Summary[edit | edit source]
A highly lethal, highly disruptive, "too soon for the world to be well prepared", and with a really fast and unstoppable onset, flu pandemic is possible.
No-one considers it a certainty, but it's also true that the probability appears to be unknowable, which is why this page frames the issue as a "scenario".
This scenario invites us to consider the possibility of of a severe pandemic happening, with a few initial months where only basic non-pharmaceutical interventions would be available in most of the ~200 countries of the world, i.e. a big proportion of the 8 thousand million people alive today.
An illustrative scenario, presented not as a prediction but with the intention of framing what "bad enough" would mean, might include the following:
- It quite likely it would start quickly and spread before it's noticed:
- See https://afludiary.blogspot.com/2023/05/ukhsa-investigating-two-potential.html which links to https://afludiary.blogspot.com/2023/03/uk-novel-flu-surveillance-quantifying.html which links to https://www.gov.uk/government/publications/avian-influenza-influenza-a-h5n1-technical-briefings/investigation-into-the-risk-to-human-health-of-avian-influenza-influenza-a-h5n1-in-england-technical-briefing-3 which in turn states that "The UK now estimates it would likely take between 3 and 10 weeks before community spread would become apparent to authorities, after anywhere between a few dozen to a few thousand community infections. And this is for the UK. The Time To Detection (TTD) in many less-developed regions would presumably take longer."
- It can be argued that a highly lethal pandemic flu would be detected sooner. Maybe not 3-10 weeks but rather 1-3 weeks, if the first cases emerge where there are resources and awareness. That is to say, if the keys fall near the street lamp. Which may or may not happen. And, of course, in 1 week, what's the probability that some cases will already be somewhere else?
- Pandemic flu would be as easily transmitted as winter flu. Winter flu causes symptoms in maybe 10% of the world population each year. A flu pandemic would see higher numbers, maybe 20-30% - and if it's deadly we'd all want to lower that number which in turn causes disruption, which could be big if reasonable fear is big.
- And, in this scenario, it would be "bad": it would have the potential to cause disease in maybe 1/3 of the world population, with cases needing hospitalisation in 1/5 of those with symptoms, and death in 1/10 to 1/20 of those with symptoms, including in the young and previously healthy. (These figures are compatible with what we know of the flu in 1918 - at least with some of the estimates - and of course things would be different with a different age distribution, etc. Those figures are also clearly not as bad as H5N1 appears to be at the moment. Those uncertainties are what makes prediction difficult and scenarios useful.)
- What about "soon"? If it starts in the next many years (given that the preparation is stagnant or advances at glacial pace), we'd need to assume present resources. That is to say, no vaccines, no ventilation & filtration, no good quality masks - at least in meaningful quantities to meet the demands of the world.
- The idea that the world's response would be fast and effective is a possibility. If that happens naturally, the contribution from this page would be "not very relevant", which is fine for a low scale effort such as this portal. If you have reasons to believe "It would be fine" please share them. But maybe the world - all of us humans - would need all the help it can get: we might have to truly cooperate, and ask our governments to truly cooperate. The purpose of this page is to contribute to that - in necessarily small ways.
We don't need to believe a "bad and soon" is likely to make some preparedness effort, just like we don't need to fear a flat tyre before we check the tyres of a school bus.
Most of the world would need to make the most out of just a handful of possibilities. The full menu is detailed in Aerosol pandemic. Here we outline the selection that would be required in the above scenario:
- Fast and effective education on aerosol transmission, including knowledge of how to reduce the number of respiratory contacts, about how & where/when to do effective masking, and ventilation where possible. Do we know how much people know already, i.e. what the starting point is? How do we ramp up humanity's knowledge in an effective way, across countries and cultures? Also, education is not enough, and good actions need to be facilitated at scale. Do we know how to do that, with or without government assistance?
- Templates to facilitate reduction of the number of respiratory contacts. See Aerosol pandemic/Reduce. How do we collect what's already been done? How do we detail what hasn't been thought of? How do we make sure it's operationally ready to be implemented in a massive scale?
- Available masks, mostly surgical, complemented with DIY or rapidly produced braces/adjusters. See Aerosol pandemic/Adjusters. We are not aware of studies or data about the capacity of the world to manufacture enough FFP2/N95 or elastomeric respirators in enough quantity for at least 10% of the world's population in a short time. We'd have to assume that a proportion of those PPE would go to people who don't need it, but want it for their own protection or for trade. So maybe it's safe to assume that there would be need to produce at least a billion disposable respirators per week for several weeks. Could the world do that? How do we learn what's possible? How do we increase what's possible?
- Surveillance may help, and some of it can be done massively with waste-water surveillance at least in the largest cities of the world.
- But many people will simply need protection so they can keep carrying out vital jobs, like supplies, healthcare of all sorts, and transport. See resiliencemaps.org.
Many of these questions need a team of people commited to finding out, and casting a wide net to capture the needed knowledge. Could that job be done in a month, and refined later? Thanks for helping. twitter: lucasgonzalez.
What we knew already[edit | edit source]
(The section "what we knew already", with its 3 sections - "Biology of flu viruses", "Pandemic challenge", and "Some pandemic candidates - including H5N1" - is taken from resiliencemaps.org/files/fluscim with permission.)
