# FluSCIM-69p-English (part 1 of 6)

> One source from the archive of Vinay Gupta's work at guptaoption.com, as plain text for AI agents: [174], part 1 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 1 of 6
[p. 1 to 4](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=1) Severe influenza pandemic in Macaronesian Islands: Preparedness and Response Lucas González Santa Cruz December 15, 2011 Creative Commons License “Attribution-Noncommercial-Share Alike” Author: Lucas González Santa Cruz. Version: December 15, 2011. Translation and updates: March 17, 2013. License: This work, including the attachments, is licensed under Creative Commons “Attribution- Noncommercial-Share Alike” 2.0 England and Wales. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/2.0/uk/deed.es_PE or send a letter to Creative Commons, 171 Second Street, Suite 300, San Francisco, California 94105, USA. Financing: Gestión de Servicios para la Salud y Seguridad de Canarias (Management of Services for Health and Safety in the Canaries, GSC, a public company of the Canary Islands, attached to the Canary Islands Ministry of Presidency, Justice and Security, and to the Ministry of Health), under the PLESCAMAC2 project (Health Emergency Plan in case of Disaster in the Macaronesia 2, Activity 6, specific objective 2), within the Transnational Cooperation Programme Madeira-Azores-Canaries (MAC) 2007-2013. Acknowledgments: This work is based in part on Dealing in security (understanding vital services and how they keep you safe), Vinay Gupta, published under Creative Commons “Attribution-Noncommercial-Share Alike” license 2.0 England & Wales. Archived in http://archive.org/details/TheGuptaStateFailureManagementArchive. It is also based in part on the OODA loop by Colonel John Boyd (USAF). The author would like to thank Elizabeth Sweet for her invaluable assistance as copy editor for the English translation. Abbreviations: • WHO: World Health Organization http://www.who.int • ECDC: European Center for Disease Control http://www.ecdc.eu • CDC: Centers for Disease Control and Prevention of the United States http://www.cdc.gov • SCIM: Simple Critical Infrastructure Maps http://ResilienceMaps.org • OODA: Observation, Orientation, Decision and Action loop Índice I. INTRODUCTION............................................................................................................. 1 II. PANDEMIC CHALLENGE...........................................................................................2 1. The biology of influenza...............................................................................................2 1.a) Influenza viruses..................................................................................................................2 1.b) Mutation and hybridization..................................................................................................3 1.c) Animal species.....................................................................................................................3 1.d) Transmissibility....................................................................................................................4 2. History of pandemics....................................................................................................4 2.a) Development of a pandemic................................................................................................4 2.b) Attack rate, lethality, mortality and hospitalization rates.....................................................5 2.c) Pandemics in past centuries.................................................................................................5 2.d) The 1918-19 pandemic........................................................................................................6 3. Animal-human influenza – H5N1................................................................................6 3.a) Pandemic candidates............................................................................................................6 3.b) H5N1’s lethality...................................................................................................................7 3.c) Secondary cases...................................................................................................................7 3.d) Possible futures....................................................................................................................8 4. Impact of a severe pandemic.......................................................................................10 4.a) Severity factors..................................................................................................................10 4.b) An illustrative scenario......................................................................................................10 4.c) Direct and indirect effects in a severe pandemic................................................................11 4.d) Complex global crises........................................................................................................13 III. CURRENT PREPAREDNESS SITUATION.............................................................14 1. Design of preparedness and response phases.............................................................14 1.a) Pandemic phases according to WHO................................................................................14 1.b) Pandemic intervals according to the CDC.........................................................................15 2. Preparations for detection, control, mitigation and recovery.....................................15 2.a) Detection............................................................................................................................16 2.b) Control...............................................................................................................................17 2.c) Mitigation...........................................................................................................................18 2.d) Recovery............................................................................................................................20 3. Looking ahead............................................................................................................. 