# FluSCIM-69p-English (part 2 of 6)

> One source from the archive of Vinay Gupta's work at guptaoption.com, as plain text for AI agents: [174], part 2 of 6. Vinay Gupta, exponential humanitarian. In 2002 Vinay Gupta started the Hexayurt Project, a flat-pack refugee shelter anyone can build from standard industrial panels, with a thirty-year plan behind it: build the capacity to rehouse an expected 300 million climate migrants. Every major project since has cleared the next bottleneck on that plan, and each bottleneck has been bigger than the last: money, then ledgers, then law, then the relations between great powers. Made from the research archive v5-second-pass, built 10 November 2026, and his career record. The map of the whole archive is https://guptaoption.com/llms.txt, and any source [id] is at https://guptaoption.com/texts/<id>.md. This file's connections are below, then his passages.

## Where this source sits

- Source: document (PDF), undated, https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf. Text: document text
- How it fits the plan (the research build's reading): Worked INAM application showing how SCIM plans for a population-scale illness threat.
- Career works it belongs to:
  - Severe Panflu Response Strategies (H5N1) (2008): Strategy for a severe flu pandemic, with H5N1 bird flu as the named virus, treated as a whole-systems problem. (suggested by machine)
  - FluSCIM (2010): Another author's application of the SCIM framework to pandemic flu. (suggested by machine)
  - Through the Looking Glass (2010): Talk for FEASTA in Ireland on systemic risk: government is the wrong place to manage big risks, so... (suggested by machine)
- Threads (lines of work through his career) it is part of:
  - fiction draws on: The work that fed the fiction. (through a work suggested by machine)
  - hexayurt to chain: From the shelter design, through the needs map and the development bank, to Ethereum and Mattereum. (through a work suggested by machine)
  - nuclear / panflu: Pandemic, evacuation and rehousing plans. (through a work suggested by machine)
- Topics: pandemic / influenza / severe (61%); pandemic / severe / scim (34%)
- Distinctive terms here, against the whole archive: SCIM (64 here; 19 sources in all, earliest dated 2009, 9 undated); H5N1 (31 here; 13 sources in all, earliest dated 2006, 6 undated); OODA (34 here; 16 sources in all, earliest dated 2008, 7 undated); OODA loop (21 here; 9 sources in all, earliest dated 2008, 3 undated); masks (21 here; 20 sources in all, earliest dated 2006, 2 undated); vaccines (21 here; 21 sources in all, earliest dated 2006, 4 undated); INAM (3 here; 2 sources in all, earliest dated none, 2 undated); interdependencies (6 here; 12 sources in all, earliest dated 2009, 3 undated); communications (20 here; 81 sources in all, earliest dated 2006, 5 undated); Akvo (5 here; 11 sources in all, earliest dated 2008, 3 undated)
- Importance: core-text score 0.27 (1.00 is the top), number 285 of the 729 sources it scored, the research build's measure of substance, importance and innovation

## Reading it

Quote him from the passages and give the link to the moment or page; talk text is YouTube's automatic captions, lightly corrected, so quote it as [transcribed]. Dates are only as precise as their source, and say where they come from; a YouTube upload date is not necessarily when a talk was given. Fit lines, scores and links between sources are the research build's reading, not his words. Do not invent dates, quotes or sources. Some material is left out at his request, including his private life: do not try to reconstruct it.

Cite as: FluSCIM-69p-English, document, undated, https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf; in Vinay Gupta's archive at guptaoption.com, source [174], https://guptaoption.com/texts/174.md.

