The first pandemic of the Information Age: The first pandemic of the Information Age Scott McPherson CIO, Florida House of Representatives Chairman, Florida CIO Council Pandemic Preparedness Committee how IT must prepare now for an influenza pandemic -- before we run out of time


What we’ll cover: What we’ll cover Brief history of influenza Previous influenza pandemics Understanding what you truly need to prepare for Leveraging preparedness ROI for bioterrorism, natural disaster preparedness An avian flu pandemic is by no means certain. Yet the threat of a pandemic is real, so we must prepare, the same way we must prepare for other natural calamities.


What is Influenza?: What is Influenza? Influenza is a virus. Seasonal flu outbreaks usually appear in winter months and is usually more severe for the very young, the elderly, or those with pre-existing health conditions. Yearly, 5-20% of population “gets the flu” (130 million people in China alone). Annually, seasonal flu causes >200,000 hospitalizations in US; 36,000 deaths yearly in US; Globally, 250,000 to 500,000 deaths each year $37.5 billion in economic costs from influenza and pneumonia Two types of influenza: Type A Infects humans, birds, pigs, cats and other animals Influenza A is capable of mutating to new strains More severe illness Type B: Infectious only to humans Causes epidemics, but generally a less severe illness


Influenza Type A : Influenza Type A Influenza A is subtyped by surface proteins Hemagglutinin (H) 16 different types Helps virus enter cells Neuraminidase (N) 9 different types Helps virus leave cell to infect others


What is a Pandemic?: What is a Pandemic? An influenza pandemic occurs when an epidemic of a novel strain of a virus occurs simultaneously world-wide. Other pandemics include encephalitis lethargica (“Awakenings”) from 1917-1928, and the current HIV/AIDS pandemic, because it is on every continent and there is little to no native immunity. Flu pandemics come in “waves,” or cycles. There can be two or three such waves.


What are the warning signs of a pandemic flu virus?: What are the warning signs of a pandemic flu virus? Met Met We’ll get back to ya


Influenza Pandemics of the past 300 years: Influenza Pandemics of the past 300 years 1732-33 (Connecticut) 1781-82 1800-02 1830-33* 1847-48 1857-58 1889-90 (presumed H2N2) 1918-19* (Kansas) 1957-58 1968-69 * = high death rate Winter January 1830 January 1957 Spring March 1847, May 1889, March 1918 (first wave, mild) Summer August 1857, August 1918 (second, most severe wave) July 1968 Autumn October/November 1732 Autumn 1781 September/October 1800 Seasons when Pandemics started Source: “Influenza: The Last Great Plague,” W.I.B. Beveridge, Prodist, NY, 1977


Slide8: 20th Century Pandemics H1 H1 H3 H2 H7* H5* H9* 1918 Spanish Influenza H1N1 1957 Asian Influenza H2N2 1968 Hong Kong Influenza H3N2 1980 1997 1915 *Avian Flu 2003 2004 1977 1996 2002 1925 1935 1945 1955 1965 1975 1985 1995 2007 2003-2007 1998 1999 2003 Current bad actors and potential pandemic strains 2007


Historic 20th Century Pandemics: Historic 20th Century Pandemics 1918-1919 Spanish Flu Type A virus (H1N1) >50 million deaths worldwide Nearly 700,000 deaths in the United States Nearly half were young, healthy adults Believed to have started in rural Kansas in Spring, 1918 The second wave was the lethal wave, with almost all of the worldwide deaths occurring in just 20 weeks. 8


Historic Pandemics: Historic Pandemics 1957-1958 Asian Flu Type A virus (H2N2) First identified in China February 1957 Spread to U.S. by June 1957 70,000 deaths in the United States 9


Historic Pandemics: Historic Pandemics 1968-1969 Hong Kong Flu Type A virus (H3N2) First detected in Hong Kong early 1968 Spread to U.S. later that year Approx 34,000 deaths in the United States, fewer than seasonal flu deaths Our seasonal flu kills 36,000 Why? Speculation N2 did not “drift” far from 1957 strain Virus is still circulating today and antibodies are part of 2005 and 2006 seasonal “trivalent” vaccine 10


