pandemic influenza

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A pandemic is an epidemic that expands out of human capacity to control, and effectively touches or potentially touches every person in a population. Given globalization of all human activities, it is thought infeasible to contain a pandemic even to one continent in this century. In the last century, there were such breakouts in 1918, 1957 and 1968.

As of 2006-03, the considered H5N1 bird flu to be the number one health threat in the world]. See ((H5N1.

individual case symptoms

A UK study of a new influenza strain of the same virulence as the 1918 Spanish Flu and likely scenarios arising, emphasized shutdowns of all urban services early in the spread. Fear is amplified by the unpredictable effects of the flu:

Most people are sick 3 days then recover, a minority have severe bleeding from all facial orifices and other frightening symptoms that spread panic.

Dr. Michael Osterholm, who studies this problem, differentiates the effects of ordinary flu as "muscle aches, fever, cough and feeling terrible all over - not diarrhea, not a runny nose" but notes that "the bird flu virus causes a different kind of disease where it affects your lungs...cause immune system response" against which Tamiflu is not effective "unless you have drug on board and are taking it at the time you are infected, you need it within hours".

He advocates reserving Tamiflu to healthcare workers so that they will continue to come to work. He emphasized, in a January 24, 2006 appearance on the Oprah show, the extreme vulnerability of North America to a pandemic.


Oprah remarked that "there's so much white noise about it...the media treats this with the same seriousness as they treat Brad and Angelina." This ignorance seems likely to amplify panic.

"Unlike HIV/AIDS and unlike malaria, the pandemic influenza will so change the world..." claimed Osterholm, that "we need to hold our leaders accountable... translate that into action." Osterholm considers the worst problems to be:

drug supplies

1. Pharmaceutical drug supplies, due to very thin supply chains, where one factory in one country supplies world needs but could easily be shut down or its supplies diverted. This would apply not just to flu drugs but to all drugs, including those to deal with cancer, HIV or diabetes. Flu vaccine is only the worst of the problems:

In a TV interview on the Oprah Winfrey show, he said "we have the technology to a make a vaccine, ahead of time, and make it available to the world - we just haven't committed to it".

However other drugs are typically impossible for ordinary people to stockpile more than a 30-day supply, which is not enough to last a pandemic.

food and chemical supplies

2. no just in time delivery of other goods

According to Osterholm, water supply problems will become serious as "many cities have no more than 5-7 days of chlorine on hand" and chlorine supply could be limited or deliveries disrupted.

The food supplies in major cities last only a few days - Osterholm recommends four to five weeks' food supply on hand and notes that relief won't be coming from outside because there won't be any outside with everyone suffering similiar effects. In addition disruptions in agricultural fuel and chemical supplies will quickly reduce food supply.

"the private sector has to understand the economic implications are huge - it's not just about life and death but the economic implications are critical.." and precautions are required "to allow business continuity", says Osterhom, "many of these businesses will be threatened when an eighteen-month pandemic hits the earth". Similar challenges were outlined by Sherry Cooper in two reports for the Bank of Montreal in 2005.

bodies everywhere

3. dealing with casualties

Osterholm cites the fact that it took six months before all the dead were buried in a 1960s flu pandemic of much smaller scale. Failing to deal with the dead has serious psychological and also water supply and infrastructure consequences, as in New Orleans.

Paradoxically the people who would ordinarily be most able to help deal with the problems and the solutions might be among the dead. A full 7% of the population between ages of 20 and 40 died in Boston in 1918, according to John Barry's book on the topic - the most dangerous flu virus turns on the immune system and those with the healthiest immune system have the highest risk. 55% of pregnant women died in 1918 and that is likely to occur again.

Osterholm notes that there is no surge capacity in intensive care medicine, and that no one will receive it during pandemic, let alone elective surgery. On a given day during a mild flu season emergency rooms in Chicago shut down. This same effect will keep them shut.