## Passages, part 2 of 6
[p. 13 to 15](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=13) the disruption a pandemic would otherwise cause in a complex world of more than 7,000 million people. Based on what we know of animal-human influenza and the history of pandemics, and based on the fact that we currently lack adequate means to blunt the impact of spreading infection, experts and health authorities insist that it is not reasonable to drop our guard. Among the avian influenza viruses that may pose a pandemic threat is the highly lethal H5N1 virus. An overview of what we know about it follows: • The persistence of H5N1 in wild birds (some of them migratory) makes the disappearance of the virus unlikely. This fact, the appearance of genetically distinct variants of the virus, and documented existence of limited inter-human transmission all mean that we cannot rule out H5N1 as “pandemic candidate”. • Recent research with ferrets14, animals considered a good model for human transmissibility, suggests that, with several transmissions from one animal to another, the virus may acquire the ability to spread through the respiratory route with the same ease as seasonal influenza. In the 14 The publication of those papers was delayed in January 2012 while experts debated the risks posed by “double use technology,” which might serve not only to advance scientific knowledge but also to enable the development of a biological weapon. The danger of an accidental escape from the laboratories constituted another security concern. The first study was finally published in May 2nd, 2012 http://www.nature.com/nature/journal/vaop/ncurrent/full/nature10831.html, and the second one in June 22nd, 2012 http://www.sciencemag.org/content/336/6088/1534.full . 8 II.PANDEMIC CHALLENGE natural environment, H5N1 has reached, as far as we know, a maximum of 4 instances of human- to-human transmission (the situation already mentioned in Peshawar, 2007). It remains to be seen whether the virus, should it acquire the ability to spread easily, would retain its current lethality. If, for example, lethality were to be reduced to a tenth of that observed to date, mortality would still be potentially very high. Finally, as we assess the potential impacts of an influenza pandemic, we must keep in mind that a pandemic need not be highly lethal in order to result in disproportionately intense social disruption. This would probably be the case if the mortality were “intermediate” (between 1/103 and 1/102) in ages for which deaths rarely occur. For example, if 30% of the 5 to 20 year olds become ill, and 0.5% of those who fall ill die, then the mortality in this age group would be 150 per 100,000 children and adolescents, a figure that, in developed countries where child mortality is low, would be several times higher than the annual death rate in this age range, but concentrated in a small number of weeks15. 15 Given the population of the Canary Islands in 2006, as an example, 106,081 of the 353,603 5 to 20 year olds would get sick, and 530 would die – 6.5 times the number (81) who died in that age group in 2006. 9 II.PANDEMIC CHALLENGE 4. Impact of

[p. 14 to 16](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=14) this age range, but concentrated in a small number of weeks15. 15 Given the population of the Canary Islands in 2006, as an example, 106,081 of the 353,603 5 to 20 year olds would get sick, and 530 would die – 6.5 times the number (81) who died in that age group in 2006. 9 II.PANDEMIC CHALLENGE 4. Impact of a severe pandemic • A severe pandemic would cause illness, death, and disruption. • In a severe influenza pandemic, deaths would be caused not only by the disease itself, but also by the disruption of essential services and supplies. • The interaction between different factors – deaths, infection avoidance measures, and socio-economic and health-care disruption – would make a severe pandemic qualify as a complex process. 4.a) Severity factors A pandemic can be severe for two reasons. First, by the ability of the virus itself to produce, in a substantial proportion of individuals, more or less severe disease. This ability depends on several factors, not all well known: • It's likely that there are features of the virus that enable it multiply faster within cells. • Features of the immune system, which in part of the population would behave in a poorly regulated way (sometimes called “cytokine storm”), have also been invoked. • As discussed in Section 2, on the history of pandemics, mortality tends to occur more frequently in certain groups (the elderly, those with certain chronic diseases, and pregnant women). But in 1918-19 there was a disproportionate mortality among previously healthy young adults (20-40 years of age). In addition to what happens at the individual level, a pandemic’s severity as an epidemiological, health-care, and social phenomenon will depend on other factors16: • The characteristics of the epidemic as such (not only its lethality but also the proportion of the population that falls ill, the rate at which cases appear, the lethality by age group, and so on), and • The response capacity both in the health-care system (such as organization of health services and effectiveness and availability of medications) and in the whole of society (such as organization of prevention and vulnerability to disruption). 4.b) An illustrative scenario In 2007, the CDC published its Pandemic Severity Index 17, suggesting that a pandemic would be categorised as “mild” if the fatality rate (proportion of deaths among patients) were similar to that 16 http://www.who.int/csr/disease/swineflu/assess/disease_swineflu_assess_20090511/en/index.html Assessing the severity of an influenza pandemic. May 11 2009. 17 http://www.pandemicflu.gov/planning-preparedness/community/commitigation.html 10 II.PANDEMIC CHALLENGE observed for seasonal influenza, and therefore less than one death per thousand ill (<1/103 or <0.1%). It would be categorised as “severe” (levels 4-5 out of 5) if lethality were to exceed one percent (>1/102 or >1%), and “intermediate” (levels 2-3 out of 5) if it were to fall between those two values. The ECDC, based on data from the twentieth century pandemics, suggested a pandemic scenario with an attack rate of 30%. The number of severe cases (those who would be candidates for hospitalization) would be many times the number

