Published on March 26, 2008
The Avian Flu: The Avian Flu A Potential Catastrophic Threat that could create a National & Global Security Crisis Anthony Barrasso University of Arizona & Manny Wilson University of South Florida August 4, 2005 The Deadly Flu: The Deadly Flu Overview: The Threat What it is How it’s spread It’s current status Historical Comparisons Between other Outbreaks, Disasters, and Threats Situational Concerns Infectious Cultural Practices, Vulnerabilities, Capabilities, and New Deadly and Possible Threats Recommendations Forward looking research and policy Overview Epidemic Influenzas: Epidemic Influenzas The flu is a contagious respiratory illness caused by influenza viruses. There are three virus types: Influenza A viruses that infect mammals and birds Influenza B viruses that infect only humans Influenza C viruses that infect only humans It can cause mild to severe illness, and at times can lead to death. Those at high risk for complications include people 65 years or older, people with chronic medical conditions, pregnant women and young children. The A type of influenza virus is the type most likely to cause epidemics and pandemics. This is because the influenza A virus can undergo an antigenic shift and present a new immune target to susceptible people Virus’s are the number one killer of humans. Flues alone kill anywhere between 200,000 to 500,000 people annually worldwide. 36,000 annually in the United States In annual influenza epidemics 5-20% of the population are affected with upper respiratory tract infections. Seasonal epidemics are caused by subtypes of influenza viruses that are already in existence among people, whereas pandemic outbreaks are caused by new subtypes or by subtypes that have never circulated among people or that have not circulated among people for a long time (WHO, March 2003). Pandemics Influenzas ...the History of Lethality: Spanish Flu (1918) Globally Infected: over 300 million Killed: 40 Million United States Infected: 25-30% of population (25,802,000-30,962,400) Killed: 675,000 (1/152 people) Approx 663,000 more than “normal” flu season Pandemics Influenzas ...the History of Lethality World United States Hong Kong Flu (1968) Globally Infected: 252 million Killed: 750 thousand United States Infected: 7-10% of population (14,049,423-20,070,605) Killed: 34,000 Approx 10,000 more than “normal” flu season Asian Flu (1957) Globally Infected: 290 million Killed: 1 million United States Infected: 10-15% of population (17,198,413-25,797,619) Killed: 70,000 Approx 50,000 more than “normal” flu season The Spread of Influenza: The Spread of Influenza Animal to animal spread: Bird Secretions Nasal Feces Contaminated soil or dust Contaminated surfaces Human to human spread: Respiratory droplets from coughing or sneezing. Aerosol from coughing or sneezing Touching something with the virus on it and then touching your mouth, eyes, or nose. You can begin to infect others 1 day before you even show symptoms and about 7 days after being sick. Illustration of an Influenza Virus: Illustration of an Influenza Virus Influenza Viruses are composed of two antigen proteins. The Hemagglutinin is named because of the spikes capable of adhering to red blood cells, causing them to be agglutinated. The Neuraminidase is an enzyme which forms a mushroom-shaped projection on the surface. The enzyme assists in the release of newly-formed virus particles from the surface of an infected cell (A.A. of S, 7 July 2005). Composition of Influenzas: Composition of Influenzas H1 H2 H3 H4 H6 H7 H8 H9 H10 H11 H12 H13 H14 H15 H5 N2 N3 N4 N5 N6 N7 N9 N8 N1 Only two subtypes that can cause Highly Pathogenic Avian Influenza There are 15 known subtypes for the Hemagglutinin antigens (H1-H15) There are 9 known subtypes for the Neuraminidase antigens (N1-N9) The Transmission of Influenzas ...from Aquatic Birds to Domestic Chickens: The Transmission of Influenzas ...from Aquatic Birds to Domestic Chickens Natural Avian Influenza cycle Half Century of Outbreaks of Highly Pathogenic Avian Influenza : Half Century of Outbreaks of Highly Pathogenic Avian Influenza Outbreaks with Significant Spread to numerous farms resulting in great economic losses = Here to Stay The Transmission of Influenzas ... from Chickens to Pigs to Humans: The Transmission of Influenzas ... from Chickens to Pigs to Humans Natural Avian Influenza cycle Can be spread from Domestic Chicken to Human Or From Chicken to Pig to Human 30 years of Influenzas …with isolated Avian-Human Transmission: 30 years of Influenzas …with isolated Avian-Human Transmission The Transmission of Influenzas ...with Human to Human Transmission: The Transmission of Influenzas ...with Human