Biology of flu viruses[edit | edit source]
Influenza (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)-pdm09, 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.
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.
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 is believed to spread 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 – is a highly pathogenic virus in poultry that continues to produce large losses in affected countries.
Some pandemic candidates - including H5N1[edit | edit source]
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 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 poultry associated with occasional human cases, and since then it became a persistent problem.
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 fourth. Some of them were diagnosed after taking international flights. https://www.cidrap.umn.edu/avian-influenza-bird-flu/who-confirms-h5n1-case-pakistan-cluster
Pandemic challenge[edit | edit source]
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 8,000 million people.
Based on what we know of animal-human influenza and the history of pandemics, and based on the fact that we currently lack adequate means to blunt the impact of spreading infection, experts and health authorities insist that it is not reasonable to drop our guard.
The persistence of H5N1 in wild birds (some of them migratory) makes the disappearance of the virus unlikely. This fact, the appearance of genetically distinct variants of the virus, and documented existence of limited inter-human transmission all mean that we cannot rule out H5N1 as “pandemic candidate”. Research with ferrets, animals considered a good model for human transmissibility, suggests that, with several transmissions from one animal to another, the virus may acquire the ability to spread through the respiratory route with the same ease as seasonal influenza. http://www.nature.com/nature/journal/vaop/ncurrent/full/nature10831.html http://www.sciencemag.org/content/336/6088/1534.full
Our current challenge[edit | edit source]
The above information about the threat, and the considerations about the difficulties of preparing for a threat of unknowable timing and severity, are known since at least 2010.
More recently, covid happened, massive developments happened, and now we have some more news:
- In 2023, research from 2022 and surveillance in wild animals show H5N1 in several mammal species. See https://afludiary.blogspot.com/2023/02/cdc-ask-expert-on-hpai-h5n1.html
- Possibly as a result of heightened surveillance, a human case with a number of extra "positives" has been found in Cambodia. Around her, 1 more case, possibly from shared exposure. (And lots of confusion in the news from less than perfect translation.) https://crofsblogs.typepad.com/h5n1/2023/02/11-year-old-cambodian-girl-dies-of-h5n1-bird-flu.html
The previous historical and biological knowledge about flu (and now covid), together with the recent events with H5N1, confront us with a very specific, narrow scenario: what if a severe flu pandemic were to start in the near future? https://thetyee.ca/Analysis/2023/02/16/H5N1-Bird-Flu-Home-Roost/
This, in turn, begs the question: taking into account that "whatever we can do in the short term" will be less than "all the theoretical practical steps we may have thought would be desirable", what is the short, doable list of actions that we could (and therefore should) carry out, in practice, in this short term?
Notice how this page has a tight focus, and how, from this page's perspective, all other actions (from good old "world solidarity" to the most sophisticated and affordable "air quality technology") can be done by others, in parallel, or by ourselves, a bit later.
How ready are we?[edit | edit source]
First, let's ask ourselves: How ready are we?
- We know germ theory, and we know it's aerosols, and what to do (in theory). "We" is really "an unknown % of us". Could we find out how many of us know it, and how well?
- We have technologies: masks of all kinds, filters and UV, vaccines, apps for contact-tracing, rapid tests, surveillance systems, some treatments, and ways to do research. We also have a world with substantial amounts of conflict, inequality, denial, and a number of other concurrent crises (climate change, etc).
- The set of "possible actions we could take" has to be tagged as "in theory" because in practice our methods & technology, and their deployment, could (let's be kind) use a number of improvements, all of which would need attention, time and resources that are not available in enough abundance to get things done in time for our scenario. In practice, we don't know how much time is available, and if the other resources are not there then any amount of time would be insufficient. And we know we're not ready: https://www.theguardian.com/world/2023/feb/20/there-may-still-be-surprises-jeremy-farrar-warns-of-pandemic-perils-ahead
What's being done[edit | edit source]
A number of things are already being done:
- Experts talk about vaccines, surveillance, etc. They usually mention whatever happens to be their field. Which is good but not necessarily good enough.
- Non experts would tend to worry, complain and demand, etc. Part of that is probably an ineffective misuse of our imagination, but part of it is also a very natural "adjustment reaction" (see psandman.com).
- Some are developing technologies, which in some cases need to be refined and in all cases need to be deployed. Some of the suggestions may or may not be useful: http://kevinparcell.net/About/BIRDSHOT.html
A "Bad and Soon" scenario[edit | edit source]
Let's suggest a scenario that is clear enough. It could be better or worse than this, but this is not a prediction. It's a scenario. Ready?
"H5N1 acquires the capacity to be transmitted from person to person as easily as winter flu, and, because there's no preexisting specific immunity, more people fall ill than in winter. Also, because the virus is very different from the ones our bodies have met before, it causes more severe cases, in all ages, and deaths in those who were previously healthy, including the young. If allowed to rip, it might cause illness in 30% of humanity, and the death of 5% of those who fall ill. Some may want to add that we wouldn't know, and not want to know, about longflu. We're also assuming that it spreads from those with and without symptoms."
