Canadian Pandemic Preparedness Meeting: H1N1 Outbreak Research Response

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July 8, 2009
Sheraton Gateway Hotel
Toronto, Ontario

Table of Contents

Executive Summary
Meeting Overview
Background
Welcome and Opening Remarks
Plenary session

Workshops
Open Forum: Facilitating Research
Closing Remarks
Evaluation of the Meeting by Participants
Appendices

Executive Summary

In April 2009, the first deaths from a novel strain of H1N1 influenza A virus were reported in Mexico and the United States. The virus quickly spread to other countries including Canada. In June 2009, the World Health Organization (WHO) issued a phase 6 pandemic influenza alert indicating that an influenza pandemic is underway. As of July 2009, the WHO reported almost 100,000 confirmed cases of human infection worldwide and almost 500 deaths, including 25 in Canada. The actual infection rate, however, may be in the millions because only a relatively small number of individuals have been tested for the virus.

The virus, known now as the pandemic H1N1/09, continues to spread in many countries throughout the world. While most infected individuals experience mild symptoms, a proportion develop severe respiratory symptoms requiring prolonged stays in intensive care units and ventilator support. Intensive care units in countries in the Southern hemisphere, currently at the start of its flu season, are beginning to reach their capacity. There are concerns that increased numbers of cases will overwhelm resources during the upcoming flu season this fall and winter in the Northern hemisphere. There is also the risk that the virus will mutate to become more pathogenic.

Health-care providers and policymakers are under significant pressure to make informed health-care and public health decisions based on scientific information. To facilitate this process, the Canadian Institutes of Health Research (CIHR), Rx&D Health Research Foundation (HRF) and Canadian Food Inspection Agency (CFIA) sponsored a one-day research meeting of more than 180 influenza and pandemic experts from across Canada on July 8, 2009, in Toronto. The goals of the meeting were:

  • to facilitate information sharing among researchers and other influenza experts;
  • to network and develop collaborations in order to focus the Canadian research response to the pandemic; and
  • to discuss gaps in research knowledge about the pandemic H1N1/09 virus.

The meeting consisted of three parts: a plenary session, two sessions of concurrent workshops and an open forum.

Dr. Bhagirath Singh, Scientific Director of CIHR Institute of Infection and Immunity (CIHR-III) opened the meeting by giving an overview of the Pandemic Preparedness Strategic Research Initiative (PPSRI), which was established with funds from the Government of Canada in 2006. The goal of the Initiative is to support and promote research in pandemic influenza preparedness. Although the main focus of PPSRI has been on avian H5N1 influenza—which remains a threat—the initiative has greatly increased research capacity and should enhance Canada’s response to both the pandemic and seasonal influenza. To coordinate current efforts, CIHR-III expanded the PPSRI Task Group with additional H1N1 experts. The H1N1 Outbreak Task Group has been meeting regularly by teleconference and consulting with the research and public health community since April.

In the plenary session that followed, Dr. Frank Plummer, the Public Health Agency of Canada’s (PHAC) Scientific Director General based at the National Microbiology Laboratory (NML) gave an overview of the epidemiology of the current outbreak and clinical features of human infection. The pandemic H1N1/09 virus is a unique combination of genetic sequences with similarity to influenza viruses found in pigs, humans and birds. Individuals over the age of 51 appear to have some protection against the virus, while a greater proportion of young adults and older children develop severe respiratory symptoms upon infection. Dr. Plummer summarized several gaps in knowledge concerning pandemic H1N1/09, including determining why a small number of individuals infected with the virus succumb to severe disease.

Dr. John Pasick of the National Centre for Foreign Animal Disease at the CFIA then gave an overview of swine influenza and the human/animal interface. Influenza in pigs, including disease caused by pandemic H1N1/09 virus, is generally mild. Dr. Pasick emphasized pig-to-human infections occur via the nasopharyngeal route and not via consumption of meat.

Dr. Ross Upshur, Director of the University of Toronto Joint Centre for Bioethics outlined several of the ethical challenges in pandemics including the research response. In this regard, guidance and innovative approaches are urgently needed to speed approval times for clinical trials, permit collaborative research and facilitate tissue and data sharing amongst researchers.

