Severe Panflu Response Strategies
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Historical evidence shows that the 1918-1919 flu epidemic virus, H1N1, was extremely lethal (CFR > 60%) in isolated communities without prior exposure to similar viruses. This raises the extremely frightening possibility that H5N1 could have a similar effect on the general population. This paper briefly reviews the evidence for this position, and re-examines preparedness measures in this light.
Video presentationWatch a ten minute presentation on this approach.
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Also see Simple Critical Infrastructure Maps which addresses how to keep infrastructure and networks stable during times of crisis. Please take a look. This work provides a serious and stable analytical framework for mapping the systems which keep people alive.
Re-examining Pandemic Flu Behavior in 1918-1919
Current worst-case pandemic flu models, like the CDC pandemic severity scale, assume at most 2% fatalities among those infected. The current strain of H5N1, however, appears to be 60%+ fatal, with some countries reporting 85%+ lethality.
This disconnect is based on using a softened vision of the past to predict the future: it is said that the flus in the historical records have been, at worst, around 2% fatal and therefore the expectation is that the upcoming flu will not be more fatal than those flus. In fact, those figures would be true, at most, for the US and Europe, but not for the world as a whole: in the 1918-19 pandemic, it's generally assumed that some 50 million people died; if the population was around 2 billion and about 30% fell ill, that would mean an 8.3% lethality. Assuming 2% as a historical ceiling is optimistic and developed-world centered.
However, the situation is even worse than this.
In a handful of isolated communities, the 1918-1919 pandemic flu strain, H1N1, was massively infectious and massively lethal, mirroring the observed 60 to 85%+ fatality rate of currently non-pandemic avian flu, H5N1, while remaining highly infectious. The same H1N1 that was a few percent fatal in the general population killed most of the adults in communities which lacked resistance. Given these precedents, to assume that H5N1 must reduce its lethality from 60-85% to below 2% in the process of becoming highly infectious is not reasonable.
History has warned us that high infectiousness and high lethality are not mutually exclusive. There is a significant risk that H5N1 will affect the entire world as badly as H1N1 affected the isolated communities without resistance.
The 50/50 Scenario
This scenario is a simplified way of thinking about a severe pandemic flu scenario. It starts with a a high case attack rate (CAR) of 50%, meaning half the population gets infected over time, and a 50% case fatality rate (CFR) among those who fall sick, resulting in 25% of the global population perishing. That is about 1.6 billion people.
This is sobering, but by no means a worst case. In some countries, the current H5N1 strain has been 85% fatal, and H1N1 left villages without a single adult alive. Quarantine and other containment measures may simply disintegrate under the toll of such an organism.
However, in the past thousand years, many civilizations have experienced worse disease disasters than the 50/50 scenario. The Black Death is one instance. European settlers in North and South American is another. Smallpox in Iceland in 1750 killed 30% of the population. Cultures can and do survive decimation at the hands of disease, although not all by any means.
Hope and Despair in the 50/50 Scenario
Human beings can take some effective measures to get a head start on any disease organism with highly lethal pandemic potential. The InSTEDD approach of "early detection, early response" offers significant hope of cordoning off and destroying such organisms before they cause disasters. Pre-emptive slaughters of infected animal populations, good basic hygiene, pharmaceutical blanketing, rapid vaccine development and many other approaches offer hope.
The 50/50 scenario is an analysis of what to do where there is no hope of containment because the virus is already pandemic. Assuming that early response measures fail to contain the virus, and that none of the "magic bullet" technologies deliver, how should such a scenario be managed?
The answer is that we work with what nature has given us: available resources, the natural characteristics of the virus and human immunity, and human will. At these levels of lethality, however, planners must redefine their mission to be effective. Focus must shift from preventing death to preserving life.
In the presence of an uncontained CFR 50% virus, hundreds of millions of people will die. There is literally nothing that can be done to stop that unfolding if the "early detection, early response" levels fail. The loss of life is overwhelming.
However, if we shift focus to the survivors, we see a different picture. 4.8 billion people will live through the 50/50 scenario. With effective planning, perhaps that number can be raised over 6 billion survivors. The paralysis which comes with contemplating death is replaced by the optimism which comes from preserving life.
Do not count the dead. Count the living.
Getting Over Helplessness
It is critical to understand that we cannot control finding ourselves in the 50/50 scenario. A mutation in a farm animal on the other side of the world can place the world here, and at that point in history our only responsibility is to cope as best we can.
Success is measured in reducing the CAR from 50% to something more manageable and keeping as many people alive as possible through the inevitable infrastructure failures, food shortages and supply chain problems that will result from such a crisis.