Of course, this is the low end of "bad". It could be 10% in the previously young and healthy. In 1918-19 estimates differ, but 50 million deaths in 1800 million people with a third having symptoms... you do the maths. Spoiler: 1800, 600, 50... 5/60 is ~8% case fatality rate. Would there be disruption because people want to avoid catching it? Would we want to reduce contagions while keeping vital services running? This is just a scenario, but can you locate yourself, and all the people you know or have heard of, in it?
Of course, it could be "Not H5N1", but another respiratorily transmissible microbe. We still need the actionable items for the world.
A few of us could focus on getting this page ready, and to take the actions that stem from it. You may want to look at it this way: a few of us (1% of 1% of 1% of 1% of all people), working part time on this for a few weeks, giving it a few hours in total - is very cheap insurance.
Advantages of doing this even if there's no "soon and bad"[edit | edit source]
This work, looking at the "H5N1 bad and soon scenario" and doing some work on a few actionable items, is good for at least 3 reasons:
- By itself: bad & soon is realistic.
- As part of work for "bad & later".
- Helps us see covid & longcovid differently: what if we actually decided to tackle it now? What would that look like? Regarding longcovid and all the other effects of the current covid situation, part of what needs to happen, and the speed at which it is needed, are identical.
What to do[edit | edit source]
People's knowledge - Actionable #1[edit | edit source]
Let's try and find what people really know about aerosols. Links, experts, how to find out. Experts is "experts in finding out what people really know". In % and with some detail.
More importantly, if human knowledge is an asset in the assumed scenario, how do we grow it intensely, quickly, and effectively? Could we do some of that work now, in preparation? Think "EXIT" signs. A % of people guide those who are too stressed to remember what to do. Our experience is that many of this big Us that is humanity did learn quickly... to wash their hands and to not go out. So, next time, Aerosols. (The covid pandemic is still ongoing but let's gloss over that for a moment, and keep our Tight Focus.)
Make appropriate action easier - Actionables #2, #3 and #4[edit | edit source]
Knowledge is not enough. If many know how to stop transmission, how do we make it easy for many, really fast? The next actionable bit is physical resources. I hear some of us saying: "we know aerosols but masks are bad & air quality needs money". And people would gather anyway. And because, in that scenario, there will be No Time to build infrastructure all over the world (pan-demic = all-people), we need a few things fast.
- The best masks are, surprise, whatever is available, improved. It will be N95 tied behind the head, elastomerics that fit people perfectly... or probably not. It may be layers of cloth & surgical with braces to improve fit. Who knows 😷 🌐 production? Aerosol pandemic/Adjusters might be part of it, but maybe someone knows how to facilitate Elastomerics For All/Most/Many In A Month Or Less. Can you contribute?
- Now, the best "distance". "Distance" actually means 2 things, and we chose the cheaper one. We chose "distance in meters". We're in the same room, away from the other person. We need to talk about The Unthinkable Distance. And make it doable. The Unthinkable Distance is reorganise things so that we will each have _way less_ respiratory contacts. There is no need to have conflict over "schools or no schools", given that we can get over that false dichotomy by using design. We could have a % of the children in small groups, in places that are outside schools, using the model of Rural Schools. Say, 10 children & 2 adults. Real, physical, designed, facilitated... "bubbles"? "Sustainable bubbles"? We could do so much better with Reducing Unnecessary Respiratory Contacts (RURC?). It needs to become thinkable for a few, and then grow from there. Aerosol pandemic/Needs and Systems Make it work with templates for many situations. What's done & who can help?
- We need to talk about making sure everyone stays alive through the (long) crisis. We need to be able to work together as "SCIM teams" at all levels. I don’t think we know how to do that. @leashless wrote http://resiliencemaps.org & @lucasgonzalez used it http://resiliencemaps.org/files/fluscim but nobody knows if it's any good in practice, or how to test, develop or replace it with something better if you have it. The gist is: We need to coordinate our actions in a bad one. PandemicFluGame which would help with everything outlined in this page? What's the tiniest version of that game? We'd need to coordinate actions flexibly & guided by vital priorities for all. How do we train ourselves in practice? The Game is 8k people each taking care of 1 million people, getting points if we all win.
But, but, I want / need to focus on other things![edit | edit source]
It's ok. This page, and the efforts that stem from it, need only a fraction of human kind.
And, of course, once this effort has some shape, there are other scenarios and issues to take care of.
Even still focused on "a bad one", there are efforts that need sustained attention, probably very specialised: develop better air quality systems, etc.
We can work in parallel.
What now?[edit | edit source]
Add a calendar to try and finish this part of the job, to the best of our abilities, in a couple of weeks at most. I.e. by the end of February 2023 or beginning of March. UPDATE: April 2024, even as we see H5N1in birds and mammals including cows, no-one has responded to this call. There's need to see why, and how to change that. Please help. Or say why none of this is needed. Thanks.
And you? Maybe publicise this effort using hashtag #H5N1BadSoonScenario, contact twitter.com/lucasgonzalez for ideas, contact people who can help in specific actionable tasks, or become an appropedia editor to help with these pages?
Thanks.