Dr. Scott Halperin, Director of the Canadian Center for Vaccinology gave an overview of the newly established PHAC/CIHR Influenza Research Network (PCIRN). The Network will develop and test methods to evaluate influenza vaccines including safety and effectiveness. The Network includes investigators at 30 institutions across Canada. The original plan was to build capacity over a three-year period, but PCIRN is now accelerating its activities to be fully operational in the fall when a vaccine against pandemic H1N1/09 virus is expected.

Dr. Danuta Skowronski, Physician Epidemiologist at the UBC/BC Centre for Disease Control emphasized that public health research is urgently needed to guide the pandemic response. She proposed that the single most important current research question is: who is most likely to become severely ill, and by what increased level of risk compared to others? To address this full risk analysis, we must go beyond surveillance information alone and engage in focused rapid response research that includes control groups.

In workshop sessions covering a series of focussed topic areas, participants engaged in pandemic H1N1/09 research presented current results and research plans. Workshop participants then discussed questions that required additional research attention and ways in which they can work together to focus their research on the current pandemic. The topics of the workshops were:

  • Aboriginal Populations and H1N1;
  • Biology of the Virus, Immune Response and Antivirals;
  • Clinical Pathogenesis & Infection Prevention;
  • Diagnostics;
  • Epidemiological Characteristics of Spread, Public Health Interventions and Health Services;
  • Research Ethics and Ethical Issues;
  • Mathematical Modelling; and
  • Vaccines and Host Adaptive Immune Response.

Key research strategies from each workshop were brought back to the plenary open forum for discussion facilitated by the meeting chair, Dr. Earl Brown from the University of Ottawa.

Dr. Singh closed the meeting by announcing a new CIHR funding opportunity to support networking and collaboration of pandemic H1N1/09 virus research teams. The primary objective of this funding opportunity is to catalyze the mobilization of teams focused on pandemic H1N1/09 research by providing seed money for planning and development activities of expert teams to advance research in priority areas determined by the H1N1 Outbreak Task Group. This new funding will add to previous CIHR investments in pandemic preparedness. The deadline for applications to this funding opportunity entitled “Catalyst Grant: Pandemic Outbreak Research Response” is August 10, 2009.

Meeting Overview

Over 180 influenza and pandemic experts attended the Canadian Pandemic Preparedness Meeting: H1N1 Outbreak Research Response meeting in Toronto on July 8, 2009. The overall goal of the meeting was to assist researchers in coordinating their research response to the recent outbreak of a novel strain of influenza A virus that developed into a world-wide pandemic in June 2009. Specific goals were to help experts:

  • share research results and plans;
  • network and build collaborations; and
  • identify gaps in research knowledge.

The meeting was sponsored by the Canadian Institutes of Health Research (CIHR), Rx&D Health Research Foundation (HRF) and Canadian Food Inspection Agency (CFIA). The day began with a plenary session in which participants were given an overview of the current pandemic from experts in epidemiology, animal science, ethics, vaccines and immunization and public health.

Participants then gathered in smaller groups for workshops focused on specific research areas. The workshops included short presentations on current research results and plans related to the pandemic and provided an opportunity for participants to discuss research needs and ways to work together. The meeting closed with an open forum plenary session in which critical aspects of Canada’s research response were discussed.

Background

The first deaths from a novel strain of H1N1 influenza A virus (pandemic H1N1/09 virus) were reported in Mexico and the United States in April 2009. The virus quickly spread to other countries including Canada. In June 2009, the World Health Organization (WHO) issued a phase 6 pandemic alert indicating that an influenza pandemic is underway. As of July 2009, the WHO reported almost 100,000 confirmed cases of human infection worldwide and almost 500 deaths, including 25 in Canada. The actual infection rate, however, may be in the millions because only a relatively small number of individuals have been tested for the virus. Pandemic H1N1/09 virus continues to spread in many countries throughout the world.

While currently most infected individuals have mild illness, experts worry that the virus will mutate to become more virulent or pathogenic. In addition, infected individuals occasionally develop severe respiratory symptoms requiring prolonged ventilator support in intensive care units. These facilities are beginning to be overwhelmed in the Southern hemisphere, which is currently experiencing its flu season. There are concerns that increased numbers of cases expected during upcoming flu season this fall and winter in the Northern hemisphere will overwhelm resources here.