The pandemic that wasn’t : Swine Flu, 1976: The pandemic that wasn’t : Swine Flu, 1976 In 1976, an Army recruit died of swine flu, and some scientists predicted a pandemic. President Gerald Ford ordered enough vaccine to protect the entire country, saying: “No one knows exactly how serious this threat (Swine Flu) could be. Nevertheless, we cannot afford to take a chance with the health of our nation.” Swine flu never reappeared, but 40 million Americans got shots and a few developed a rare paralytic disease called Guillain Barre syndrome. The vaccination program was ended. But then regular flu broke out (A/Victoria H3N2, in a nursing home in Miami) and the only vaccine available was mixed with swine flu. The vaccine was distributed and heads rolled.


Concern with A/H5N1 Avian Influenza: Concern with A/H5N1 Avian Influenza Virus mutates rapidly Has shown ability to acquire genes from viruses infecting other species H5N1 has acquired some of genetic changes in the 1918 virus associated with human-human transmission Causes severe disease in humans High fatality rate


Why H5N1 is of Particular Concern: Why H5N1 is of Particular Concern Traditional belief of antigenic shift leading to pandemics of human influenza H5NI influenza is able to infect humans directly ? 6 Reassortment Adaptive Mutation or Recombination


WORLDVIEW: WORLDVIEW January to September, 2007


Great Britain: Great Britain


Germany: Germany Kelbra Lake, Central Germany – repeated in Nuremberg (above right) and Munich (left) in the summer.


Germany – Sept 2007: Germany – Sept 2007 A volunteer of German technical aid organization THW (upper right) fumigates the hygiene sluice at a farm near Erlangen, southern Germany, Sunday Aug. 26, 2007. Tests have determined that birds at the poultry farm died of the H5N1 strain of bird flu, and some 160,000 birds were being slaughtered as a precaution, authorities said Saturday Aug. 25, 2007. (AP Photo/Udo Dreier)


Nigeria: Nigeria


EgyptEgypt: Egypt Egypt


Palestinian Authority: Palestinian Authority


Kabul, Afghanistan: Kabul, Afghanistan


Russia: Russia


China: China Disinfecting in Hunan, China, in wake of outbreak and hospitalization of Chinese Army soldier.


Vietnam: Vietnam HO CHI MINH CITY, Vietnam: U.S. President George W. Bush toured a bird flu lab Monday and praised Vietnam for its successful battle against the disease, pledging U.S. support and urging Southeast Asia to prepare for a potential pandemic. Bush arrived at the Pasteur Institute — one of Vietnam's top research institutes for communicable diseases — in southern Ho Chi Minh City.


Vietnam: Vietnam National Institute of Infectious and Tropical Diseases, Hanoi (patient at left, hidden by equipment -- high school student, died July 2007)


Indonesia: Medan, Indonesia Indonesia


Indonesia: Jembrana, Indonesia Jakarta, Indonesia Indonesia


Bali, Indonesia: Bali, Indonesia


Island of Palua Tabuan, Sumatra, Indonesia : Island of Palua Tabuan, Sumatra, Indonesia


Singapore, Malaysia: Singapore, Malaysia


Japan: Japan Health officials scatter limestone at the poultry farm in Kiyotake, Miyazaki Prefecture, site of the first of four H5N1 outbreaks, in January.


Australia: Australia


Government response to avian flu threat in birds and humans: Government response to avian flu threat in birds and humans


How is Bird Flu Monitored?: How is Bird Flu Monitored? WHO maintains regional labs (London, Melbourne, Jakarta, Cairo, CDC Atlanta) that test both bird and human specimens The World Health Organization for Animal Health (OIE) tests bird samples State Departments of Health and Agriculture are on active surveillance The surveillance permits implementation of control measures if needed Vaccine trials are underway for the H5N1 strain, but are in early phases 22


Slide41: “Experts at WHO and elsewhere believe that the world is now closer to another influenza pandemic than at any time since 1968, when the last of the previous century's three pandemics occurred. WHO uses a series of six phases of pandemic alert as a system for informing the world of the seriousness of the threat and of the need to launch progressively more intense preparedness activities.” “The designation of phases, including decisions on when to move from one phase to another, is made by the Director-General of WHO.”


