A presentation to the U.S. Department of Transportation

Volpe National Transportation Systems Center, Cambridge, Mass., 8
December 2005

[GLOBAL AVIAN FLU PANDEMIC PLANNING TRANSPORTATION IMPACTS]{.underline}

> Clark C. Abt, Ph.D.
>
> Chairman Emeritus,
>
> Abt Associates Inc.\
>  

ABSTRACT  

    For at least the year ahead, there is an as yet unfulfilled urgent
need for short-term local/state/national/international planning for a
global humanly communicable avian flu pandemic in the likely absence of
effective and sufficient vaccines and antibiotics and hospital care
surge capacity in both affluent advanced and developing nations. \
    Experience of the 1918 flu pandemic and the 2003 SARS pandemic
indicate that in the absence of effective and sufficient vaccines and
antivirals and hospital treatment surge capacity, isolation (of the
uninfected), social distancing, and quarantine (of infected and
symptomatic individuals and their contacts) is the only approach that
can work for containing/limiting humanly highly contagious influenza
pandemics.

Transportation Impacts on air, surface public and private, and ocean
transportation will be acute, both in extreme changes in demand and
supply. Airline traffic may be restricted to essential travel, and to
proven healthy individuals as tested on departure and arrival at
certainly international but also smaller municipal airports.
(Singapore/Taiwan examples).

> International airports could plan to screen/examine all arriving
> passengers, divert those coming from infected areas to adjacent
> holding facilities for testing and potential quarantine or release.
> FAA may need to mandate all passenger aircraft having HEPA filters and
> UV to sanitize cabin air circulation. Though costly, this is less
> costly than shutting down all passenger air travel for a period of
> weeks.  Provisions need to be made maintain aircrews and ground
> maintenance crews free of infection and provide for their families so
> they won\'t need to leave work to do so.\
>     Rail and bus terminals, such as South Station, NY\'s Penn Station,
> DC\'s Union Station, may institute departing and arriving passenger
> screening for potentially infected individuals similar to that at
> international air terminals.\
>     Ocean transport, both of passengers on cruise ships and
> particularly of poultry and other animal products, including
> livestock, may need to be restricted and screened, far beyond current
> capacities of Coast Guard, Customs, TSA, FDA, HHS, DOA, and US
> national, state, and municipal Public Health Services at US and
> foreign ports of entry.\
> \
>     What are the decision protocols for restricting, screening, even
> halting air, surface, and ocean transport in a bird flu pandemic
> public health emergency? When should the President (or a Governor, or
> a Mayor) declare a Public Health Emergency, shut down the airlines,
> airports, seaports, rail and bus terminals, even interstate highways,
> on the basis of what criteria, given the huge economic and political
> cost of premature or false alarm actions, and the even higher economic
> and human cost of late and too late decisions? When should mayors and
> governors, airlines and rail and bus lines, coordinately or
> unilaterally shut down, restrict, or screen transport, and how enforce
> it? Under what circumstances of trying to isolate the population of a
> port city such as Boston from infectious individuals arriving
> should/could state police halt incoming road traffic, inspect it for
> obvious illness, and enforce restricted or blocked entry to the SMSA?\
>     To what extent are vital transportation workers, such as subway
> motormen, pilots, mechanics, air controllers, railroad engineers,
> ambulance drivers, firemen, traffic police, motivated to remain at
> their duty posts, even eating and sleeping there, if their families
> are not protected by sheltering in place with adequate supplies?\
> \
>     All these and related transport issues can be best dealt with in
> advance of the arrival of a deadly global avian flu pandemic, but only
> sporadically and badly if not thought out and organized in advance.
> That can be done, should be done, but in most cases of international,
> national, state, and local pandemic preparedness plans has not been
> done. If not now, when? If not us, who? 
>
> \*\*\*

ACTION PLANS for public health emergency preparedness and transportation
emergency preparedness should specify the key decision-makers and
decisions and associated choices to be made and their operational,
economic, and socio-psychological consequences; identify information
critical in making these decisions promptly and rationally; assess the
adequacy of pre-pandemic event, trans-event, and post-event information
available from the decision-makers' existing and potentially mobilized
additional sources in each of those three successive phases; initiate
new analysis and research to acquire additional information as needed in
each successive phase; and incorporate the information, whether acquired
from existing sources or from original research, into a robust and
flexible evidence-based decision-making process at all levels from local
city and county to state to national to international levels of
government and public and private sector operations. Do these
multi-level, multi-sectoral public health and transportation emergency
preparedness plans do all this?