Welcome and Opening Remarks

Dr. Bhagirath Singh, Scientific Director, CIHR-III
Dr. Singh began by welcoming participants to the July 8 meeting in Toronto. The meeting had been much anticipated amongst influenza and pandemic experts because it was one of the first opportunities since the start of the pandemic for experts from across Canada to gather together to network, build collaborations and discuss preliminary research results and new research questions.

Dr. Singh provided an overview of the Pandemic Preparedness Strategic Research Initiative (PPSRI), which was established in 2006 with funds from the Government of Canada. Its goal is to support and promote research in pandemic influenza preparedness. Although the main focus of PPSRI has been on avian H5N1 influenza—which remains a threat—the Initiative has greatly increased research capacity and should enhance Canada’s response to both the pandemic and seasonal influenza. For example, the number of researchers currently engaged in influenza and pandemic research is over 80 compared to approximately five before the start of the Initiative.

To coordinate and support research efforts related to the current pandemic, CIHR-III expanded the PPSRI Task Group with additional H1N1 experts. The H1N1 Outbreak Task Group has been meeting regularly by teleconference and consulting with the research and public health community since April. Identified priority research areas are:

  • Epidemiology, natural history, public health & health services;
  • Biology of the virus & antiviral response;
  • Viral immune response & contributing cofactors;
  • Ethical issues; and
  • Vaccine development & evaluation

Other issues identified by the Task Group include: the need for a Canadian repository of samples and reagents with links to clinical data and the need to develop methods for data sharing and communication amongst researchers.

Dr. Singh closed by thanking members of the H1N1 Outbreak Task Group and Organizing Committee and the Meeting Secretariat (Appendix 1), especially Ms. Carol Richardson and Ms. Michelle Hume, for establishing the meeting program and for organizing the meeting in less than five weeks.

Dr. Earl Brown, Professor, University of Ottawa
As chair of the meeting, Dr. Brown welcomed participants and gave an overview of the meeting program (Appendix 2). See Appendix 3 for a list of meeting participants and Appendix 4 for a summary of participants’ pandemic-related research. Dr. Brown also welcomed members of the media, who were invited to attend the first two presentations in the plenary session.

Plenary session

H1N1 –The Current Outbreak Situation

Dr. Frank Plummer, Chief Science Advisor, PHAC and Scientific Director General of National Microbiology Laboratory, PHAC
Dr. Plummer began his summary of the current influenza pandemic by thanking CIHR for organizing the July 8 meeting in Toronto. Dr. Plummer then went on to give an overview of the epidemiology of the current outbreak and clinical features of human infection. Pandemic H1N1/09 virus is a novel and unusual mix of influenza viral genetic sequences from four unique sources: humans in North America, pigs in both North America and Eurasia and birds in North America. H1N1/09 virus is phylogenetically more closely related to previous swine H1N1 influenza viruses that have infected humans compared with seasonal human H1N1 influenza virus. PHAC’s National Microbiology Laboratory has been involved in the sequencing of pandemic H1N1/09 viruses isolated from different individuals and has observed considerable sequence similarity between the viral isolates, but there are a few interesting variants.

There appear to be two different clinical presentations of human pandemic H1N1/09 viral infections. In the vast majority of cases, symptoms are mild with expected complication rates associated with underlying chronic conditions. Over half of these infected individuals do not have high fever. Much less frequently, viral pneumonia develops with severe symptoms including breathlessness and the need for early ventilator support. This form is most prevalent in young individuals without the usual risk factors for severe influenza and is associated with high mortality rates. The severe form is cause for concern because intensive care units can be rapidly overwhelmed with individuals who require prolonged ventilator support.

Areas that PHAC has identified that need research attention include: infection control and prevention, epidemiology, public opinion research, biology of the virus and host, vaccination, anti-viral drugs, mathematical modelling and ethics. In the area of biology of the virus and host, PHAC is working with a number of partners to undertake a large intensive care unit study to determine the human cytokine responses and genetic factors that contribute to the severe illness seen in a minority of people infected with the H1N1/09 virus.

Dr. Plummer concluded by stating that even though the initial wave of the pandemic H1N1/09 virus is not over, we have to start thinking about and preparing for the next flu season. He believes that Canada’s research community can make important contributions to Canadian and global readiness and that this Toronto meeting is a critical step in mobilizing Canada’s research community to meet the Canadian and global public health needs.