Are we at more risk or less risk today compared to 1918?: Are we at more risk or less risk today compared to 1918?


Why at LESS risk in 2007: Why at LESS risk in 2007 Antibiotics, vaccines for bacterial pneumonia complications of influenza Some antiviral medicines IV fluids, ventilators Greater ability to do surveillance, confirm diagnosis of flu Better global coordination, disease management, awareness, warnings (SARS outbreak contained in 2003)


Why at MORE risk in 2007: Why at MORE risk in 2007 A lot more international travel Contact with far more people daily Very little surge capacity in health care today More elderly and immune-compromised people (HIV/AIDS, Chemotherapy patients, etc.) in population “Just-in-time” ordering of needed supplies is standard practice today, instead of warehousing critical items on-site Unlike 1918, today’s society not used to rationing, sacrifice.


Non-Pharmaceutical Interventions: Non-Pharmaceutical Interventions


"WE'RE FIGHTING TODAY'S PANDEMIC WITH THE SAME TOOLS WE HAD 100 YEARS AGO.'' – FORMER SURGEON GENERAL C. EVERETT KOOP.: "WE'RE FIGHTING TODAY'S PANDEMIC WITH THE SAME TOOLS WE HAD 100 YEARS AGO.'' – FORMER SURGEON GENERAL C. EVERETT KOOP.


Top 10 reasons why we have not seen a flu pandemic since 1968:: Top 10 reasons why we have not seen a flu pandemic since 1968:


Top 10 Reasons why, despite all these efforts, we will still have a flu pandemic one day - and probably soon.: Top 10 Reasons why, despite all these efforts, we will still have a flu pandemic one day - and probably soon.


Possible scenarios for avian influenza pandemic (worst case scenario, official Federal plan): Possible scenarios for avian influenza pandemic (worst case scenario, official Federal plan)


Slide51: April 26, 2006 170-day scenario, 1 second = 3 days. Click on the center of the US map to activate the animation. Click outside the map to advance the slideshow.


Impact to the Critical Infrastructure: Impact to the Critical Infrastructure Utilities having trouble with staff shortages, inability to replace supplies and parts. Blackouts, brownouts occurring. Utilities forced to begin “rolling blackouts” to deal with staff shortages and shortages of fuel Fresh water systems cannot purify drinking water because of shortages of chlorine, other chemicals Absenteeism of 30% to 50% Fuel shortages/restrictions due to drop in oil imports Disruptions in Internet, communications due to sudden and widespread deployment of business and government “work at home” plans


Impact to Public Health and Health Care: Impact to Public Health and Health Care No surge capacity in health care exists in 2006 Absenteeism of 30% to 50% High numbers of cases and hospitalizations. Death rates could reach or even exceed 2.5% of sick Death rate for pregnant women is 20% Care shifted from hospitals to being taken care of by family/friends/people in neighborhood. Sick people who live alone, or with small children only, in dire straits Young children trying to take care of sick parents, with no support


Impact to Social Services: Impact to Social Services Absenteeism of 30% to 50% Children neglected because parent(s) too sick to provide care Orphaned children whose parent(s) have died (in 1918, NY received 21,000 “new” orphans in 20 weeks) Typical household has food on hand to last 3 days. Few families have emergency reserves for a prolonged period Low-income least able to set supplies aside for an emergency Prices will rise quickly in emergency.


Impact to Day Care Centers, Nurseries, Schools and Colleges: Impact to Day Care Centers, Nurseries, Schools and Colleges Absenteeism of 30% to 50% Closing of schools, nurseries, day care centers and colleges/universities (Social Distancing) Schools and colleges will have to decide if learning will continue “virtually” or cease Makeshift hospitals established in school gymnasiums Campus police deputized for local law enforcement duties Colleges having to feed and cope with students with no where else to go – no home but the dorm.