to Human Transmission Natural Avian Influenza cycle Can be spread from Domestic Chicken to Human Or From Chicken to Pig to Human A Century of Influenza …with Human to Human Transmission: A Century of Influenza …with Human to Human Transmission 1900 Several Unconfirmed Isolated Cases of Human to Human Transmission Several Unconfirmed Cases of H5N1 in Pigs The Avian FluWhat is the Avian Flu?: The Avian Flu What is the Avian Flu? Avian influenza or H5N1 (also known as bird flu) is an “A” type influenza which originated in aquatic birds but has become very virulent among domestic birds. Has killed over 120 million chickens in just 3 months. Higher than the sum of all previous outbreaks in the last 40 years. The Avian Flu has a 100% lethality rate among chickens and a 54% lethality rate among humans. Of the 109 cases so far, 59 people have died. The Avian Flu has targeted the same population as the Spanish Flu of 1918. 1918, 99% of the individuals killed were under the age of 65. Pandemic flues target those in prime of their life, young healthy individuals between the ages of 15-35 (MISMIS). The Avian Flu is highly pathogenic, moving rapidly and lethally The virus can survive in contaminated manure for at least 3 months It can survive in water for up to four days, or 30 if below 0 degrees C. 1 Gram of contaminated manure containing the Avian Flu Virus can infect up to 1 million Chickens, (WHO, Jan. 29). “Within a country, the disease spreads easily from farm to farm. Large amounts of virus are secreted in bird droppings, contaminating dust and soil. Airborne virus can spread the disease from bird to bird, causing infection when the virus is inhaled. Contaminated equipment, vehicles, feed, cages or clothing – especially shoes – can carry the virus from farm to farm. The virus can also be carried on the feet and bodies of animals, such as rodents, which act as “mechanical vectors” for spreading the disease. Limited evidence suggests that flies can also act as mechanical vectors.” The Avian Flu …Background: Late 1800’s, Avian Flu is thought to emerge in the aquatic bird population Originate in the ducks of Southern China’s Guangdong Province The Avian Flu …Background Slide17: 1997, First appears in the human population in Hong Kong Sickened 18, killed 6 1.5 million chickens exterminated The Avian Flu …Background Slide18: The Avian Flu …Background 1998-2001, H5N1 goes through a series of re-assortments and the “z” virus surface. Now tougher and more capable of withstanding a wider range of environmental challenges Slide19: The Avian Flu …Background 2004, Introduction of the “z+” virus By January the virus killed over 11 million chickens in Vietnam and Thailand By April over 120 million chickens in Asia had either been killed by the flu or were exterminated Now super-virulent and capable of spreading to a broader range of species, i.e., rodents, pigs and humans. “Chairul Nidom, a virologist at Airlangga University’s tropical-disease centre in Surabaya, Java, found the H5N1 virus in five of ten pigs tested from Banten in western Java ( Nature, 26 May 2005).” Danger Zone: Avian Flu + Pigs + Human Flu = Re-assortment => Antigenic Shift Able to spread from Human to Human Humans will have little to no immunity Contains surface proteins (H&N) not previously seen in influenza viruses that infect humans Is Avian the Next Pandemic?: Is Avian the Next Pandemic? A virus emerges from the pool of animal life that has never infected human beings and is therefore one to which no person has antibodies. The virus has to make humans seriously ill. The virus must be capable of moving swiftly from human to human through coughing, sneezing, or just a handshake. “No virus of the H5 subtype has probably ever circulated among human, and certainly not within the lifetime of today’s world population. Population vulnerability to an H5N1— like virus would be universal (WHO, pg.19).” The virus has killed 54% of the 109 People already infected. The scientist are saying it’s not a matter of if, but when the virus will be capable of human to human transmission. Avian Comparisons: …Looking through Different Lenses: Avian Comparisons: …Looking through Different Lenses Viral Outbreaks and Impacts Spanish Flu, Asian Flu, Hong Kong Flu, AIDS, SARS “Probabilistic” Threats Tsunami, 9/11 A Catastrophic Threat Traditional Warfare, Weapons of Mass Destruction Viral Outbreaks and Impacts: …Number infected/killed – Worst Case Scenario : Severe Acute Respiratory Syndrome (SARS), 2004 Infected : 8098 Killed: 774 Acquired Immune Deficiency Syndrome (AIDS), 1981 Infected: 70 million Killed: 30 million Avian Flu (H5N1), 1997 Potential to: Infect: < 2 billion Kill: < 400 million 80,000,000 Americans