Osterholm is also sure that difficult triage problems will emerge, such as making the use of ventilators for elderly patients difficult to sustain when there are others more likely to be saved by their use. There are only 140,000 of these devices in the entire USA, far less than would be required to save millions of patients.

who has to respond

All serious analysis of the problem assumes that
"communities will be on their own." US Senator Dr. Bill Frist posited a scenario of "50 million victims worldwide... more victims in 24 weeks than HIV in 24 years. In the US bodies pile up in the streets, there aren't enough morticians...doctors or nurses to tend to the sick." There would simply be no capacity to respond. Unlike a natural disaster of limited scope like Hurricane Katrina hitting New Orleans, where 47 states could respond, in a pandemic everyone is hit at once and there is disruption in all supply chain relationships and logistical problems due to dropouts of regular services.

The municipal role in emergency response will be the only role, since all larger levels of government will be required to devote all their resources to specific and exceptional problems that cannot be anticipated easily in advance.

According to Kofi Annan "...economic and social progress will be reversed." There may be no more resources than a community emergency response team with minimal or no training, especially if many first responders are out of action after the first weeks of the pandemic

most likely scenario

The following most likely scenario came from a UK study:

The first three months would be characterized by many service failures - 20% of staff out of action in the information technology sector alone might lead to failures that no one is able to correct. And extreme stress on hospital, medical, police and military staff. While voluntary isolation groups might keep a large number of phone and computer based services, and some food and manufacturing, going, it is not likely that this could continue for more than three months without breakdowns in these groups, as they must be isolated also from their family.

Global stores of food and fuel and industrial inputs would begin to run out near the end of this period, though earlier in many urban areas. Minor looting would begin if social services had broken down, as people sought supplies they need.

The second three months would be characterized by increasing civil disorder as the flow of trade and goods and services stopped. Capacity of the healthcare system to respond would be utterly exceeded. By pandemic day 95, "hospitals so choked the dead can't be removed to make room for the dying" would be refusing patients and out of medicines.

African cities packed with dead and dying and without antibiotics would suffer a worse death toll, creating civil breakdowns in weak regimes.

By pandemic day 110, the medical community would be several months away from a vaccine that works; vaccines are typically only available 5-6 months after a pandemic begins.

http://www.cdc.gov/ncidod/eid/vol5no5/meltzer.htm A major study that estimated the possible effects of the next influenza pandemic in the United States - also analyzed the economic impact of vaccine-based interventions - tells a grim story:

"Using death rates, hospitalization data, and outpatient visits, we estimated 89,000 to 207,000 deaths; 314,000 to 734,000 hospitalizations; 18 to 42 million outpatient visits; and 20 to 47 million additional illnesses. Patients at high risk (15% of the population) would account for approximately 84% of all deaths. The estimated economic impact would be US$71.3 to $166.5 billion, excluding disruptions to commerce and society."

This disruption would however be very extreme in all credible scenarios. By pandemic day 117, according to a CBC documentary, Black Dawn, the stresses would yield a

"Boiling cauldron of very very distressed people... a formula for potential social dissaster".

Civil disorder would become widespread, with military actions against looting spread across many cities at once simultaneously stressing the military capacity. Since military face to face contact with the public with military weapons is uncomfortable, troops can only back the police in most cases. Police stress and resignations, as in New Orleans, would be extreme and likely to lead to breakdowns. European countries already have public security plans taking this into account.

By the end of the fourth month, around day 120, a shortage of coffins and body bags will lead to ice rinks being used to hold bodies. Canadians may miss hockey season, because of this and all the funerals, further depressing morale.

By pandemic day 140, the Canadian death rate would hit a record high, exceeding even 1918. Care givers would be totally overwhelmed;

Some experts think that before the end of the fifth or sixth month, a social implosion might be possible, similar to the effect of infectious diseases on North American natives and even worse than the bubonic plague, distributed unevenly in the world's population and even in the national populations, creating vastly different appetites and attitudes to change.

A revolution of some kind might follow as those who were less disadvantaged by the pandemic sought to keep economic and political relations in place using military force while those more disadvantaged sought compensation, relief, humanitarian aid, perhaps blaming those less disadvantaged or in power for their losses. A US [http://www.cbo.gov/showdoc.cfm?index=6946&sequence=0 Congressional Budget Office study of the macroeconomic effects suggests that the risks of this are significant as the world economy would be very much changed.