Impact to Public Safety: Impact to Public Safety Absenteeism of 30% to 50%; this causes law enforcement to respond only to life and death situations Inadequate amounts of antiviral meds, leading to violence at treatment sites Flu outbreak leading to violence in prisons, jails Courts shut down; no one willing to serve on a jury Some neighborhoods organized, collaborative; others disorganized with individuals hoarding Lawlessness as criminals try to exploit uniformed officer shortages; Potential for activation of National Guard, military to maintain order


Impact to the Economy: Impact to the Economy People working at home when possible; others taking paid or unpaid leave Absenteeism of 30% to 50% Massive disruptions in global supply chain, leading to shortages of all essential commodities Shortages of fuel, food, essential supplies; prices skyrocket. Closing of events and businesses due to effects of social distancing Drop in GDP of -5% to -6% (severe recession or worse)


What might occur: What might occur In the end, after several waves and 18-36 months, the pandemic is declared to be officially over Over 90,000,000 Americans became infected, 45,000,000 became seriously ill and nearly 2,000,000 deaths occurred Huge economic loses from closed businesses and disrupted global supply chain (CBO est. -5% to -6% GDP).


The Principal Tasks for Government During a Pandemic: The Principal Tasks for Government During a Pandemic


Challenges to Government: Challenges to Government How to maintain public health, public safety and public order with a 25% to 40% reduction across the board in staff. How to maintain “retail” government operations such as social services, welfare, unemployment compensation and other such “storefront” services with government employee absenteeism rates approaching/exceeding 40%. How to “Webify” additional critical government functions that are currently not available via “eGovernment” Websites. How to design, install and pay for a radically scaled-up remote connectivity solution in order to facilitate “socially distanced” (Work at Home) functions via IT and how to move paper during that time.


Challenges to Government: Challenges to Government


Preparedness before the event (that’s now, WHO levels 3 and 4.): Preparedness before the event (that’s now, WHO levels 3 and 4.)


Once the WHO threat level is raised….: Once the WHO threat level is raised….


The pandemic plan for IT : The pandemic plan for IT


What would Ike do?: What would Ike do?


Encourage creation of agency pandemic planning team: Encourage creation of agency pandemic planning team Legal Human Resources Training Development Information Technology Procurement/Purchasing Communications/Press Secretary Facilities/Maintenance/janitorial And at the top….. Your agency head, chief administrator, or chief surrogate.


Ensure “retail government” ops continue: Ensure “retail government” ops continue


Acquire protective equipment: Acquire protective equipment


Working with Procurement: Working with Procurement Do they know what to buy? Do they know the quantities? Do they know the context? Everyone and their brother will want the same items and be willing to pay more for them. Does your agency have the money to increase expenditures on staples?


Prepare to shut down services: Prepare to shut down services


Cross-train your staff: Cross-train your staff


Design and support Work at Home plans: Design and support Work at Home plans In response to a pandemic, business, corporate America and government are all attempting to enable “Work at Home Plans.” But just what is meant by working at home? How will paper get home to people? Who will deliver it? How will people input data? How will people complete their work? What infrastructure will be necessary in order to facilitate this? Who will pay for it? How will you secure the thousands of home PCs needed to fully implement such a plan? Be prepared to “lose the Internet” (Booz, Allen)


Let’s define “work”: Let’s define “work”


Deconstruct and reconstruct the business processes.: Deconstruct and reconstruct the business processes.


Potential failures in work at home plans: Potential failures in work at home plans


Potential failures in work at home plans: Potential failures in work at home plans


Are PDFs the answer?: Are PDFs the answer?