Not in most countries today, and not in most states and cities and rural
counties, and even where health and transportation emergency
preparedness plans do exist, as in the city of Boston, the State of
Massachusetts, the U.S. Department of Health and Human Services and CDC,
and worldwide at the UN's World Health Organization, they are everywhere
incomplete. The best and most current influenza pandemic preparedness
planning documents have been produced by WHO\* and US HHS\*\*, but they
also lack specificity of advice and recommendations for the state and
local levels of action under the current and probably at least
six-months persisting circumstances of absence of effective vaccines and
anti-virals. Advice to local governments, institutions and enterprises
concerning non-medical health interventions to stop the pandemic, and
operations and business continuity planning is almost totally lacking.
The transportation logistics of maintaining continuity of operations of
government, industry, and commerce in a deadly humanly contagious avian
flu pandemic environment is almost totally neglected, and urgently
requires much detailed study, analysis, planning, and implementation
training and evaluation.

## OFFICIAL SOURCES

\*WHO[: Responding to the avian influenza pandemic threat: Recommended
Strategic Actions]{.underline}.18 pages. Communicable Disease
Surveillance and Response, Global Influenza Programme, 2005

[WHO global influenza preparedness plan: The role of WHO and
recommendations for national measures before and during
pandemics]{.underline}, 49 pages,

Department of Communicable Disease, Surveillance and Response, Global
Influenza Programme, 2005

[WHO checklist for influenza pandemic preparedness
planning]{.underline}. 30 pages.

Department of Communicable Disease, Surveillance and Response, Global
Influenza Programme, 2005

[WHO Outbreak Communication: WHO Influenza Pandemic Handbook for
Journalists]{.underline}, updated 1 November 2005. 15-page booklet. See
especially "Non-medical health interventions: Other potential ways to
stop the pandemic.", p.8-10

\*\*[HHS Pandemic Influenza Plan]{.underline}, U.S. Department of Health
and Human Services. November 2005. Approximately 200 pages.

See especially "PART 2 -- PUBLIC HEALTH GUIDANCE FOR STATE AND LOCAL
PARTNERS", and

"Supplement 8: Community disease control and prevention", pp. 1-36,

"Supplement 9, **Managing travel-related risk of disease
transmission**", pp. 1-17.

And "Supplement 10, Public health communications", pp. 1-17

# Commonwealth of Massachusetts: **Influenza Pandemic Preparedness Plan**

# Revised October 5, 2005. Massachusetts Department of Public Health. 58 pages. 

BRAZIL CONTINGENCY PLAN TO CONFRONT AN INFLUENZA PANDEMIC- PRELIMINARY
VERSION, Health Ministry, Health Surveillance Secretary, 9/2005

"Emergency assistance for early detection and prevention of avian
influenza in eastern and southern Africa", FAO/OIE (World Organization
for Animal Health), 11/2005.

## UNOFFICIAL BUT USEFUL SOURCES

Tyler Cowen, "Avian Flu: What Should Be Done", Working Paper Series,
Mercatus Center, George Mason University, November 11, 2005.

Mike Davis, [The Monster at Our Door: *The Global Threat of Avian Flu
*]{.underline}

New York, The New Press, 2005

John Hart, [H5N1 Virus: How to Protect Your Family Against The Coming
Pandemic]{.underline}

Oregon City, Oregon. Urgent eBooks, January 2005

"The Threat of Pandemic Influenza: Are We Ready? Workshop Summary",

Board on Global Health, The National Academies Press, 2005

APPENDIX A:

"Dr Abt,

Here is the file for the ASHRAE standard. Look under 6.3.1

**Claude THIBEAULT MD**\
Medical Advisor , International Air Transport Association,\
Tel +1 (514) 390-6810\
Fax +1 (514) 874 2662\
thibeaultc@iata.org

**International Air Transport Association**\
800, Place Victoria, P.O. Box 113\
Montreal, Quebec, Canada, H4Z 1M1\
[www.iata.org](mip://01e319a0/www.iata.org)
\<\<ASHRAE_Stds_CabinAir.zip\>\>

6.3.1 Recirculated Air Quality\
All air that is recirculated through the aircraft systems shall pass
through a high efficiency\
particulate air (HEPA) filter before it is supplied to the cabin. HEPA
filters used for this purpose\
shall meet or exceed the requirements of Institute of Environmental
Science and Technology\
(IEST) Filter Type \"B,\" MERV 17 or H13 according to EN 1822-1, and
shall provide 99.97%\
collection efficiency for 0.3 micron particles. The leak tests conducted
to meet this requirement\
shall be on the standard aircraft holding frame used for the filter in
accordance with IEST-RPCC0034.1 or EN1822-4. These filters and their
mountings shall be designed, installed and\
maintained according to manufacturer recommendations to prevent
bypassing of unfiltered air\
due to media failure, improper installation, or other causes. Air used
for recirculation should be\
extracted from the cabin at locations where the air is expected to be
the least contaminated "