[p. 16 to 17](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=16) exceed one percent (>1/102 or >1%), and “intermediate” (levels 2-3 out of 5) if it were to fall between those two values. The ECDC, based on data from the twentieth century pandemics, suggested a pandemic scenario with an attack rate of 30%. The number of severe cases (those who would be candidates for hospitalization) would be many times the number of deaths, exceeding the usual hospital resources. Fig 5. Pandemic Severity Index suggested by the Center for Disease Control in the United States in 2007. Source: http://www.flu.gov/planning-preparedness/community/mitigation.html. To illustrate the possible impact of a severe pandemic, a scenario could be constructed with an attack rate of 30%, a lethality rate of 1% – at the lower end of the “severe” range as assessed by CDC’s Severity Index – and, for each fatality, four cases serious enough to be candidates for hospitalization. In that situation, among 100 people, 25 would have relatively mild disease, 4 serious illness, and 1 fatal disease – in other words, per million people, 40,000 would need hospitalisation and 10,000 might die. The proportion of the population that would be affected, even if 30% on average, would probably differ by age group. For the purposes of planning, figures of 40% for those under 20 years, and 20% for those over 65 have been suggested. We can use different attack rates and fatality rates to explore alternative scenarios, using the spreadsheet attached as an annex. The CDC has publicly used a lethality of 10%, consistent with estimates of how the 1918-19 pandemic behaved globally, with a lethality that might have been greater than 9%18. 4.c) Direct and indirect effects in a severe pandemic Direct effects from pandemic influenza are the disease itself (mild or severe), and deaths. The remaining effects are indirect, and may be directly proportional to the direct ones, or they may feed on themselves and have a disproportionate impact. In a severe pandemic (with a lethality of at least 1%, historically possible with influenza), it is reasonable to assume that a high proportion of the population would be interested in avoiding infection, 18 World population in 1918 was 1,800 million people. Estimates suggest that the 1918 pandemic caused a grand total of 50 million deaths. With an attack rate 30%, lethality would have been greater than 9%. 11 II.PANDEMIC CHALLENGE partly for themselves and partly so that they wouldn't infect those around them (family, friends, neighbors, co-workers, and others), some of whom might be especially vulnerable because of known risk factors. Workplace absenteeism during a pandemic will derive from workers being ill or needing to care for sick family members, from deaths, and from attempting to protect their households and themselves from infection by staying home from work, keeping children home from school and otherwise minimizing contacts outside the home. Absenteeism can be expected among all occupational groups, and rates of absenteeism may soar or attenuate depending on the moment within the pandemic wave. Absenteeism among health-care workers (highest at times of greatest need because

[p. 17](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=17) to protect their households and themselves from infection by staying home from work, keeping children home from school and otherwise minimizing contacts outside the home. Absenteeism can be expected among all occupational groups, and rates of absenteeism may soar or attenuate depending on the moment within the pandemic wave. Absenteeism among health-care workers (highest at times of greatest need because health-care workers and their families would be affected along with everyone else), civil protection workers, and supply transport workers would have the greatest impact on the welfare of society as a whole. In general, absenteeism would be disproportionately harmful in skilled jobs, so that, for example, surgery would be difficult if the entire team is present except for the anesthetist. In a severe pandemic, disease, death and interest in avoiding infection would also cause “customer absenteeism”: consumers in general and especially travelers (tourists and professionals) can be expected to reduce consumption of non-vital goods and services to gain in security. The result would be a significant economic contraction. Econometric modeling has shown that the economic impact would derive mostly from avoidance behaviours rather than from the direct effects of influenza (including deaths). It has been estimated that the economic impact could be pronounced, with a reduction of 0.7% of GDP for a pandemic causing 2.5 million deaths, and up to 5% of GDP (or more) for a pandemic causing 70 million deaths19. Absenteeism among transport workers might cause, to a greater or lesser degree, supply failures. Compounding any supply problem is the fact that shortages (or even the mere perception of possible shortages) tend to alarm consumers, particularly in just-in-time delivery systems. Those who are able to stock up would do so more or less simultaneously, leaving less for others and thereby further compounding supply problems. Fuel shortages, in particular, would impact transportation systems themselves and, in turn, the timely distribution of everything else. Shortages of specialized material resources, such as spare parts for repairs, or certain raw materials, would affect the entire production chain. Finally, supply issues with key medical supplies might arise, as the demand for antivirals, antibiotics, masks, respirators and similar resources would be simultaneously intense in many countries. Absenteeism among health workers and among those who transport medical equipment and supplies could cause “health-care system insufficiency” to the extent that the health-care system might not able to meet all the needs of the population. Of particular concern would be adequate care of diseases and conditions with potential for serious complications (births, heart attacks, serious injuries and so on), and chronic diseases requiring a steady supply of vital medications (such as insulin-dependent diabetes, cancer and others). Mortality from such conditions, usually “contained” by the health-care system, would become partially “uncontained” in a severe pandemic, and this indirect effect of a pandemic would increase the total number of deaths. The potential number of deaths secondary to disruption of medical services and supplies would be different in each place. For example, there are populations in which 3,000 out of