infected and 16,000,000 Americans killed...444% jump Viral Outbreaks and Impacts: …Number infected/killed – Worst Case Scenario Spanish Flu,1918 Infected: 372 million (1.3 billion today) Killed: 40 Million (217 million today) 675,000 Americans killed (2,600,000 today)...1/153 people, 531% jump Asian Flu, 1957 Infected: 290 million (650 million today) Killed: < 1 million (2.2 million today) 70,000 Americans killed (156,800 today)...237% jump Hong Kong Flu, 1968 Infected: 252 million (458 million today) Killed: 750 thousand (1.3 million today) 34,000 Americans killed (58,800 today)...40% jump Viral Outbreaks and Impacts: …Lethality Comparison: Viral Outbreaks and Impacts: …Lethality Comparison The Spanish Flu was estimated at killing anywhere from 40-100 million people, with only a 3% lethality rate. The SARS coronavirus outbreak had a 10% lethality rate and was not as infectious as the Spanish Flu. The Avian Flu currently has about 54% lethality rate among humans and a 100% lethality rate among chickens. It is highly pathogenic virus, much more infectious then SARS. Estimated Potential Lethality Range Possible Lethality Range “Probabilistic” Threats …the Impact of Inaction: “Probabilistic” Threats …the Impact of Inaction Walking a Different Path may… Minimalize or even avoid this pattern Prediction of Event Recommendation for “Prudent Measures” Push Back by Industry Marginalization of Predictions/Predictors Government Inaction Event Recovery Efforts Tsunami, 9/11, and Avian Flu Tsunami 2004: In 2003, Dr. Phil Cummins, an Australian seismologist, said that a Tsunami was likely to hit in the Indian Ocean Scientists suggest that a Tsunami Warning System is needed in the Indian Ocean Region. The Tourist Industry Lobbies against the Tsunami Warning System, out of fear it will deter tourist from visiting. There hasn’t been a tsunami on the Indian Ocean since the Krakatoa eruption of 1883. Spending millions on a tsunami system would be a waste of money and would hurt the surrounding nations tourist industry. No action is done in the Government to produce a Tsunami Warning System Billions spent on recovery efforts, still 108,221 people are missing. . Tsunami occurs, December 26, 2004: 282,517 Dead or Missing. . Tsunami 2004 Prediction of Event Recommendation for “Prudent Measures” Push Back by Industry Marginalization of Predictions/Predictors Government Inaction Event Recovery Efforts 9/11: 9/11 Billions spent to: reconstruct World trade towers/ Pentagon, aid the families, fight the war on terror, and increase our homeland defenses. Recovery Efforts: September 11, 2001 Occurs: 2,985 Dead Event: No action is done in the Government to better secure our airlines. It would cost billions to increase security measures at airports, and even millions just to install locks on the cockpit doors. Without any real foreseeable threat money should be spent elsewhere. Airlines stated that current security was adequate. Various recommendat-ions were made that the United States needs better airport security. Intelligence suggests that terrorist are training to fly planes. Intelligence suggests that airport security is inadequate. Government Inaction: Marginalization of Prediction: Push Back by Industry: Recommendation for “Prudent Measures:” Prediction of Event: Avian Flu: Avian Flu Could cost anywhere between 2-3 trillion dollars. Recovery Efforts: Avian Occurs: 2 – 3 billion could be infected and 400 million – 1.2 billion could be killed Event: Government has taken actions to o increase our defenses for a pandemic (Hasn’t quite occurred yet) Pharmaceutical Industries refuse to stockpile due to potential economic losses. Roche Pharmaceutical has a patent on the antiviral Tamiflu that could work for the H5N1 virus, but they lack the capacity to produce in large numbers. These organizations are in agreement that actions need to be done to better prepare the world for such an outbreak. Scientist of the CDC, WHO and various other medical experts have suggested that the Avian Flu poses a real and serious threat.. Government Inaction: Marginalization of Prediction: Push Back by Industry: Recommendation for “Prudent Measures:” Prediction of Event: Are they doing enough? A Catastrophic Threat: …Possible/Likely: A Catastrophic Threat: …Possible/Likely The Four Security Challenge Categories in the National Military Strategy A National Security Crisis: A National Security Crisis IMPACT Traditional Warfare = = = Weapon of Mass Destruction Potential Pandemic The impact an Avian Flu pandemic could be greater than a WMD attack The likelihood of a natural occurring pandemic or a terrorist initiated outbreak could be even more likely than a WMD attack The U.S. and the