Swine Influenza and the Animal/Human Interface

Dr. John Pasick, National Centre for Foreign Animal Disease, CFIA
Dr. Pasick gave an overview of swine influenza. Worldwide, there are three types of influenza A virus in pigs: H1N1, H3N2, and H1N2, which differ genetically from human influenza viruses. Influenza in pigs, while seasonal, can circulate throughout the year because of confined methods of swine production and renewal of a susceptible population. Swine influenza, including disease caused by pandemic H1N1/09, is generally mild with recovery in one to three days.

Wild waterfowl are the natural reservoir of influenza A viruses, but avian influenza viruses occasionally acquire the ability to cross species to infect pigs or humans. This, in part, allows for reassortment (rearrangement) of genetic components of viral subtypes. Swine-to-human transmission occurs because of occupational and environmental exposures, and not via consumption of meat. Human-to-swine transmission has also been observed. In fact, Dr. Pasick and his team recently identified a case of human-to-swine transmission of pandemic H1N1/09 on a farm in Leslieville, Alberta.

Dr. Pasick concluded by stating that the recent emergence of pandemic H1N1/09 emphasizes the ongoing need to examine influenza A viruses in pigs for human pathogenic potential. He also suggested that strategies could be developed to reduce the risk of these transmission events between species including bird-proofing swine barns, using treated water and sick policies and vaccination of swine workers.

Ethical Challenges in a Outbreak Research Response

Dr. Ross Upshur, Director, Joint Centre for Bioethics, University of Toronto
Dr. Upshur provided an overview of the ethical challenges and unresolved issues related to the current influenza pandemic. Given the need for an ethical framework to guide decision makers during a health crisis, Dr. Upshur and his colleagues produced a report entitled "Stand on Guard for Thee" that is being adapted by national and international organizations including the WHO and Centers for Disease Control and Prevention (CDC). More recently, he and his team have established the CanPREP Program, which builds on the report. Part of the Program, includes gathering public perspectives on ethical challenges faced during a pandemic including: health workers’ duty to care; restrictive measures to protect the public good; priority setting and allocation of scarce resources; and global governance.

Dr. Upshur then discussed research ethics -- another important area that requires immediate attention and innovative solutions. Currently, there are no guidance documents for research ethics in a public health emergency. Issues include the need for accelerated research ethics board approval, defining the differences between research and public health activities, tissue and data sharing, risk to research workers and protecting intellectual property. Dr. Upshur outlined some possible ways to address these issues. These include: centralized review, rapid response teams, governance models, delegated review, pre-approved protocols, rolling ethics approval, use of e-technologies and drawing on non-obvious resources.

Dr. Upshur closed by reminding participants that all of humanity is under threat during a pandemic. It will be essential for investigators to work in a highly collaborative manner with the free exchange of ideas and reagents in order to help mitigate the impact the current pandemic.

PHAC-CIHR Influenza Research Network

Dr. Scott Halperin, Director of the Canadian Center for Vaccinology, Dalhousie University
Dr. Halperin gave an overview of the PHAC/CIHR Influenza Research Network (PCIRN), which was established in May 2009. Its purpose is to develop and test methods related to the evaluation of influenza vaccines, including safety and effectiveness, as well as program implementation and evaluation. There are five main research themes (Rapid Trials, Rapid Implementation, Vaccine Coverage, Vaccine Safety and Vaccine Effectiveness) and three support groups (Laboratory Support, Information/Data Management, and Knowledge Translation and Training), each theme or group is directed by a different principal investigator. Research will be performed at over 30 institutions across Canada. While the original plan was to build capacity over a three-year period, PCIRN is now accelerating its activities to be fully operational in the fall when a new vaccine against pandemic H1N1/09 virus is expected.

Dr. Halperin then described the specific research plans and activities under each research theme. For example, the Rapid Trials group plans to perform a seasonal vaccine study at four centers to test data management, laboratory capacity and rapid analysis and reporting, while other centres will work with GlaxoSmithKline Inc. on pre-licensure pandemic H1N1/09 vaccine trials. The Vaccine Safety group is developing a network of medical specialists who will monitor safety of influenza vaccines. The Rapid Implementation group plans to establish mechanisms to monitor and evaluate the implementation of immunization programs in urban, rural and remote regions.