Personal Communication of additional comments from Claude Thibault, MD,
12/8/05, in response to questions by Clark Abt:

On the feasibility of using the HEPA filters to detect H5N1 and other
pathenogenic viral or bacterial loads by removing the filters after
international flights from bird flu-infested locations and testing them,
Dr. Thibault suggested that the filters should be left alone to be
changed only after the recommended 4000 hours of many flights. He
believes that while a picked-up virus might remain in the core of the
filter, it would be logistically impossible to change filters after
every long flight. When filters are changed, mechanics should put on
gloves to reduce the probability that some virus remains on the outer
surfaces of the filter.

Concerning the addition of ultraviolet radiation before or after
filtering the cabin air with the HEPA filters, Dr. Thibault questioned
the utility of this addition, suggesting that it was not needed to
supplement the 99.97% effectiveness of the HEPA filters.

Concerning the in-flight isolation of sick passengers that passed entry
screening, he said that segregating them in the rear of the cabin with
at least several rows of separation could significantly reduce
probability of transmission of infection to healthy passengers, because
the air supply for the forward and mid sections of the cabin would pass
through the HEPA filters before recirculating from the floor returns
from the rear, and because studies had shown that physical separation of
a few rows would reduced the probability of aerosol transmission.

Concerning air terminal entry and exit screening of passengers and
aircrews, there is thermal screening in Hong Kong, Singapore, and there
was exit screening in Vancouver and Toronto during the SARS pandemic in
2003. The procedure for responding to departing passengers detected as
febrile is to not let them board their flights and divert them to a
holding room for further assessment by public health authorities,
together with voluntary interviews and questionnaire completion and
review, to determine if they should be quarantined or otherwise treated
and/or isolated. For arriving passengers in Singapore and Hong Kong, the
same procedure is believed to be followed.

In the US and many other countries, the legal civil rights to freedom of
movement and privacy of medical information cannot be violated by
enforced detention or restriction of movement without a declaration of a
public health emergency by either the President or the State Governor.
This is not likely to be declared before numerous cases appear both
abroad and probably in the US, so initially the efficacy of passenger
and aircrew airport and aircraft entry and exit screening is likely to
depend entirely on voluntary compliance with screening, containment and
diversion procedures. Means of motivating voluntary compliance with
ideal -- from the public health point of view -- screening procedures,
by some combination of education and incentives, needs much further
study, as do the decision criteria for legalizing enforcement of
involuntary screening of uncooperative passengers by Governors' or
presidential declarations of a public health emergency.

An international meeting and technical conference on airport and airline
contingency planning for a influenza pandemic emergency and the above
and related issues of airline and airport global influenza pandemic
preparedness planning is currently being organized by ICAO and WHO for
February 2006 in Singapore, where Dr. Genil Singh is the medical
director. Dr. Anthony Evans is ICAO medical director.

APPENDIX B Presentations on Influenza Pandemic Preparedness by Clark C.
Abt

I

# A Presentation to the Cambridge College Forum, Newton Marriott Hotel, November 28, 2005: 

#  "Prescription for Success: The Management of a Healthy HMO"

#  by Clark C. Abt, Ph.D., Chairman Emeritus, Abt Associates Inc. 

# 

#  [BE PREPARED FOR A BIRD FLU PANDEMIC IN 2006]{.underline} 

**A CHECK LIST OF WHAT GOVERNMENT AND YOU CAN DO**

##  TO PROTECT YOURSELF, YOUR HOME, FAMILY, AND WORKPLACE

**[PREPARE FOR A WORST CASE SCENARIO]{.underline}:** **TV and radio news
report outbreaks of deadly, humanly contagious avian influenza (aka bird
flu) in China, Indonesia, Europe, and in San Francisco, Chicago, and New
York. Untreated, one third of the people infected die. Hospitals and
clinics are overwhelmed, but in hospitals where anti-viral and
respiratory treatment is available fatalities drop to 10%. Such
treatment is available only to one percent of the population. There is
no specific vaccine available, and will not be for months. People across
the state stay home out of fear of contagion, and absenteeism rises
dramatically at workplaces, including at some hospitals, clinics, police
and fire stations, subways and bus lines, and banks.**