world is extremely vulnerable to this threat, arguably even more so than a WMD attack. Contributing Factors/Problems: Contributing Factors/Problems Livestock Production/Distribution Practices Transparency Globalization Science False Assumptions Current State of Play Darwinian Law Military Operations Bioterrorism Possibilities Livestock Production/Distribution Practices: Asia: Gap between Aquatic Birds/Domestic Chickens/ Pigs/and Humans is closing. China’s affluent economy has had effects on their taste preferences: In 1968 the number of pigs in China was 5.2 million and the number of chickens was 12.3 million. Today there are over 508 million pigs and 13 billion chickens. Setting us up for disaster. The majority of chickens and pigs are bought from small farms that lack hygienic standards, creating a petrie dish for pig to chicken transmission. The majority of these are sold live in markets, creating a petrie dish for pig and chicken to human transmission. Livestock Production/Distribution Practices Lack of Transparency ...The Great Wall: It took 87 days and over 400 people infected until China acknowledged that outbreaks had occurred. At this point the government stated that the outbreaks had stopped Even though they were still getting 40-50 new cases a day and the virus had no spread to 6 different cities (Abraham, pg.25).. Similar pattern occurring today with China and the Avian Flu (Washington Post, 25 July 2005). It wasn’t until April 19, 2004, 5 months after SARS began, that China was openly forthcoming with the information about SARS that they tried vigorously to repress. Lack of Transparency ...The Great Wall Transparency Impact & Speed of Spread ...As it applies to SARS: Timeline Boxes: Red boxes = Spread Dark Red = WHO Advisories Purple = Clues Green = Lack of China Trnsparency Blue = Transparency from Chinese Transparency Impact & Speed of Spread ...As it applies to SARS SARS becomes global and spreads to 5 countries in 24 hrs, Feb. 24th-25th May. Apr. Mar. Feb. Jan. Dec. Nov. SARS Outbreaks SARS Becomes a Global Outbreak Number of Countries with SARS Outbreak Nov. 16th – First known case of SARS occurs in Guandong Province, China, but is not identified as SARS until much later Feb. 21st- – China, Hong Kong – First superspreader event: A 64 year-old physician from Zhongshan Univerisity, Guandong Province, stays at Metropole Hotel in Hong Kong and transmits the disease to at least 16 other people. Mar. 4th – Hong Kong – Second superspreader event in Hong Kong: A resident who had visited the Metropole Hotel infects 25 hospital staff in a week. Jul. 5th – WHO HQ – WHO announces that the global SARS outbreak has been contained. Nov. 27th – Canada – Global Public Health Intelligence Network picks up reports of a “flu outbreak” in China through A.I./D.M. cap. Mid-December – WHO Headquarters, Geneva - WHO requests further info. on the “influenza outbreak”. Chinese gov. says influenza activity is normal and no unusual strains of the virus detected by surv. system. Jan. 23rd – Guandong Province – Guandong provincial health authorities produce report on outbreak detailing nature of transmission, clinical features, and suggested. preventative measures which is circulated to hospitals in the province but not shared with WHO or Hong Kong. Feb. 11th- – WHO / Guandong Province – Chinese Ministry of Health officials and Guandong health officials report to WHO a total of 305 cases and 5 deaths of acute respiratory syndrome, however, they were getting 40-50 cases a day, yet said outbreaks had stopped. Feb. 23rd – China – A team of WHO experts, including CDC staff, arrive in Beijing but are given limited access to information (at the central level only) and Chinese authorities deny WHO’s repeated requests for permission to travel to Guandong Province. Feb. 24th – WHO HQ, Geneva – GPHIN detects Chinese newspaper report that more than 50 hospital staff in Guangzhou are infected with “mysterious pneumonia.” in the city of Guangzhou. Mar. 10th – China – Chinese Health Ministry asks WHO for technical/laboratory support to clarify cause of the Guandong outbreak of atypical pneumonia. Mar. 15th – WHO HQ – WHO issues a rare travel advisory as evidence mounts that SARS is spreading by air travel along international routes. WHO names the mysterious illness after its symptoms: severe acute respiratory syndrome and declares it “a worldwide health threat.” Mar. 17th – WHO HQ – China provides a first brief report to WHO about the Guandong outbreak. The outbreak is said to have tapered off. Apr. 3rd – China – WHO team arrives in Guandong and all team requests for access to sites and interviews with all levels of health staff are granted. Apr. 14th – WHO – The