20 3.a) The issue of motivation......................................................................................................20 3.b) Ongoing activities..............................................................................................................21 IV. SIMPLE MODELS FOR COMPLEX CRISES.........................................................22 1. Simple critical infrastructure maps (SCIM)...............................................................23 1.a) Vital needs of individuals...................................................................................................24 1.b) Levels of provision............................................................................................................25 1.c) Provision alternatives.........................................................................................................26 1.d) Needs of groups.................................................................................................................28 1.e) The role of groups in a crisis..............................................................................................28 1.f) Needs of organizations.......................................................................................................29 1.g) Needs of states...................................................................................................................30 2. OODA loop..................................................................................................................30 2.a) Observation........................................................................................................................31 2.b) Orientation.........................................................................................................................31 2.c) Decision.............................................................................................................................32 2.d) Action.................................................................................................................................32 3. Using SCIM and OODA.............................................................................................32 3.a) Inter-pandemic and pandemic phases: preparedness and response....................................32 3.b) Government levels: vulnerabilities....................................................................................33 3.c) Among organizations: interdependencies..........................................................................34 V. RESPONSE TO A SEVERE PANDEMIC...................................................................35 1. Scenarios and information.........................................................................................35 1.a) Numerical

[p. 4 to 6](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=4) 1.e) The role of groups in a crisis..............................................................................................28 1.f) Needs of organizations.......................................................................................................29 1.g) Needs of states...................................................................................................................30 2. OODA loop..................................................................................................................30 2.a) Observation........................................................................................................................31 2.b) Orientation.........................................................................................................................31 2.c) Decision.............................................................................................................................32 2.d) Action.................................................................................................................................32 3. Using SCIM and OODA.............................................................................................32 3.a) Inter-pandemic and pandemic phases: preparedness and response....................................32 3.b) Government levels: vulnerabilities....................................................................................33 3.c) Among organizations: interdependencies..........................................................................34 V. RESPONSE TO A SEVERE PANDEMIC...................................................................35 1. Scenarios and information.........................................................................................35 1.a) Numerical scenarios: simulated waves..............................................................................35 1.b) Qualitative Scenarios: Integrated Needs Map...................................................................36 1.c) Epidemiological and virological