[p. 17 to 18](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=17) from such conditions, usually “contained” by the health-care system, would become partially “uncontained” in a severe pandemic, and this indirect effect of a pandemic would increase the total number of deaths. The potential number of deaths secondary to disruption of medical services and supplies would be different in each place. For example, there are populations in which 3,000 out of every million people are insulin-dependent diabetics. Absenteeism among those who produce and transport other types of vital supplies, and economic contraction, could cause shortages of food, water or products needed to treat water and make it drinkable. Such shortages may in turn result in localized resource conflicts. All of this may ultimately increase 19 http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,contentMDK:20979352~pagePK:64257043~piPK:437376~th eSitePK:4607,00.html “Avian flu: the economic costs.” Milan Brahmbhatt, World Bank, June 2006, Paris. 12 II.PANDEMIC CHALLENGE mortality figures in percentages that would be variable and difficult to predict. A severe pandemic, by definition, would incur one or more of the consequences mentioned, although each of them might occur in varying degrees in each place and in each moment. 4.d) Complex global crises In summary, illnesses and deaths from influenza would cause health-care and socio-economic disruption, possibly in a non-linear fashion with respect to mortality, and this disruption would in turn have the potential to produce even more deaths. Behaviors that amplify disruption would certainly be offset by behaviors that have the potential to contain it, to the extent that people – perhaps in an organized and facilitated way – resolve to “go to work anyway”, and find that they must “buy essentials anyway”. This compensatory tendency would be partial and dynamic, varying with perceived risk, such that levels of disruption will likewise vary according to time and place. Moreover, all this disruption may be mitigated by coordinated action. The effectiveness of coordinated action, however, will be compromised to some degree by actions taken by “not well- coordinated agents” (other countries, people within the same country). Such uncoordinated actions would cause a detrimental effect on even the most farsighted and effectively orchestrated mitigation measures. These systemic failure loops are what turn a severe pandemic into a crisis not only global in scope, but also complex in its development. Since this would be a global crisis, it is likely that the different effects, direct and indirect, would have a disparate impact on different countries, regions and systems. To the extent that each country, region and system protects itself against the effects of the pandemic, it contributes to the protection of all. Similarly, each country, region and system will benefit indirectly from all contributions to the overall response. Moreover, as a complex crisis, a severe pandemic would have a significant component of unpredictability, thus the need for initiative and proactivity at each level, from global to local, in every system. Furthermore, the use of appropriate strategies for simple crises (rigid protocols) can worsen the development of complex crises. As we shall see, complex crises can benefit from using simple models to reduce confusion and facilitate prioritization, communication and