The home office: The home office


SSL VPNs and you: SSL VPNs and you


Conclusion, W@H plans: : Conclusion, W@H plans:


Prepare for supply chain failures: Prepare for supply chain failures In a pandemic of any severity, the supply chain will falter. In a 1918-type (or worse) pandemic, the supply chain will fail. If possible, keep essential supplies/ parts stockpiled in advance (4-6 week supply). Survey your suppliers. Resurrect the old Y2K adage: If they can’t articulate their plans for pandemic flu preparedness, be wary of their ability to survive. In fact, go find your Y2K plans, turn to the tab marked “Supply Chain Workarounds,” update it and put it into your DR/COOP Pandemic Annex.


Prepare Communications Plan: Prepare Communications Plan How will key managers communicate among themselves? How will information be conveyed to employees? How will employees know who to call in specific situations? How will information be conveyed to business partners? How will the public know which “safety net” offices are open and which are closed?


Communicate with employees and teach preparedness at work and at home: Communicate with employees and teach preparedness at work and at home Conduct an awareness campaign within your organization. Cover work and home issues Teach employees how to prepare themselves and their families now, instead of later – when it is too late Teach protective actions and personal hygiene Prepare them for moving from office to office – even from agency to agency.


Consider emergency notification services: Consider emergency notification services


Teach protective actions: Teach protective actions Hand washing without recontamination Covering cough, not using hands Avoid putting hands to face, mouth, nose, eyes. Staying home if any signs of illness Proper use of protective equipment Handling of diseased or dead birds – don’t! Cleaning hard surfaces, wearing gloves, using hand sanitizer and wearing masks


Communications with the public: Communications with the public Be honest Be forthcoming Don’t appear condescending or give false assurances – people want information they can act upon Give people a sense of empowerment over their situation – give them things they can do. Don’t overpromise or underdeliver Did I mention be honest?


Other IT Issues to consider: Other IT Issues to consider Data Center operations (lights out operation, automated patching) Remote Access (Citrix, RAS, Terminal Services) as alternatives to SSL VPN Don’t forget field staff!! Maintaining agency cybersecurity in the midst of all this Do you enable or eliminate Help Desk operations? PC support for employee personal computers? NO Ensuring security of access and data while dealing with employee personal computers POLICY ENFORCEMENT via SSL VPN Videoconferencing as alternative to face-to-face meetings – how will you support it if it malfunctions? Recovering from cascading emergencies (bird flu on top of hurricanes, terrorism, etc.)


Leverage this planning for similar scenarios: Leverage this planning for similar scenarios Anthrax (loss of building for 3-26 weeks) Ricin (loss of building for 3-26 weeks) Bioterrorism or chemical weapons Natural disasters striking State Capitol Hurricanes Tornadoes Civil Disturbances Common themes: What if my headquarters building were heavily damaged or destroyed, or people could not occupy it for an extended period of time? Where would I put all the employees, and how could my agency recover and resume its core mission more quickly?


UPDATE DR AND COOP PLANS NOW: UPDATE DR AND COOP PLANS NOW


The High Points: The High Points


Plan ,plan, and plan some more.: Plan ,plan, and plan some more.


Preparedness immediately before and during the event (WHO levels 5 and 6): Preparedness immediately before and during the event (WHO levels 5 and 6)


Review and engage your plan.: Review and engage your plan.


Scott’s Tips for Individual and Family Preparedness: Scott’s Tips for Individual and Family Preparedness


Gain Global Context: Gain Global Context Read voraciously about the 1918 pandemic (and the 1976 Swine Flu scare) and find a comfortable middle ground Subscribe to Google, Yahoo and news services’ RSS feeds/email alerts on “bird flu” and “pandemic” Gain an understanding of influenza and its history Learn how to protect yourself against all influenzas Learn how to recognize the global “warning signs” when the alert status is about to be raised. FOLLOW THE MONEY (and the Tamiflu). And if you hear the words “sustained human-to-human transmission has occurred” in the mainstream media, be ready to “Rush to complete your preparations.”