**[WHAT GOVERNMENT WOULD DO]{.underline}: The President goes on TV and
radio and announces a national public health emergency, restricting
international and inter-city air and rail travel to essential personnel
pre-screened for being free of bird flu; a crash program to mass produce
Tamiflu and other anti-viral medicines and human bird-flu-specific
vaccines to begin being distributed in 'a few months'; and urges state
and local governments to institute their pre-planned pandemic control
procedures and to consult the CDC, FEMA and WHO web sites for further
information and more detailed recommendations.**

Public health officials acting under governors' declaration of a public
health emergency will try to isolate suspected patients entering the
city at airports, railroad & bus stations, or residents there, set up
flu-shot centers to deliver any available vaccines and antivirals, and
treat suspected and confirmed flu victims in isolation wards hastily
arranged at or near hospitals and clinics.

Governors and big city mayors will order schools closed, theaters
closed, major public gatherings like sports events and concerts
cancelled, restrict and possibly reduce public transport and other
public services such as garbage collection, and recommend that
non-essential workers work and shelter at home, while essential workers
wear face masks and minimize their social contacts. Shopping centers,
department stores and restaurants are allowed to stay open, but many
close voluntarily. Possibly police and/or firemen and/or national guard
troops will be ordered to take over food shops and pharmacies and help
distribute food and essential medicines to the doorsteps (thus avoiding
physical contact) of unprepared homebound elderly, sick and poor people.

**[WHAT YOU CAN DO]{.underline}: Prepare to shelter at home with your
family or at your critical workplace with co-workers for 4 weeks, by
stocking up on non-perishable foods, medicines, warm clothing, and
batteries for radios and flashlights. Stay away from crowded spaces like
subways, buses, shopping centers, and restaurants. If you must go out,
wear a disposable surgical mask, don't handle pay phones, railings, or
door handles, and don't touch your mouth or eyes afterwards if you do.
Wash your hands often. If you can get enough of it, take Tamiflu every
day you go out until the pandemic is over as announced on radio and TV.
Keep well informed by tuning in daily to radio and TV news, and to US
Government CDC, HHS, FEMA, and WHO websites. Continue your work at home
or in small groups at isolated workplaces. Stay in touch with relatives,
friends, and neighbors and prepare to share pre-stocked food if any run
out. Ask your employer to prepare pandemic business continuity plans,
including provisions for telecommuting for those sheltering at home and
food supply for those at critical workplaces such as hospitals.**

A good triggering point for action would be *sustained human to human
transmission, anywhere in the world of a flu strain with high morbidity
and mortality*.

 

This is what is assumed may happen if the avian flu (which has a high
mortality rate in humans) crosses with a human strain (i.e.
transmissible human to human) and a new strain emerges that retains the
high morbidity and transmissibility.  Of course a new strain may not
have the same characteristics.

 

The spread of avian flu amongst birds is not in itself a danger to
humans.  It is a significant problem economically for farmers etc, but
as long as the strain is not transmissible from human to human it is not
a significant threat to human health.  The most likely place for a new
strain to emerge that is a cross between the avian flu and a human
transmissible strain, is in a less well

II

Special Session of UN Project LINK chaired by Prof. Peter Pauly,
November 2, 2005

UNCTAD, Geneva. Conference Room 23, Building E

### ECONOMIC ASPECTS OF A GLOBAL BIRD FLU PANDEMIC 

Clark C. Abt, Ph. D.

A global avian influenza ('Bird Flu') pandemic is the greatest threat to
the world economy today, and probably for the next decade or more,
depending on what actions are taken now and in the next few years to
reduce the risk. Public health and biomedical experts at the UN's World
Health Organization (WHO), the US Centers for Disease Control and
Prevention (CDC), and other national public health authorities are in
agreement that such a pandemic -- an epidemic that spreads across a
large region -- will occur, perhaps this year, or next, or later. The
way the public health authorities put it is that it is no longer a
question of 'if', but 'when'. Other uncertainties remain: How
long-lasting? How many successive waves? How likely to mutate from a
deadly disease killing millions of chickens, ducks, geese, and infecting
over a hundred humans and killing half of them, to a deadly contagious
human-to-human form potentially infecting a billion people and killing
many millions? How deadly a human-to-human strain? How contagious and
transmissible, to humans and other animals? How treatable? How damaging
to the world and national economies? How costly is it to prevent
human-to-human bird flu, or if it cannot be prevented, how costly is it
to reduce the risk, reduce deaths and damage to economies and societies?