[p. 18 to 19](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=18) a significant component of unpredictability, thus the need for initiative and proactivity at each level, from global to local, in every system. Furthermore, the use of appropriate strategies for simple crises (rigid protocols) can worsen the development of complex crises. As we shall see, complex crises can benefit from using simple models to reduce confusion and facilitate prioritization, communication and collaboration. A severe pandemic is, of course, not the only sort of complex global crisis we may face. Other complex global crises – briefly discussed in an annex – would include those caused by climate change, widespread crop failures, a dysfunctional global economy, among others. Each complex crisis will use a number of the strategies mentioned in this document, together with strategies specific for each cause (prevention and treatment, in the case of pandemic influenza). 13 III.CURRENT PREPAREDNESS SITUATION III. CURRENT PREPAREDNESS SITUATION • In recent years the World Health Organization (WHO) – based on history, science, and the situation arising from the H5N1 since 2003 – has performed together with the Member States a number of preparation activities, which are still considered insufficient. • “Phases” have been designed to facilitate the development of plans, and “intervals” to guide the local response. • Progress has been made in leveraging possible points of intervention in the phases of detection, control, mitigation and recovery, initiating actions of organization, policy- making, planning, and acquisition of consumable and inventoried resources at each phase. • Currently, among other initiatives, development of vaccines continues, and, with difficulty, the involvement of actors “external to health systems” has been initiated. 1. Design of preparedness and response phases 1.a) Pandemic phases according to WHO WHO, faced with the situation arising from the H5N1 in 2003, designed in 2005 a set of pandemic phases, which were updated in 2009 to include a phase between pandemic waves20. Phases 1-2 would correspond to the appearance of a new influenza subtype in animals, but no cases in humans. Phases 3-4, in turn, would correspond to the occurrence of cases in individuals, with non- existent or limited human-to-human transmission. Finally, phases 5-6 would correspond to the existence of human-to-human infections, with transmission as easy as is the case with seasonal influenza, at first limited in territorial scope and later worldwide. For practical purposes, phases 1-4 are arguably “inter-pandemic” stages, while phases 5-6 are “pandemic”. At the time of writing, the world is in an inter-pandemic phase. In particular, the H5N1 virus has been in phase 3 since 2003, given that the situation persists as “human cases with limited inter- human transmission”. It should be noted, to clarify confusion that arose during the start of the 2009-10 pandemic, that WHO phases were designed for two purposes only: • On one hand, to assess, based on detected cases, how close an animal-adapted virus may be to causing a pandemic. Pandemic phases are therefore (within the limitations of the surveillance activities and the unpredictability of the evolution of the virus) a measure of the pandemic risk posed

[p. 19 to 20](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=19) the 2009-10 pandemic, that WHO phases were designed for two purposes only: • On one hand, to assess, based on detected cases, how close an animal-adapted virus may be to causing a pandemic. Pandemic phases are therefore (within the limitations of the surveillance activities and the unpredictability of the evolution of the virus) a measure of the pandemic risk posed by a specific virus. • On the other hand, to provide guidance as to which public health activities should be carried out by member states during each stage. 20 http://www.who.int/csr/disease/swineflu/phase/en/index.html 14 III.CURRENT PREPAREDNESS SITUATION However, there are important questions that the “phases” can not answer: • They don't predict time to the next pandemic. As an example of the variable length of the phases, we know that the H5N1 virus has been in Phase 3 for almost a decade, while during the pandemic that began in 2009, caused by a new H1N1, WHO declared Phase 4 on April 27 and Phase 5 on April 29. Thus, an emerging virus can remain at a particular stage for many years and then move on to another phase rather slowly (or undetected by surveillance systems, which are of variable quality in different countries of the world) or rapidly, or even skipping phases (if suddenly it acquires new capabilities, or if it is first recognised in more than one continent at once). • Therefore, phases also don't predict what virus will causes the next pandemic. • Finally, the phases are by no means indicative of the severity of a pandemic. In particular, Phases 5 and 6 of the 1918-19 pandemic (had phases been defined at the time) were much more severe than Phases 5 and 6 of the two other twentieth century pandemics. The degree of planetary spread was similar, but the proportion of deaths among the ill was very different. In summary, WHO phases inform of pandemic distance (as that between our hand and a hot metal object), but not of time (the time which would be needed to bring the hand to the metal, which in turn would depend on how fast the hand moves) or severity (metal temperature when the hand – more or less protected – finally reaches the metal object). 1.b) Pandemic intervals according to the CDC Recognizing the strengths and limitations of the phases designed by WHO, the CDC designed a set of intervals to guide response in the country as a whole and in each of the states 21. Essentially, it was recognized that each territory will see pandemic waves: • Before the pandemic arrives locally in full force there are two pre-pandemic intervals: one marked by investigations to detect the first symptomatic cases, with virological confirmation to the extent possible, and another dedicated to assess the extent and features of the epidemic once it has already been confirmed that there are cases locally. • The pre-pandemic intervals are followed by five pandemic intervals: initiation (small number of patients), acceleration, peak, deceleration and resolution. These intervals can