WHO team in Beijing fails to secure permission to visit military hospitals. Apr. 19-20th – China – Change in political stance by Chinese leadership. Top leaders advise officials not to cover up cases of SARS; Beijing mayor and Health Minister, both of whom downplayed the SARS threat, are removed from their posts. Mar. 30th – WHO HQ – Third superspreader event in Hong Kong: Health authorities announce that 213 residents of Amoy Gardens housing estate have been hospitalized with SARS. Apr. 2nd – WHO HQ – WHO issues most stringent travel advisory in its 55-year history, reommending that people postpone all but essential travel to Hong Kong and Guandong Province until further notice. Apr. 16th – WHO – Exactly one month after its establishment, the WHO laboratory network announces conclusive evidence of the SARS causative agent: a new coronavirus. A Network Problem requiring a Network Solution SARS brewed in China and Hong Kong for three months before its rapid spread internationally. Shown in the representation below, when the virus eventually spreads on international air travel routes, it does so from Hong Kong—a country very connected economically and globally, and a major hub in the international air travel grid. Once the virus made its way on this grid, the spread goes vertical, shot-gunning out rapidly to multiple countries. Within 48 hours, SARS was in 6 countries. The spread continued its climb, taking off and spreading around the world, and in less than 10 weeks 27 additional countries were infected. SARS signifies how important transparency and the willingness from nations to share information and cooperate are to curbing a transnational disease outbreak. SARS infections occurred in China for approximately 3 months before Chinese officials notified the WHO of the outbreak and five months before being 100 percent transparent. If the virus would have been reported during the 3 months that it brewed, the crisis could have been greatly mitigated or prevented altogether. With biological challenges, time is not on our side—everyday, hour, and second that goes by, the danger of disease or biological agents, either from natural occurrences or attacks, is greater than before. Unless we act and turn that equation around by taking advantage of today’s explosion in information technology and information networks, the future of biosecurity is not safe. Everyday the internet and capability of information technology grows—a capability where time is on our side. By leveraging this capability against the threat of disease, we can turn that equation around. The first clue about the SARS outbreak in China occurred from the WHO’s Global Public Health Intelligence Network (GPHIN) which picked up reports of what it identified as a possible “flu outbreak” November 27, 2002. The GPHIN uses internet crawlers and data-mining/artificial intelligence capabilities which scan news articles on the internet detecting spikes in queried words hinting an outbreak. GPHIN detection was the first clue the WHO received and from this information, they then requested information from China. Globalization: Globalization Data Source: World Tourism Organization Increases in travel and mobility increase the threat of infectious diseases The scope, scale, frequency, and speed to which people move around the world has greatly increased In 1993, it was estimated that 500 million people crossed international borders on airplanes. By 2001, that number rose to 1.4 billion per year This trend will only continue as global economic growth continues, resulting in increased resources among populations, including large populations such as China and India. Travel platforms are a vehicle for transmission Increased dispersion opportunity and Increased transmission from the confined space and re-circulated air during transit (e.g. airplanes) Slide35: Impact of Globalization ...on a Viral Outbreak and 27 countries in less than 10 weeks SARS was able to spread to 5 different countries within 24 hours. Science: Science Vaccines It is difficult to produced a vaccine for H5N1, because it’s lethality in chicken eggs, just like chickens, is also 100%. If a vaccine could be created it still takes 6 to 9 months to produce. Currently, there are only 9 pharmaceutical companies in the world producing vaccines. In one year these companies produce a combined total of 300 million vaccines. The United States alone would need 300 million vaccines. That would leave about 6.2 billion people unvaccinated. Antivirals Tamiflu The Avian Flu is thought to be susceptible to the antiviral medicine Tamiflu Problems: Not completely sure it will work Produced and patented by one company, Roche Pharmaceuticals in