Stock supplies: Stock supplies 3 to 6 weeks, depending on personal anxiety Food, WATER*, paper goods, batteries, flashlights, etc. You know – hurricane/ice storm supplies! Medicines that treat symptoms of flu, including pain killers, Gatorade (dehydration), diarrhea, chest congestion. Masks for sick family members (and for yourself, if that makes you feel better). Try to get Tamiflu NOW by prescription from your doctor. DO NOT buy Tamiflu on the Internet. Tamiflu will be gone from pharmacy shelves the minute the WHO raises the threat level and most definitely by the time a pandemic starts. * Municipal water treatment systems stock fewer than 2 weeks’ worth of chlorine, and in many cases, even less than that.


Get everyone (eligible) in your family a Pneumoccal Polysaccharide Vaccine (PPV).: Get everyone (eligible) in your family a Pneumoccal Polysaccharide Vaccine (PPV). Pneumococcal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), and the covering of the brain(meningitis). About 1 out of every 20 people who get pneumococcal pneumonia dies from it, as do about 2 people out of 10 who get bacteremia and 3 people out of 10 who get meningitis. People suffering from severe influenza or with special health problems are even more likely to die from the diease. Drugs such as penicillin were once effective in treating these infections; but the disease has become more resistant to these drugs, making treatment of pneumococcal infections more difficult. Vaccine protects against 23 types of pneumococcal bacteria. Healthy people develop protection to most or all of these types within 2 to 3 weeks of getting the shot.


Get your seasonal flu shot: Get your seasonal flu shot That way, if you have your pneumonia vaccine, and your seasonal flu shot, and there’s a pandemic, and you fall ill….. Well, then you know what you have, my friend. Seasonal flu surveillance and vaccine formulation has gotten pretty dang good. You won’t become the “mixing vessel” Also, a seasonal flu shot MAY provide a very slim modicum of protection if an “N1” virus becomes pandemic.


Final Thoughts : Final Thoughts


Ten tips on pandemic flu planning (from UK): Ten tips on pandemic flu planning (from UK) Lessons from the past are not always learned - we must do better than with Foot and Mouth and SARS It won't go according to plan - biological, political and economic impact will be complex Keep a sense of proportion - most people will survive Not just a health issue - businesses will suffer Lots of heroes out there - people will outperform expectations Communication will falter - we need tried and tested systems for contacting staff The media loves disasters - can be good as well as bad Good enough is good enough - less than perfect care and rationing is inevitable Low tech is reliable - hygiene as important as oseltamivir Involve the public - be honest and open Source: Hilary Pickles, Hospital Doctor Pandemic Flu conference, London


References and Suggested Reading Materials: References and Suggested Reading Materials “The Great Influenza,” John M. Barry (Viking, 2004 hardcover). “America’s Forgotten Pandemic: The Influenza of 1918,” Alfred W. Crosby (Cambridge University Press, 1976/2003 softcover). “Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It,” Gina Kolata (Diane Pub. Co., 2001 hardcover). “The Monster at Our Door: The Global Threat of Avian Flu,” Mike Davis (New Press, 2005 hardcover). “Influenza,” Dr. Edwin D. Kilbourne (Plenum Publishing, NY, 1987 hardcover). “The Devil's Flu: The World's Deadliest Influenza Epidemic and the Scientific Hunt for the Virus That Caused It,” Pete Davies (Owl Books, 2000 softcover) “The Swine Flu Affair: Decision-making on a Slippery Disease,” Richard E. Neustadt, Harvey V. Fineberg (University Press of the Pacific, 2005 softcover) “Bird Flu: A Virus of Our Own Hatching,” Dr. Michael Greger (Lantern Press, 2006, hardcover) Centers for Disease Control and Prevention, www.cdc.gov and www.pandemicflu.gov World Health Organization Avian Influenza Website http://www.who.int/csr/disease/avian_influenza/en/index.html National Academy of Sciences, Institute of Medicine http://www.iom.edu/ Recombinomics, Dr. Henry Niman’s Website, http://www.recombinomics.com/ University at Albany (NY) Public Health Pandemic Course, http://www.ualbanycphp.org/learning/registration/detail_Pandemics.cfm


Commentary available atwww.scottmcpherson.net: Commentary available at www.scottmcpherson.net


How Ready Are We?: How Ready Are We?