Public Health Research

Dr. Danuta Skowronski, Physician Epidemiologist, UBC/BC Centre for Disease Control
Dr. Skowronski outlined several public health research questions that require urgent attention in order to guide the pandemic response. She proposed that the single most important current research question is: who is most likely to become severely ill, and by what increased level of risk compared to others? This knowledge is critical because it will allow for effective and efficient targeting of intervention strategies and treatment. Answering this question will require a focused rapid response research that includes control groups instead of surveillance alone.

When a pandemic vaccine becomes available, there will also be a need to monitor vaccine safety and effectiveness. Since 2004, investigators in the four largest provinces of Canada have piggybacked a test-negative case-control study to the routine sentinel surveillance system to monitor vaccine effectiveness, and this will also be used in evaluating pandemic H1N1 vaccine for the coming season.

Dr. Skowronski concluded by emphasizing that influenza is a serious and recurring health issue with new seasonal influenza viruses arising each year accompanied by new pandemic strains every few decades. Therefore, a national institute for influenza evaluation and management is needed to establish national responsibility and accountability for strategic and evidence-based influenza prevention and treatment programs, as well as establish the infrastructure and rehearsal needed for rapid response research activities. If infrastructure, capacity and accountability are not already well-established, they are difficult to create and coordinate during a crisis.

Workshops

Participants then gathered in smaller groups for a series of concurrent workshops in focussed topic areas. In each workshop, current results and plans were reviewed via short presentations by three to four experts currently engaged in H1N1 research. The presenters and workshop participants then discussed questions that required research attention and ways in which they can work together to focus their research on the current pandemic. Summaries of the research needs and strategies to work together that were identified in the each workshop follow.

Aboriginal Populations and H1N1

Workshop leaders: Drs. Alan Kendal and Malcolm King

Research needs

  • Determination of the long-term outcome of intensive care cases involving individuals from First Nations, Inuit and Métis communities;
  • Relative risks of illness in these and other populations.

Strategies

  • Improve collaboration and information sharing among agencies and jurisdictions already working with these communities;
  • Efforts should be made to train more research workers from these communities.

Biology of the Virus, Immune Response and Antivirals

Workshop leaders: Drs. Earl Brown and Eleanor Fish

Research needs

  • Development of new antivirals and use of interferons;
  • Development of new infection models;
  • Improved understanding of immune correlates of protection;
  • Determination of the duration of viral replication;
  • Improved understanding of human/animal (swine) spread
  • Mathematical modelling of the effect of antivirals on viral fitness.

Strategies

  • Several areas for collaboration were identified including combining clinical and basic research on the use of the antiviral interferon in treating pandemic H1N1/09 infections;
  • An accessible database for reagent and data sharing among researchers would facilitate research and foster collaboration.

Clinical research

Workshop leader: Dr. Allison McGeer

Research needs

  • Methods to predict who will develop severe lung injury, who will require ventilator support and who will die despite maximal care;
  • Determination of how long people are contagious;
  • Methods to reduce resource needs for some patients;
  • Determination of the risk to health-care workers.

Strategies

  • There is substantial potential to answer these questions if clinical data, virology and host response data could be integrated.

Diagnostics

Workshop leader: Dr. Martin Petric

Research needs

  • Development of standardized quantitative assays and optimal testing algorithms;
  • Development of high-throughput genomic testing to study the evolution of the virus over time including mutations as they relate to antiviral resistance and/or changes in pathogenesis.

Strategies

  • Development of a network to look at standardization of rapid, reliable tests for use in prognosis, epidemiology, treatment, vaccine evaluation, clinical trials and infection control.

Epidemiological Characteristics of Spread, Public Health Interventions and Health Services

Workshop leaders: Drs. David Fisman, Jeff Kwong and Tom Wong

Research need

  • Rapid determination of populations (e.g. Aboriginal peoples, pregnant women) and risk factors (e.g. asthma, obesity) associated with severe H1N1 infections;
  • Methods for resource rationing for hospitalized patients with H1N1 (in particular intensive care patients);
  • Determination of why there is sustained transmission in some settings;
  • Methods to improve acceptance of influenza vaccines;
  • Determination of attitudes towards non-pharmacological interventions to prevent disease spread.

Strategies

  • Participants suggested that PHAC and CIHR may help to build researcher collaborations.

Research Ethics and Ethical Issues

Workshop leader: Ross Upshur

Research needs

  • Better methods for risk communication and risk perception;
  • Development of methods to accelerate research approval;
  • Improved understanding of health-care workers’ willingness and perceptions;
  • Priority setting of actions.