information....................................................................36 2. Infections reduction....................................................................................................37 2.a) Imperfect layers and the time factor..................................................................................38 2.b) Isolation and quarantine.....................................................................................................39 2.c) Reduction of respiratory contacts......................................................................................40 2.d) Barriers, hygiene and other containment measures...........................................................42 2.e) Vaccines.............................................................................................................................44 3. Caring for the ill.......................................................................................................... 45 3.a) General organization of health-care...................................................................................46 3.b) Citizen information and patient triage and transport.........................................................47 3.c) Primary care and home care...............................................................................................47 3.d) Hospitals network..............................................................................................................48 4. Continuity of vital services and supplies.....................................................................49 4.a) Individuals: Excessive heat and cold.................................................................................50 4.b) Individuals: Food...............................................................................................................51 4.c) Individuals: Water..............................................................................................................54 4.d) Individuals: Health and disease.........................................................................................54 4.e) Individuals: Safety and public order..................................................................................55 4.f) Groups: Workspaces...........................................................................................................55 4.g) Groups: Communications..................................................................................................56 4.h) Groups: Transport..............................................................................................................56 4.i) Groups: Resource control...................................................................................................57 4.j) Organizations: Shared map and plan..................................................................................57 4.k) Organizations: Shared succession model...........................................................................58 4.l) States: Population lists, borders and regulations................................................................58 VI. EXECUTIVE SUMMARY..........................................................................................59 VII. ANNEXES...................................................................................................................61 1. Training for agile response.........................................................................................61 2. Numerical simulations................................................................................................62 3. Templates..................................................................................................................... 63 4. Other causes of global systemic disruption................................................................63 5. Macaronesian Islands.................................................................................................64 I.INTRODUCTION I. INTRODUCTION History shows that, over the last few centuries, at irregular intervals of one to several decades, there have been a dozen influenza pandemics, some of which have caused an elevated number of influenza- related deaths and resulted in socio-economic disruption as they swept through populations. The most catastrophic pandemic within this period has been that of 1918-19, which killed tens of millions of people globally, many of them young and previously healthy. In recent years, various viruses among the many that cause influenza in animals have occasionally produced disease in humans, but only in the case of 2009 H1N1 has the sustained interhuman transmission that would lead to a new pandemic been observed. Other strains have sometimes infected humans, but have yet to be transmitted easily from one person to another. Among these, the H5N1 virus has caused illness in more than 600 people, of whom nearly 60% have died. The presence of these viruses in wild ecosystems makes it unlikely that they will disappear, and our current knowledge of the mechanisms of pandemic emergence does not enable us to predict when the next influenza pandemic will emerge or what virus will cause it. Therefore the possibility of a highly lethal pandemic cannot be ruled out. For the development of pandemic scenarios, a pandemic in which 1% of patients die is considered to be severe. A 1% fatality rate would mean that, if 30% of the population were to fall ill, as has happened historically during influenza pandemics, then 300,000 people per million inhabitants would fall ill and, of these, 3,000 would die from complications of influenza. (History shows worse possibilities.) But a severe and disruptive influenza pandemic may well