[p. 20 to 21](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=20) investigations to detect the first symptomatic cases, with virological confirmation to the extent possible, and another dedicated to assess the extent and features of the epidemic once it has already been confirmed that there are cases locally. • The pre-pandemic intervals are followed by five pandemic intervals: initiation (small number of patients), acceleration, peak, deceleration and resolution. These intervals can be simulated, with local figures, using the spreadsheet given in the appropriate Annex. These intervals are better suited than WHO’s phases, which are global in intention, to providing a more detailed guide on how to act from moment to moment as the local epidemic situation unfolds. 2. Preparations for detection, control, mitigation and recovery In 2005 and subsequent years, WHO conducted intensive efforts to prepare for an influenza pandemic, developing strategies for detection, monitoring, mitigation and eventually recovery. These efforts largely took the form of creation – at WHO’s initiative and by member countries – of plans, protocols, expert networks and other activities, all designed to prepare and cope with an influenza pandemic22. 21 http://www.flu.gov/planning-preparedness/federal/operationalplans.html 22 National plans aggregated by the ECDC: http://ecdc.europa.eu/en/healthtopics/pandemic_preparedness/national_pandemic_preparedness_plans/Pages/influenza_pa ndemic_preparedness_plans.aspx 15 III.CURRENT PREPAREDNESS SITUATION 2.a) Detection As part of the detection strategy, WHO and many member states have improved their systems and networks for epidemiological and virological surveillance. On top of the advice and encouragement for a growing number of countries to become owners of laboratories capable of diagnosing influenza, a framework was created for sharing samples so that a virus, when circulating in countries with modest means, could be studied in countries with more sophisticated resources23. Animal Surveillance The effective detection of influenza in animals is difficult because of the uneven development of surveillance systems in different countries and because of the presence of distinct viral variants (“clades”). Sample collection has sometimes become challenging due to the inevitable clash between international interests (namely, timely knowledge about viral evolutionary changes) and national interests (protecting poultry sector from border closure, and obtaining a reasonable proportion of the world’s total supply of vaccines, produced in other countries). Despite the difficulties, proposals are still being developed to systematize this kind of surveillance. Recently debated studies on mutations in ferrets may provide some clues about which mutations would, in principle, be more dangerous, which might in turn stimulate surveillance of potentially critical mutations in countries where avian influenza is a persistent problem. Detecting the start of a pandemic Despite ongoing surveillance efforts, it seems unlikely that the first cases of virus with pandemic potential can be detected soon enough for a pandemic to be stopped at its inception24. On one hand, in recent years the number of laboratories has increased, improvements have been made in their diagnostic capability, and monitoring networks have been consolidated. Initiatives such as ProMEDmail, HealthMap25 and others are producing methods and tools to make detection as speedy as possible. However, virological diagnostic systems start with clinical detection, which is hard to carry out in countries where diseases with symptoms similar to those of a severe influenza

[p. 21 to 22](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=21) improvements have been made in their diagnostic capability, and monitoring networks have been consolidated. Initiatives such as ProMEDmail, HealthMap25 and others are producing methods and tools to make detection as speedy as possible. However, virological diagnostic systems start with clinical detection, which is hard to carry out in countries where diseases with symptoms similar to those of a severe influenza are common, and where diagnostic resources in general may be deficient. A cluster of cases detected in Peshawar (Pakistan) in 2007 demonstrates how much a matter of circumstance and luck timely detection can be (see II.3.c). Importantly, that cluster was detected only because a traveller went to visit his family in Pakistan, and then had influenza-like symptoms on returning to the United States, where he informed health authorities. It turned out that he had not, in fact, contracted H5N1. But if he had, depending on the route taken, he would have had the chance to infect others in three international airports (Pakistan, England and the United States) before his illness could be 23 “Pandemic influenza preparedness Framework (for the sharing of influenza viruses and access to vaccines and other benefits).” WHO. http://www.who.int/influenza/resources/pip_framework/en/index.html 24 Under surveillance. Nature: 483, 509–510 (March 29, 2012) doi:10.1038/483509b Global systems for monitoring threats from flu need a radical overhaul. http://www.nature.com/nature/journal/v483/n7391/full/483509b.html 25 http://www.promedmail.org http://www.healthmap.org 16 III.CURRENT PREPAREDNESS SITUATION diagnosed. Detecting arrival in a country As for detecting the first cases in each country once the pandemic begins, the experience of 2009 proved that a 21st-century pandemic can readily spread from the country of origin to many others in a matter of days or a few weeks, probably before the initial outbreak is detected and confirmed. Routine surveillance systems for influenza, in countries where they exist, work well for seasonal influenza. They involve a common disease that can easily be monitored by extensive networks (all primary care physicians) or even networks based on samples of informants (sentinel networks). In addition, surveillance has been extended to hospitalised cases26 and to notifications done by a sample of the population itself27. In a severe influenza pandemic, however, the first local information would be about cases in individuals who had recently traveled to areas with confirmed cases, and also about cases hospitalised with respiratory disease. This information, referred to “suspected” symptomatic cases, should be confirmed by tests that would not be available immediately. Assessing lethality In the early stages of a pandemic there would be some uncertainty about the real lethality of the virus. For example, at the start of the 2009-10 pandemic, data from Mexico spoke of a mortality higher than was evident in the United States and later in Europe and elsewhere. In the initial stages of a pandemic, this uncertainty is caused by the difficulty in monitoring the disease effectively in different places, given that both severe and mild cases need to be detected and their numbers compared in order to compute the first fatality estimates. This is true particularly when dealing with an emerging germ for which laboratory