Switzerland. Lack the manufacturing capabilities to meet the demand if Avian broke out…lack the capabilities to meet their current demand. Right now it is being bought up by the more developed nations and the underdeveloped nations aren’t given the chance. False Assumptions: “The arrival of pandemic flu will trigger a reaction that will change the world overnight. There will be immediate response from leaders to stop the virus entering their countries by greatly reducing and even ending foreign travel and trade — as was seen in parts of Asia in response to the severe acute respiratory syndrome (SARS) epidemic. These efforts are doomed to fail given the infectiousness of the virus (Osterholm, Center for Infectious Disease Research and Policy).” “Should early containment fail, once a certain level of efficient transmission is reached, no interventions are expected to halt international spread, and priorities will need to shift to the reduction of morbidity and mortality (WHO).” False Assumptions “Quarantines as a fall back plan” Currently, no evidence exists that influenzas can be quarantined It is thought that quarantining can prove to be counterproductive in regards to social and economic disruption. Quarantine Implementation Would be a likely immediate response from nations to an outbreak First within nations, and then between nations Global Travel Represents a new set of challenges associated with disease outbreaks and Exacerbates utility of quarantines. False Assumptions: False Assumptions “A Flu pandemic could bring human tragedy and a global economic catastrophe. Let’s hope world leaders heed the warnings (Nature, 26 May 2005).” “This is Asia’s problem.” SARS spread to 27 different countries in less then 10 weeks SARS was in 27 different countries within 10 weeks It cost the airline industry 5 times more then 9/11 With the level of infectiousness of influenzas, the rate of spread is going to be considerably higher than SARS...making it a more eminent global issue False Assumptions: “We have enough to cover the ‘at risk’ population.” Current vaccines and antiviral policies are based on the assumption that the amount of vaccines/antivirals needed are only enough to cover the number of population that is at risk. Currently, policy defines the population at risk as the young, elderly, or people with chronic medical conditions. According to experts, the Avian Flu will put the 15-35 age range at the highest risk, but all ages are susceptible. False Assumptions “Spanish Flu preferred the prime of life, causing most deaths in young and healthy persons in the age range of 15-35 years...99% of deaths occurred in people younger than 65 years (WHO,pg.25).” Current State of Play ...Department of Defense, Pacific Command: Current State of Play ...Department of Defense, Pacific Command Source: -- USPACOM Pandemic (PI) Response Planning-- Command Surgeon, May 26, 2005 Influenzas can jump stages Does not take into account the speed of transparency or ineffectiveness of quarantines Current State of Play…DoD-PACOM: Current State of Play …DoD-PACOM Plan of Action will prove not to be effective if based on the wrong assumptions Current State of Play ...issuing an Executive Order: Current State of Play ...issuing an Executive Order Lack the sensing capabilities to make this order relevant Currently unable to detect an influenza at the airport short of running lab tests on anyone showing symptoms Influenzas can begin to be transmittable before you begin to show symptoms. Potential Conflict on the Horizon ...political/economic realities: Potential Conflict on the Horizon ...political/economic realities Darwinian Law: Almost all of the world’s influenza vaccine is produced in nine countries — Australia, Canada, France, Germany, Italy, Japan, the Netherlands, the United Kingdom and the United States. 40% of the worlds supply of inter-pandemic influenza vaccines is used in countries that do not produce their own vaccines In times of crisis self-preservation is a nations number one concern. It can be expected that government leaders will “nationalize” their vaccine production facilities. The United States did on just the threat of an outbreak with the Swine Flu fiasco in 1976 Sanofi Pasteur, the only vaccine producer based in the United States, is only capable of producing 50-60 million vaccines a year. That would leave about 250 million unvaccinated in the United States alone, if a pandemic were to breakout. Back against the wall The past has shown that governments immediate reaction to outbreaks is usually to quarantine, including both people and nations. If an outbreak were to occur embargos are likely to be put on the host nation. The interdependency of nations