[p. 6 to 7](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=6) is considered to be severe. A 1% fatality rate would mean that, if 30% of the population were to fall ill, as has happened historically during influenza pandemics, then 300,000 people per million inhabitants would fall ill and, of these, 3,000 would die from complications of influenza. (History shows worse possibilities.) But a severe and disruptive influenza pandemic may well also claim the lives of people who never catch the virus. When pandemic influenza infection rates soar, many among the workforce may be sidelined by illness or caretaking responsibilities. The systemic disruptions that may result, cascading through supply chains and services, are discussed in detail in section II.4 on “Impact of a severe pandemic”. Thus, to deaths from pandemic influenza we would have to add deaths incurred as a result of the disruption of vital services and supplies (including medical ones). Faced with the threat of a deadly and disruptive pandemic, global preparations intensified after 2005. There were improvements in coordination between countries and regions as well as in epidemiological and virological surveillance, and the production of vaccines was streamlined. The evidence about the benefits of the tools available to reduce infections was reviewed, and health-care contingency plans and recommendations to essential businesses were drawn. These activities have lost a measure of momentum after the 2009-10 pandemic, partly due to the worsening global economic situation. On the other hand, virological research and slow technological progress in vaccines persist, and international organizations continue to explore the involvement of sectors beyond those specifically dealing with health care. This document summarizes the knowledge and strategies already in place, and proposes a framework for agile and flexible response by civil protection and essential services facing a severe pandemic — a framework that could be useful in other crises, from non-pandemic origins but equally broad in terms of geography and systemic impact. It is accompanied by spreadsheets to facilitate the development of scenarios and plans, and by a presentation for the training of at least an initial number of civil protection and essential services staff. The material is published under an open license, to allow and encourage its distribution, use, and improvement. 1 II.PANDEMIC CHALLENGE II. PANDEMIC CHALLENGE • Influenza pandemics have historically emerged at intervals of one to several decades. • We know many details regarding influenza viruses and the mechanisms by which human pandemics emerge from viruses adapted to animals, but we are unable to predict which virus will cause the next pandemic, or when. • Some pandemics have produced high mortality rates, particularly the pandemic of 1918-19, which caused a high number of deaths among previously healthy young adults. • That is why we keep monitoring influenza viruses (such as the H5N1 strain) which, while well-adapted to animals, have also occasionally caused disease in people. 1. The biology of influenza To understand the pandemic potential of influenza and the apparent inevitability of pandemics, we must first look at key features of the influenza virus, the animal species in which the different strains

[p. 7 to 8](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=7) why we keep monitoring influenza viruses (such as the H5N1 strain) which, while well-adapted to animals, have also occasionally caused disease in people. 1. The biology of influenza To understand the pandemic potential of influenza and the apparent inevitability of pandemics, we must first look at key features of the influenza virus, the animal species in which the different strains of the virus are found, the mechanisms by which new varieties appear, and how influenza spreads. 1.a) Influenza viruses Flu viruses are unable to replicate autonomously. Their surface contains molecules of hemagglutinin (H) which enable them to adhere to the surface of the cell, which they are then able to penetrate. Once the virus invades, the cell replication system creates new copies of the virus, which leave the cell using other surface molecules (neuraminidase, N). There are three types of influenza viruses (A, B and C). Type B has no subtypes. Winter influenza is presently caused by three variants: A(H1N1), A(H3N2) and B. Only type A has proved capable of causing pandemics, which is why the rest of this document refers only to type A. The type A virus is categorised into subtypes, named according to their hemagglutinin and neuraminidase variants: H1N1, H3N2, H5N1, and many others. Fig 1. Naming of influenza viruses. Source: Wikipedia. 2 II.PANDEMIC CHALLENGE 1.b) Mutation and hybridization Viral replication within a cell has no effective mechanism of “quality control”, so it is relatively frequent that some copies are different from the original. Many of those imperfect copies are not viable. Most of the viable ones result in viruses functionally identical to their parent. In some cases, however, mutations involve the acquisition of new capabilities of some importance, such as being resistant to the previous year's vaccination or to antiviral treatment. In rare but important cases, the mutation generates a virus substantially different from their parents, maybe able to invade a species different from that to which it was originally adapted. Thus, it was an avian virus that led to the pandemic of 1918-19, which resulted in the order of 50 million deaths within a world population of 1,800 million people. The second known mechanism by which new influenza viruses have emerged is hybridization, which occurs when an animal – a pig, for instance – has a dual infection (e.g., by one virus adapted to humans and by another virus adapted to birds). In this case, the genetic material of both viruses may be present in the same cell at the time of replication, allowing the emergence of a genetically mixed virus. The pandemics of 1957-58, 1968-69 and 2009-10 – each of which caused a much lower mortality than that of 1918-19, and more similar to seasonal flu – were caused by hybrid viruses. A case in point, the H1N1 virus that resulted in the 2009-10 pandemic contained genetic material from influenza viruses adapted to humans, pigs and poultry. Fig 2. Reproductive cycle of influenza viruses. Source: Wikipedia. 