emotion on decision making, social identity, and evolutionary and neuroscientific models of political science. She is currently involved in a series of projects investigating the endogenous sources of aggression, and a book project on pandemic disease.
Herbert Abrams is a professor of radiology, emeritus, at the Stanford School of Medicine and a member-in-residence at CISAC, where he directs the Project on Disabled Leadership. He was Professor and Director of Diagnostic Radiology at Stanford from 1960 to 1967, and was then appointed and served as Philip H. Cook Professor and Chairman of Radiology at Harvard University from 1967 to 1985. He returned to Stanford in 1985 as Professor of Radiology in order to spend most of his time in research in CISAC. Dr. Abrams' present focus is on presidential disability and its potential impact on decision making.
Reuben W. Hills Conference Room
Biodefense in the 21st Century: The Political Realities
Abstract: In 2003, General John Gordon, Assistant to the President for Homeland Security and former Deputy Director of the CIA asked his staff to do an end-to-end evaluation of U.S. biodefense posture. As a result, Homeland Security Staff, directed by Dr. Kenneth Bernard, Special Assistant to the President, did a government-wide review of national preparedness and response to a bioterrorist attack. The resulting assessment led in 2004 to the combined Homeland Security Presidential Directive #10 and National Security Presidetial Directive #17: "Biodefense for the 21st Century." Dr. Bernard will discuss the process and outcome of this policy that remains the U.S. national strategy for preventing and responding to a bioterrorist event. Accomplishments, outcomes and remaining gaps will be detailed, along with budget and policy implications for the next administration.
Admiral Kenneth Bernard was appointed by President Bush to be Special Assistant to the President for Biodefense on the Homeland Security Council (HSC) in November 2002. Dr. Bernard chaired the Whitehouse Biodefense Policy Coordinating committee and drafted Decision Directives for President Bush on both "Biodefense for the 21st Century" and Agricultural Bioterrorism, and he was the White House point person on Project Bioshield - a $5.6 billion congressional bill that is speeding development and procurement of new countermeasures against biological, chemical and radiological terrorist threats.
In January 2001, Dr. Bernard was assigned by the U.S. Surgeon General to the office of Senator Bill Frist to work on international health issues of priority concern to both the Congress and the Department of Health and Human Services (HHS). After September 11, however, he was called back to HHS to create the position of Special Adviser for National Security, Intelligence and Defense for the Department of Health and Human Services. From August 1998 to January 2001, he served on President Clinton's National Security Council (NSC) staff as Special Adviser to the Assistant to the President for National Security Affairs. Prior to joining the NSC, Dr. Bernard served as the International Health Attaché and senior representative of the U.S. Secretary of Health at the U.S. Mission to the UN in Geneva, Switzerland (1994-1998). From 1984-1989, he held positions as the Associate Director for Medical and Scientific Affairs in the Office of International Health, HHS, and as International Health Policy Adviser to the Director of the U.S. Peace Corps. He retired from the USPHS as a Rear Admiral.
He received his AB degree from the University of California, Berkeley in 1971, an M.D. from the University of California, Davis in 1975, and the DTM&H degree from the University of London School of Hygiene and Tropical Medicine in 1977. He is a member of the Council on Foreign Relations.
Reuben W. Hills Conference Room