There is plenty that can be done now to increase global options in this crisis should it arise. The rest of this paper will outline five possible approaches, which can be researched and validated now, and which would stand the world in good stead in H5N1 or other pandemic scenarios.
There is good, but early, evidence that 70%+ humidity and temperatures over 70F significantly slow or even stop the spread of influenza in mammals. This work is some distance from describing a preventative capability, but the promise that it holds out is a generally applicable approach to very early stage panflu response. If public buildings, particularly schools, airports and hospitals can maintain a year-round humidity defense from the earliest alerts, it will slow spread in the general population, and allow for easier isolation of early clusters due to reduced size and increased necessary contact between people for transmission. This measure is good for all scenarios, not only 50/50.
Social Distancing and Reserve Infrastructure
Social distancing really means reducing the opportunities for infection by people meeting. Measures like masks and gloves can contribute to reducing infectious contact. There are a range of interventions in this category, including trip substitution, food stockpiling, family quarantines and so on. A closely associated set of work exists on creating resilient household infrastructure, including micropower, sanitation, communications, cooking / heating systems and so on. These systems help maintain quality of life, and keep people at home, during more severe pandemic waves.
These factors, in a 50/50 scenario, may seem to pale in the face of the crisis, but also represent one of the few tangible measures an ordinary person can take to increase their odds of survival. Furthermore, effective sanitation using composting toilets, for example, could reduce deaths from secondary epidemics of cholera and similar diseases. Keeping some framework of normal life going, even in simple matters like cooking at home, is an important part of survival.
The Survivor Reserve
There are a wide range of scenarios in which the only resource one can count on having more of during the progress of a pandemic is survivors. In a severe pandemic flu scenario, the survivors must be rapidly promoted into the front line of response in all areas, from critical infrastructure and vaccine research through to peacekeeping and quarantine duties. However, chains of command of whatever kind that are not exclusively staffed with survivors are extremely vulnerable, and the cross-jurisdictional, do-the-right-thing nature of extreme crisis is poorly suited to most conventional command-and-control institutions. The Survivor Reserve must be an institution designed to work in tight international cooperation at all times and, given the global nature of the threat, with decentralized command and control functions, probably localized at the population-center / city level. Laying the template for this organization early is essential, including design of training materials in many world languages, and provisioning of necessary infrastructures ahead of the actual staffing up of the Survivor Reserve.
Emergency Vaccine Capability
We all already understand emergency vaccine capability to be critical. However, in a 50/50 scenario, the massive supply chain disruptions will make it vastly more difficult to keep vaccine research and, hopefully, mass production going. One of the critical functions of a Survivor Reserve is to keep these labs running. Unconventional approaches should be brought rapidly up to speed. For example, using irradiation to create vaccines directly from infected tissue samples has shown promise for some bacteria. Could a similar approach work for viruses?
Given the overwhelming criticality of vaccine research when dealing with high CFR flu strains, does it make sense to pre-position isolated, well-stocked labs? Vaccines are already understood to be critical, but are the stakes even higher than expected? If so, what must be done?
Quarantined Supply Chains
Viruses have a limited life-span outside of the body. Although precise life-span varies with conditions, a supply chain mechanism can be build which uses that required gap of a few days to effectively contain the virus. For example, a scheme where food trucks are driven to a border, and the drivers then wait for three or four days before continuing, may validate not just the driver but the load as free from infection, as long as there are no reservoirs of infection in the load, such as viruses trapped in nasal mucus. Masks are mandatory on food shipping workers.
In even more extreme cases, it may be necessary to move food stockpiles to population centers, in case of loss of future logistical capability. For example, in America, there are approximately 100 million head of cattle, each yielding approximately 500 pounds of beef at 1200 calories per pound. Combined with grain which was destined to be cattle feed, this gives a subsistence diet of 1200 calories for every American for six months. Europe and South America also have equivalent cattle reserves. Moving an entire cattle population into the reach of potentially-hungry cities is a massive undertaking in both planning and execution. Delivering the food to populations hiding at home is a job for the Survivor Reserve. Dry runs are required.
ConclusionI believe there is no doubt that a 50/50 scenario is possible within the current framework of scientific understanding about H5N1. There will be no time to prepare or plan in the event of a new strain of the virus which is both highly fatal and highly contagious. Severe and prolonged attention must be paid to maintaining global stability through this crisis because the challenge will be unlike anything faced successfully in human history. The time to act is now, while action is still possible.
I am not an expert in the field but will be glad to help in any way I can.
Mon Mar 3 14:11:00 PST 2008