1.c) Animal species The two mechanisms mentioned (mutation

[p. 8 to 9](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=8) lower mortality than that of 1918-19, and more similar to seasonal flu – were caused by hybrid viruses. A case in point, the H1N1 virus that resulted in the 2009-10 pandemic contained genetic material from influenza viruses adapted to humans, pigs and poultry. Fig 2. Reproductive cycle of influenza viruses. Source: Wikipedia. 1.c) Animal species The two mechanisms mentioned (mutation and hybridization) explain the large variability of influenza viruses, of which only a small number of known subtypes are capable of infecting mammals, such as pigs, cats, horses, dogs and even bats. Most subtypes are found in birds (especially waterfowl, in which the flu spreads through the digestive tract and produces mild or asymptomatic infections). In poultry there are viruses characterized by low pathogenicity (which cause mild infections) and highly pathogenic viruses (which kill a high percentage of the infected birds, up to 80% or higher). It has been observed that viruses of low pathogenicity can mutate, acquiring high pathogenicity. Among avian viruses, H5N1 – as we will see in more detail later – 3 II.PANDEMIC CHALLENGE is a highly pathogenic virus in poultry that continues to produce large losses in affected countries, where it has killed or forced the culling of more than 500 million birds in the last decade. 1.d) Transmissibility Although influenza in waterfowl is transmitted through the digestive tract, in poultry it is transmitted by inhalation or by direct contact. Human seasonal and pandemic influenzas are likewise transmitted by inhalation and through contact with contaminated surfaces. Transmission is more common during the early stages of infection, even before symptoms first appear (incubation period), and to a lesser extent from people who have asymptomatic infections. Regarding animal-to-human influenza (such as H5N1), until now primary transmission (from bird to human) has occurred in situations of direct intense exposure. Secondary transmission (from one infected person to another) has been very limited. Apparently, one reason might be that, when inhaled, the viruses which are adapted to birds attach themselves to cell membrane receptors abundant only in the deeper portions of the human respiratory system. Since a person must inhale the virus deeply in order for it to reach those receptors, person-to-person transmission of avian viruses is difficult. Human winter influenza viruses, however, are adapted to attach to receptors abundant in the upper, more accessible, portions of the respiratory system, facilitating more effective person-to-person transmission. It is speculated that, in order for a new influenza virus to cause a pandemic, it must first acquire the ability to bind to respiratory cells in the upper portions of the human respiratory tract. 2. History of pandemics To understand the history of influenza pandemics, we will first review how they emerge and unfold. Then we will examine pandemics of recent centuries, concluding with special attention to the 1918-19 pandemic. 2.a) Development of a pandemic A subtype of an influenza virus, one that’s new to humans, emerges as a result of mutation or hybridisation. Given the appropriate attributes and conditions, that virus can start spreading

[p. 9 to 10](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=9) we will first review how they emerge and unfold. Then we will examine pandemics of recent centuries, concluding with special attention to the 1918-19 pandemic. 2.a) Development of a pandemic A subtype of an influenza virus, one that’s new to humans, emerges as a result of mutation or hybridisation. Given the appropriate attributes and conditions, that virus can start spreading from person to person in a more or less explosive way, causing epidemic waves worldwide. These waves repeat themselves for one or two years until finally most of the human population has been exposed to the virus, which then can no longer qualify as “new”. Unlike winter influenza, which generates a single annual wave at some point in the “flu season” 1, pandemic influenza may cause more than one wave per year, at any time of the year, with waves one to several months apart from each other. In each wave, the majority of cases would occur in the weeks of the epidemic peak 2. Scenarios 1 In the northern hemisphere, influenza season goes from week 40 (first week of October) until week 20 next year (mid May). 