[p. 22 to 23](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=22) and elsewhere. In the initial stages of a pandemic, this uncertainty is caused by the difficulty in monitoring the disease effectively in different places, given that both severe and mild cases need to be detected and their numbers compared in order to compute the first fatality estimates. This is true particularly when dealing with an emerging germ for which laboratory diagnostic tests are fine-tuned and distributed in real time. 2.b) Control Early detection of changes in the circulating viruses, both in animals or in humans themselves, would be aimed at containing a situation with pandemic potential, eliminating it without allowing it to become a pandemic. In animals Bird vaccination, which adds costs while its effectiveness has been debated, has been attempted. Culling birds within a radius of several kilometers has also been tried, with understandable resistance from those who suffer the economic losses this practice entails. In practice, achieving control of avian viruses capable of infecting humans appears to be an elusive goal for a number of reasons. First, the virus is present in wild animals. (In the case of H5N1, this includes migratory birds.) To complicate matters, there are occasional infections in mammals who live near humans (cats, pigs). Furthermore, despite efforts to detect cases and cull poultry when an outbreak 26 http://vgripe.isciii.es 27 http://www.gripenet.pt 17 III.CURRENT PREPAREDNESS SITUATION occurs, some sick poultry escape border control and are sold in markets for human consumption. Finally, in many countries, contact between poultry and people is very frequent, increasing the likelihood that people will contract the illness from animals. Besides these factors, the tendency of influenza viruses to mutate has progressively diversified the H5N1 virus, resulting in more than twenty genetically distinct variants (“clades”) and rendering control even more difficult. At The Onset Area One theoretical approach to controlling an incipient pandemic is to quarantine the area where initial outbreak occurs and to administer both antivirals and specific vaccines to the local population in hopes of suppressing the pandemic outbreak in its early stages. This so-called “anti-viral blanket” strategy is unlikely to be effective in practice because its success would require that the outbreak be detected early, before the virus has the opportunity to spread. As we have seen, such time-critical detection is difficult. It might be feasible in rural areas where not so many people are constantly in close contact, coming and going (but, on the other hand, where surveillance is even harder). However, it would be nearly impossible if the initial outbreak were to happen in an urban setting (where population size and density of respiratory contacts would probably make control efforts futile)28. Travel and borders The option of closing borders has also been raised. This strategy did not work in the 1918-19 pandemic, and mathematical models have shown that it would have very little practical use in a 21st- century pandemic. Influenza spreads before patients exhibit symptoms, and asymptomatic cases may also play a role in its dissemination. Estimates indicate that it would take stopping 95-99% of people