Strategies

  • Work together to conduct focus groups with young adults;
  • Establish collaborations between research ethics boards, institutions and organizations;
  • Develop a centralized research ethics board that would identify key research themes and link researchers;
  • Foster linkages between members of research ethics boards and infectious disease experts.

Mathematical Modelling

Workshop leader: Dr. Babak Pourbohloul

Research needs

  • Integration of surveillance and modelling;
  • Obtain more insight on the effect of social distancing measures that were used in Mexico;
  • Cross validation of models;
  • Appropriate incorporation of uncertainty;
  • Timely and appropriate demographic and epidemiological data to inform the models and nimbly respond to changing circumstances.

Strategies

  • An open invitation was extended to researchers to participate in the CANPAN modelling network, which will include the use of a conferencing system that the network is establishing;
  • Collaboration among/between modelling groups to strengthen expertise nodes and reduce redundancy;
  • Prioritize modelling questions (severity, characterization, seasonality, non-pharmaceutical interventions, vaccination, anti-virals etc);
  • Bring large scale simulator to the desktop.

Vaccines and Host Adaptive Immune Response

Workshop leader: Dr. Scott Halperin

Research needs

  • Monitoring adverse events including Guillain-Barré Syndrome in infected and vaccinated individuals;
  • Methods to communicate risk;
  • Novel vaccine platforms;
  • Rationale for use of existing vaccines and identification of novel immune correlates of protection.

Strategies

  • International collaboration could be established to more rapidly assess the incidence of Guillain-Barré Syndrome in vaccinated individuals.

Open Forum: Facilitating Research

Key research needs and strategies identified in the workshop sessions were presented by Dr. Brown based on the summaries provided by the Workshop chairs. The presentation was followed by a wide-ranging discussion among meeting participants. Discussion points are summarized below:

  • There is a need to develop a large communication network so that researchers and those in applied fields including health care and management can rapidly share information about data and reagents. Information sharing could be facilitated via the Meeting website.
  • Studies are urgently needed to determine why aboriginal groups have higher infection rates and more severe illness. To do this research, liaisons with the aboriginal community are needed.
  • Leadership and coordination is needed to help in prioritizing the research needs that have been identified at the meeting in Toronto.
  • PPSRI-funded researchers are attempting to revise their research plans, but funds are urgently needed for new projects focused on pandemic H1N1/09. In fact, it is essential to maintain a funding base for influenza research, because seasonal influenza is a recurring health threat.
  • Intensive care clinicians who have treated patients with severe pandemic H1N1/09 viral infections currently lack the human resources to analyse the data that they have collected from their patients.
  • Veterinary aspects related to the current pandemic were largely overlooked at the meeting in Toronto. The swine industry in Canada is a billion dollar business. There is a massive need to look at the human/animal interface, especially in light of the fact that animals are reservoirs of influenza viruses.
  • Pandemic H1N1/09 has spread worldwide, but no one country currently has a large number of severe cases, therefore, international linkages should be developed, especially with a goal of understanding the cause of severe illness in infected individuals.

Closing Remarks

Dr. Bhagirath Singh, Scientific Director, CIHR-III
Dr. Singh closed the meeting by thanking the speakers and all participants for their focused effort and contributions to the meeting. He announced a new CIHR funding opportunity to support networking and collaboration of H1N1 influenza outbreak research teams. The primary objective of this funding opportunity is to catalyze the mobilization of teams focused on pandemic H1N1/09 research by providing seed money for planning and development activities of expert teams to advance research in priority areas determined by the H1N1 Outbreak Task Group. This new funding will add to previous CIHR investments in pandemic preparedness. The deadline for applications to this funding opportunity entitled “Catalyst Grant: Pandemic Outbreak Research Response” is August 10, 2009.

Evaluation of the Meeting by Participants

Participants felt that the meeting provided a good overview of the H1N1/09 pandemic and gave them a chance to learn about ongoing research in this area. Many appreciated the opportunity to network and develop collaborations. See Appendix 5 for a more detailed summary of responses to a questionnaire soliciting feedback on the meeting from participants.

Appendices

Appendix 1: Members of the H1N1 Task Group and Organizing Committee
Appendix 2: Meeting Program
Appendix 3: List of Participants
Appendix 4: Participants’ Pandemic-Related Research
Appendix 5: Summary of Evaluation of the Meeting by Participants