2 In the Annexes (see section VII.2), a spreadsheet is provided in which initial parameters can be typed (population, proportion of the population that would fall ill, proportion of those ill who would die) in order to compute the likely 4 II.PANDEMIC CHALLENGE proposed by the experts from the UK suggest that, out of every million people, 40,000 to 80,000 may fall ill each week during the peak of a pandemic wave3. The number of cases to be expected during a pandemic wave may be much higher than would be caused by seasonal influenza; thus case volume would affect primary care services. If, in addition, a significant proportion of the cases proved to be severe, hospital services would be affected, and all this at a time when a percentage of health care workers (or their families) would also be affected by illness. It should be noted that – for both seasonal and pandemic influenza – each general wave (in a country, for example) is actually the sum of local waves (regions, for example), which are not synchronous but rather begin and end at different times. So every local wave is shorter and more intense than the general one, which is, in actuality, a “summary” wave. 2.b) Attack rate, lethality, mortality and hospitalization rates In a pandemic, the attack rate, or the proportion of the population that has symptomatic influenza, can be several times higher than is the case with seasonal influenza. But, as with seasonal influenza, the attack rate for pandemic influenza is generally higher among people less than 20 years of age and lower among those who are over 65. In “mild” pandemics (similar in severity to winter influenza), lethality, or the proportion of patients who die, has been greater in those over 65, in people with chronic diseases, and in pregnant women. (Age, chronic disease, and pregnancy are all “risk

[p. 10 to 11](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=10) is generally higher among people less than 20 years of age and lower among those who are over 65. In “mild” pandemics (similar in severity to winter influenza), lethality, or the proportion of patients who die, has been greater in those over 65, in people with chronic diseases, and in pregnant women. (Age, chronic disease, and pregnancy are all “risk factors”.) Notably, compared with seasonal flu, the 2009-10 pandemic caused more severe disease in young people, in those with known risk factors, and in those with marked obesity (with a body mass index greater than 40). Mortality is the result of multiplying attack rate and lethality. So if 30% of the population falls ill and 1% of patients die, mortality would be 3,000 per million. For the hospital system the proportion of patients who become candidates for admission would be very important. We would generally expect numbers of hospital admissions to be several times higher than numbers of deaths. 2.c) Pandemics in past centuries Historians4 have agreed to classify as pandemics worldwide epidemics that unfolded as successive waves with symptoms compatible with influenza. History indicates that pandemics swept across the globe in 1580, 1694, 1729, 1781, 1830 and 1898. Twentieth century pandemics occurred in 1918-19, 1957-58 and 1968-69, and the first pandemic of the twenty-first century unfolded in 2009-10. Thus, we can say pandemics have occurred at a rate of at least one to three per century (two to three in recent centuries), at intervals of one or more decades. Pandemics have been very different from each other. Recent history shows that the pandemics of 1957-58, 1968-69 and 2009-10 could be classified as “mild”, while those of 1918-19 and 1830 were far more severe. number of ill and the likely number of deaths, and their distribution along weeks for a given scenario. 3 https://www.wp.dh.gov.uk/publications/files/2012/11/SPI-M-Modelling-Summary-15_06_12.pdf 4 Potter, CW (October 2006). “A History of Influenza”. J Appl Microbiol. 91 (4): 572–579. doi:10.1046/j.1365- 2672.2001.01492.x. PMID 11576290. 5 II.PANDEMIC CHALLENGE 2.d) The 1918-19 pandemic Of all the pandemics known to history, the 1918-19 pandemic resulted in the highest mortality 5. In a time when the world population numbered about 1,800 million people, an estimated 50 million lives were lost to pandemic influenza. (Given the current world population of more than 7,000 million people, a similar level of mortality today would translate to 195 million deaths.) The lethality of the 1918-19 pandemic is often estimated to be 2%. However, if the attack rate, more difficult to estimate than the mortality, was around 30% as in more recent pandemics, then the actual lethality would have been just over 9 deaths per 100 patients, or >9%. In any case, both figures are higher than 1%, the lower limit that would define a severe pandemic. Mortality caused by the 1918-19 pandemic showed some other special features. First, the number of deaths was much higher in the second wave than in the first. This has made experts think that the virus might have mutated after the first wave to

[p. 11 to 12](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=11) any case, both figures are higher than 1%, the lower limit that would define a severe pandemic. Mortality caused by the 1918-19 pandemic showed some other special features. First, the number of deaths was much higher in the second wave than in the first. This has made experts think that the virus might have mutated after the first wave to become more deadly and/or more contagious. Second, the lethality rate was disproportionately high in previously healthy 20-40 year-old adults. In some very isolated places such as Alaska, mortality was very high in almost all ages except in children. Because of these two facts, three hypotheses have been suggested: that a pandemic some 50 years earlier had been caused by a similar virus which protected the elderly in 1918-19, that children were protected by a distinct immunological reactivity, and/or that young adults exhibited an extreme immune response that was harmful in itself (a “cytokine storm”)6. Fig 3. Age-specific lethality in the 1918-19 pandemic. Source: Taubenberger, J; Morens D (2006). “1918 Influenza: the mother of all pandemics”. Emerg Infect Dis 12 (1): 15-22. 