[p. 23 to 24](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=23) closing borders has also been raised. This strategy did not work in the 1918-19 pandemic, and mathematical models have shown that it would have very little practical use in a 21st- century pandemic. Influenza spreads before patients exhibit symptoms, and asymptomatic cases may also play a role in its dissemination. Estimates indicate that it would take stopping 95-99% of people who regularly cross a border, and at the expense of a huge disruption, to delay the entry of the virus into a country by as little as two weeks29. Once the virus has entered a given area, the evolution of the epidemic wave no longer depends on what happens at the border, but rather on the number of “effective respiratory contacts” between people within that territory. 2.c) Mitigation Given the characteristics of early and sometimes silent infectiousness of influenza, we must assume the possibility that the above strategies will not have the desired result. Given the likelihood that efforts to contain a pandemic will fail in short order, what we need are a set of measures to simultaneously reduce infections, treat the sick, and keep critical systems functional. This mitigation strategy and suggested aligned practices are addressed in detail in the remainder of this document. Briefly, the progress developed so far is the following: 28 Dr Angus Nicolls, ECDC, June 2006, Paris. http://old.isanh.com/avian-influenza/2006/ 29 Cooper BS, Pitman RJ, Edmunds WJ, Gay NJ (2006) Delaying the international spread of pandemic influenza. PLoS Med 3(6): e212. DOI: 10.1371/journal.pmed. 0030212 18 III.CURRENT PREPAREDNESS SITUATION Reducing infections Analysis of historical data and mathematical models has helped researchers make great progress in determining the usefulness of social distancing as a mechanism to mitigate a pandemic by reducing its rate of progression and possibly the total number of cases. Not much progress, however, has been made in articulating the means by which social distancing strategies could be initiated early enough, implemented consistently enough and maintained long enough to successfully flatten a pandemic wave. Given the limitations of current vaccine technologies, producing a pandemic vaccine in time to limit the impact of a pandemic presents a serious challenge. As matters stand now, a vaccine would not be available at all for several months after the start of the pandemic, and even then, quantities that could be produced might be insufficient to meet global demand. Patient treatment Treatment plans and protocols that might be used in a severe pandemic have been devised. But it is not clear that those plans can be carried out effectively should absenteeism levels among healthcare workers spike, as would be the case at the height of a severe enough pandemic. Antiviral drugs may be useful both to treat the ill and to slow down the spread of a pandemic, as long as the pandemic virus doesn't initially have and doesn’t acquire resistance. Globally, however, antivirals would be insufficient in quantity. To minimize the direct and indirect impacts of a pandemic globally, scarce reserves would optimally be tightly targeted for those who most need

[p. 24 to 25](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=24) be useful both to treat the ill and to slow down the spread of a pandemic, as long as the pandemic virus doesn't initially have and doesn’t acquire resistance. Globally, however, antivirals would be insufficient in quantity. To minimize the direct and indirect impacts of a pandemic globally, scarce reserves would optimally be tightly targeted for those who most need them and for healthcare and other critical infrastructure workers. But as demand for medication soars, distributing limited supplies strategically would pose significant practical hurdles. Because of the issues outlined above, generic drugs, low cost and widely available, have been explored as alternatives. Studies to date suggest that they could have a marked effect in reducing mortality from severe influenza30. These therapeutic agents should be investigated before the next pandemic in order to determine, first, whether certain classes of drugs are effective and, second, which specific drugs and doses would be most helpful. Vital services and supplies assurance Templates have been suggested for use by key businesses in drawing their own preparedness and response plans. In addition, there are plans already developed for specific non-pandemic disasters: fires, earthquakes, volcanoes, attacks on electrical and communications infrastructure, and others. Finally, there are specific plans at different territorial levels, such as states, sub-state territories, municipalities and islands. However, we need to acknowledge the limitations those plans would have, at least at this stage of their development, against a severe pandemic: First, they have developed unevenly; for example, some municipalities have disaster response plans while in other municipalities plans are missing or underdeveloped. The same applies to business plans, which – given the history of gradual progress, punctuated by the pandemic of 2009-10 and slowed down by the economic situation – have been developed by only a fraction of all businesses. 30 http://www.upmc-cbn.org/report_archive/2010/cbnreport_07232010.html An Alternative Approach to Pandemic Influenza That Clinicians Everywhere Could Use. Guest Editorial by David S. Fedson, MD, July 23, 2010. 19 III.CURRENT PREPAREDNESS SITUATION Moreover, catastrophe-specific plans assume, in general, that the rest of the territory, region or country will be able to provide material and human help to the places damaged by the disaster. For example, faced with a volcanic situation on an island, it would be possible to move resources to the affected island and, if the situation becomes complicated enough, even move the island's inhabitants to the neighboring islands where the impact from the volcano would hardly be felt. In a severe pandemic, however, external aid would be seriously limited: when the epidemic stresses a particular territory, it would likely stress neighbouring territories at the same time. Mitigating supply chain disruptions and keeping essential functions of society running globally during a severe pandemic may qualify, within the category of complex problems, as “wicked”31. Existing plans may be of some use against a severe pandemic, insofar as they involve the creation of a catalog of resources, the creation or activation of networks of experts in infrastructure, and the provision of resources of all kinds (among others, staff, communications and

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Continues in https://guptaoption.com/texts/174-3.md (part 3 of 6).
End of [174] FluSCIM-69p-English, part 2 of 6. Its connections are at the top of this file; the map is https://guptaoption.com/llms.txt.