has made embargos extremely disruptive There would be major shortages in all countries of a wide range of commodities, including food, soap, paper, light bulbs, gasoline, parts for repairing military equipment and municipal water pumps, and medicines, including vaccines unrelated to the pandemic. Implications for the DoD/Military: Implications for the DoD/Military The Spanish Flu of 1918 Killed 46,000 American Soldiers—more than were killed from World War I combat The Avian Flu Far more lethal and potential more deadly With the global force posture, U.S. forces and global bases would be at risk Global Avian Flu Outbreak Impact Global military operations could be impacted. Unknown number of U.S. forces could be infected Global Avian Flu Outbreak Could require US forces to go in to countries unable to deal with the outbreak US force would be at risk catching and spreading the disease Possible Effects/Requirements on Military Military medical augmentation Law enforcement augmentation for civil unrest Distribution and transportation of vaccines, medicine, hospital bedding, forensic capabilities Quarantine Enforcement Contaminated Waste Disposal Over 400,000 military personnel positioned around the world, in over 150 countries Over 800 military bases in 60 plus countries U.S. Military Bases and/or Troops Overseas Countries with U.S. Military Bases and/or Troops Potential Impact of a Viral Outbreak …Superposition of SARS & OIF: Potential Impact of a Viral Outbreak …Superposition of SARS & OIF Operation Iraqi Freedom Over 8,000 people infected, 774 killed An Infected Chinese Medical Professor checks into hotel… Super-spreader 24 Hours 87 days SARS Outbreaks First outbreak of SARS in Guangdong Province, China Of SARS Outbreaks and Silence from the Chinese Government China acknowledges SARS outbreak SARS Spreads to 5 Different Countries 6 Months SARS Spreads to 29 different Countries SARS Becomes a Global Outbreak SARS Spreads to Taiwan, Singapore, Canada, Ireland, and Germany Bioterrorism Possibilities ...the threat of Terrorist Super-Spreaders: Bioterrorism Possibilities ...the threat of Terrorist Super-Spreaders SARS was in 6 different countries within 2 days Imagine a virus more infectious in the hands of Terrorist Super-Spreaders Terrorist Super-Spreaders: ...the Exploitation of a vulnerability: Terrorist Super-Spreaders: ...the Exploitation of a vulnerability Currently 17 countries that have active research and development programs for biological warfare. The Avian Flu is not solely a CDC issue, it is a counter-terrorism issue. Avian flu represents a potential catastrophic threat not only from a natural occurring pandemic perspective but from a human assisted / accelerated outbreak from a potential terrorist super-spreader. The likely and deadly potential exists for terrorists to acquire this disease, infect themselves and board a plane. A Complex Adaptive Virus within a Complex Adaptive System: A Complex Adaptive Virus within a Complex Adaptive System Systemic Challenge Where to go from here: “In the past pandemics have announced themselves with a sudden explosion of cases which took the world by surprise. This time, the world has an opportunity to defend itself against a virus with pandemic potential before it strikes.” Dr. Lee Jong-wook, Director-General, World Health Organization Where to go from here The time to prepare is now! Deterring Forward: Deterring Forward Resource Capabilities Transaction Rates Perfectly Predictable Surprise Breaking Point “The pandemic clock is ticking...we just don’t know what time it is.” --Ed Marcuse, Chair of National Vaccine Advisory Board Transmission Rates Surveillance, Vaccines, Antivirals, Quarantines and Aid Capabilities Large numbers of people infected/killed, Desperate measures by Governments, Inadequate # of Vaccines/Antivirals, Possible Conflicts Societal unrest Deter-Forward ...using a Multifaceted Approach: Deter-Forward ...using a Multifaceted Approach Set up a Global Influenza Surveillance System that is able to monitor influenzas among Waterfowl as well as the progression among other species. Increase Transparency between nations to enable this. Locate farms further from Natural Reservoirs that Waterfowl are likely to go. Vaccinate chickens considered to be at risk. Massive Culling of Chickens that are or could be Infected. Vaccination of pigs considered to be at risk. Separation of Chickens from Pigs with increased hygienic conditions. Separation of Humans from Chickens, and Pigs with increased hygienic conditions. Massive Killing of Pigs that are or could be infected. Setup Globally Networked Labs able to enhance the production of bug to drug. Start Global Vaccine and Antiviral Production and begin to distribute to the ‘Hot Zones.’ Quarantine Infected individuals to ensure no Human to Human transmission. Once H5N1 becomes human to human transmittable we are too late. “Should early containment fail, once a certain level of efficient transmission is reached, no interventions are expected to halt international spread, and priorities will need to shift to the reduction of morbidity and mortality (WHO).” Recommendations …Barrasso…for Deterring Forward: Recommendations …Barrasso…for Deterring Forward Increase Transparency Bilateral/Multilateral discussions with other South Eastern Asian Nations Provide economic relief to both individuals and nations that report outbreaks Increase the speed of intervention by increasing the speed of communication both within and among nations. Change the Way We Do Business Work with governments to change practices in food production/distribution chain Global Influenza Warning System Aggressively invest in “warning system” that can detect the spread of influenzas. e.g.. waterfowl-chickens-pigs-humans Executive power should be granted to the organizations that have the information. e.g.. CDC, WHO, HHS. Further work should be done to globally network labs, organizations, and people Increase Vaccine Use/Capacity Pre-deploy vaccines to areas where potential outbreaks are likely to occur. Stop the spread before it hits humans...vaccinate the poultry population. Government subsidy needed to stimulate incentive to research and stockpile among the pharmaceutical companies. Research could lead to: faster bug to drug time increased production/distribution capabilities universal vaccine, etc. It’s not just about Stockpiling...the will not solve the problem. (i.e. changes in the virus/other viruses) U.S. specifically should invest domestically so that in the mist of a crisis we could rely on the companies that reside on our soil. Suspend Intellectual Property rights If Tamiflu is proven affective for H5N1, measures should be taken to increase their production capacity to make it more readily available. This could be done by suspending their patent so that other companies could produce Tamiflu or Work with Roche Pharmaceuticals to increase their production capabilities. Recommendations…Wilson: Recommendations …Wilson Some immediate actions that could be implemented include: A robust global influenza surveillance system among wild birds, waterfowl, and other animals; A disease detection system which includes greater use of information signatures and internet data-mining capabilities; A national and global effort and strategy to diminish Asian practices which contribute to the spread of influenzas and disease; Vaccinate “at risk” animals, such as chickens, pigs, and birds; Separate chickens, pigs, and humans and increase hygienic conditions; Conduct mass culling of chickens and pigs that could be infected; Setup globally networked labs able to enhance the production of “bug-to-drug” capabilities; Start global vaccine and antiviral production and begin to distribute to likely sources of an outbreak; Put in place a national and global strategy to prevent, diminish, and respond to a global outbreak including the proper authorities, responsibilities, and capabilities to conduct quarantines, distribute vaccines and antivirals, and ensure public health; and Increase the likelihood and willingness of national governments’ around the world to share disease outbreak information and take action immediately by setting up a large global fund to cover economic ramifications incurred from nations reporting and isolating an outbreak and promote government networking on this problem. Some longer term actions include: Implement many of the CSIS “Beyond Goldwater-Nichols” recommendations establishing national security interagency planning and strategies, which would include the planning for disease outbreaks such as avian influenza (an example would be having a Interagency Mission Commander in charge of a networked interagency Command/Center for disease outbreaks much like the Combatant Commands of the military or National Conterterrorism Center under the Director National Intelligence. Transnational and multi-agency problems require interagency mission centers); Encourage collaborative internet networks for societal use during disease outbreaks; Increase intelligence capabilities and sensors for the biological domain; and Increase the number of trained medical professionals while operationalizing their use in coordination with the United States military and other agencies and conduct national and international exercises across interagency and multinational-agency lines. Questions and Discussion: Questions and Discussion ?