3. Animal-human influenza – H5N1 3.a) Pandemic candidates Viruses with the greatest potential to cause pandemics are believed to be those which infect domesticated animals, such as pigs and poultry, that are frequently in close contact with humans. Of 5 1918 Influenza: the Mother of All Pandemics. Jeffery Taubenberger, David Morens . http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article.htm 6 Protective immunity and susceptibility to infectious diseases: lessons from the 1918 influenza pandemia. Rafi Ahmed, Michael BA Oldstone, Peter Palese. http://www.nature.com/ni/journal/v8/n11/pdf/ni1530.pdf and http://www.nature.com/ni/journal/v8/n11/fig_tab/ni1530_F3.html 6 II.PANDEMIC CHALLENGE these, of particular concern are those viruses that have produced disease in people, especially when it seems likely that a virus has been transmitted from one person to another. Several influenza viruses meet these criteria to a greater or lesser extent: H9N2, some variants of H7 (N2, N3 and N7), H10N7 and H5N17. For example, a H7N7 outbreak occurred in 2003 in the Netherlands, with 89 human cases, one death, and a number of asymptomatic infections. In 1997 in Hong Kong, an H5N1 epidemic in poultry resulted in 18 human cases of the disease, including 6 deaths. Between 1997 and 2003, no human cases of H5N1 were detected. But in late 2003, the virus returned to produce epidemics in poultry8 associated with occasional human cases, and since then it has become a persistent problem. 3.b) H5N1’s lethality H5N1 has so far caused at least 603 human cases with at least 356 deaths 9, many of them in children and young people, previously healthy10. Cases have been detected in a dozen countries, with significant differences in mortality. In Indonesia, for example, 80% of cases have died, whereas in Egypt 40% have died. These differences may be due to different detection systems, or to characteristics of the virus itself, which has mutated in the last decade to give rise to more than 20 “clades” (virologically distinct variants). Beyond the number of confirmed cases, the possible existence of cases with mild or

[p. 12 to 13](https://resiliencemaps.org/files/fluscim/FluSCIM-69p-English.pdf#page=12) example, 80% of cases have died, whereas in Egypt 40% have died. These differences may be due to different detection systems, or to characteristics of the virus itself, which has mutated in the last decade to give rise to more than 20 “clades” (virologically distinct variants). Beyond the number of confirmed cases, the possible existence of cases with mild or no symptoms has been explored. It is difficult to interpret the results of these studies for methodological reasons, but the current consensus among scientists is that H5N1 produces few mild cases 11, although there are scientists who think otherwise12. Again, the genetic variability of the virus is invoked to explain why different studies – considered poor by all authors – see different frequencies for markers of previous infection. 3.c) Secondary cases H5N1 has caused a number of cases where person-to-person transmission is considered very likely. In some situations it is difficult to distinguish between parallel transmission (from one bird to two humans) and a true secondary transmission (from bird to a person and then from that person to another). The longest chain of transmission documented to date took place in Peshawar (Pakistan) in December 2007: a first human case – infected from sick birds – infected another person, the second infected a third, and the third infected a fourth13 (see also III.2.a, “detecting the start of a pandemic”). 7 Avian influenza (Bird Flu): implications for human disease. CIDRAP. http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/biofacts/avflu_human.html 8 H5N1 epidemics in birds have happened in several continents. We would not term these widespread avian epidemics a “pandemic” (as we would with humans) but rather a “panzootic”. 9 http://www.who.int/influenza/human_animal_interface/H5N1_cumulative_table_archives/en/index.html May, 2 2012. 10 Avian Influenza A (H5N1) Age Distribution in Humans. Emerg Infect Dis. 2007 March; 13(3): 510–512. 11 http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/mar1312seroprev.html 12 Seroevidence for H5N1 Influenza Infections in Humans: Meta-analysis. Taia T Wang, Michael K Parides, Peter Palese. http://www.sciencemag.org/content/early/2012/02/22/science.1218888.abstract 13 http://www.who.int/csr/don/2008_04_03/fr/ 7 II.PANDEMIC CHALLENGE Fig 4. Human transmission of H5N1 in Peshawar (Pakistan), December 2007. 3.d) Possible futures We cannot know what the next influenza pandemic will be like in terms of contagiousness and severity, or when it will start. It may happen 30 years from now, or later or sooner than that; and it may be comparable in its lethality to the relatively mild pandemics of 1957-58, 1968-69 and 2009-10 – or to the deadly pandemic of 1918-19, or even worse. Depending on how long we have before the next pandemic emerges and on how fast scientific and technological advances can be made in the interim, it is possible that vaccines or treatments may have improved to the point where they can be produced abundantly and quickly, substantially reducing 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

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