Despite the many remaining uncertainties, there exists considerable
scientific knowledge.

Drawing on the available scientific, biomedical, epidemiological, and
overall public health knowledge assembled by the WHO and national public
health and biomedical research institutions, we here attempt to identify
broadly, qualitatively, and roughly quantitatively ***the economic
aspects*** of a global bird flu pandemic, both in its current form
affecting mainly birds and other animals, and in its much more deadly
and damaging human-to-human contagious form that biomedical experts
believe is likely to occur at any time in the near and more distant
future. We also want to identify some of the major economic aspects of
bird flu pandemic prevention, containment, control, and treatment, for
both their benefits in reducing deaths and economic damage, and their
costs. Time permitting, we would like to identify at least some of the
more critical

Effectiveness-efficiency-equity tradeoffs among the available public
health, biomedical, pharmaceutical, and non-pharmaceutical containment
and treatment interventions, and what nations and populations are most
likely to bear the burdens of such a pandemic, and its costs in lives
and economy, and what nations have the resources to invest in pandemic
damage reduction measures.

Given time limitations, we are going to concentrate on the short-term
threat to the world economy, and what can be done to reduce it in the
next year or two, before enough supplies of vaccines and anti-viral
medicines can be made available to supply more than one or two percent
of the world population at risk (and ***all 6.5 billion*** of it
***is*** at risk).

WHO's Dr. Klaus Stohr, with input from CDC epidemiologists, recently
presented at the October 11 Wall Street symposium on avian influenza
sponsored by UPMC and Deutsche Bank, the relatively best case assessment
of minimum deaths and illness, extrapolating from the relatively mild
flu pandemic of 1957 and 1968, with a case fatality rate of 0.6 %. On
that basis, if humanly-transmissable bird flu broke out today, between
500 million and 1.2 billion of the world population of 6.5 billion would
become infected and clinically ill, having to spend perhaps a day or two
at home to recover. 600 to 800 million would require medical care (if
available). 6.4 to 28 million would require hospitalization (again, if
available), and there would be from 2 to 7 million deaths worldwide.
This is a conservative estimate of probably the best case of a flu
pandemic.

WHO believes that this conservative estimate of a relatively mild
humanly contagious flu pandemic alone, justifies a major prevention and
containment effort by all governments to reduce the risks of millions of
lives and billions of dollars lost.

What are the direct economic costs of this "best case" flu epidemic?
Estimates have ranged between \$150 billion and \$200 billion for the
world. In the 2003 SARS epidemic some 900 died and Canada's GNP dropped
0.2% to 1.8%. Some 10,000 people were quarantined successfully in
Toronto, and the epidemic was contained by an all-out cooperative
international effort. The economic cost has been estimated at \$30-50
billion, not including many indirect losses of trade, tourism, and labor
productivity difficult to capture. The cost of the successful
containment effort is not known, but must surely be less than 1%
(\$3-500 million) of the cost of the SARS epidemic. An under 1% public
health insurance cost seems like a very worth while and affordable
investment in saving much larger loss of life and economic welfare.

The 1918-1919 so-called Spanish flu was much worse, resulting in between
50 and 100 million deaths worldwide and 500,000 deaths in the US
population of 115 million, or a roughly case fatality rate of about half
a percent. This all happened in a few months.

There was a first wave peaking in 4-5 weeks, then abiding in two more,
then coming back with a vengeance in most destructive second wave. The
flu virus pandemic became global within three months, spread by ships
and trains. In today's interconnected world of air travel, a deadly
humanly contagious flu pandemic would become global in a couple of days,
and mass fatalities would also begin in a few days. At the 1918-19 case
fatality rate of about half a percent, assuming about two billion of the
world population would become infected (most of the urban and some of
the rural population on all continents), some 200 million people would
die within a few months, given the current and next year anti-viral and
or vaccine coverage of no more than 2% of the world population.

The essential economic issue for the short term of the next year or two,
what can be done to reduce this risk to lives and economies now, before
longer term defenses of vaccine and anti-viral mass production can catch
up to the threat, and what investments are required, what will these
short term efforts to reduce but not eliminate the damage of a humanly
transmissible avian flu pandemic?

The approach recommended by some WHO experts is to control the disease
in birds. The prospects for such control are bleak, for many reasons.
The next best measure that should be taken in any case is to strengthen
worldwide surveillance to provide earliest possible warning of an
outbreak. The 150 surveillance centers and WHO regional and country
offices will have only a very narrow 30-day window of opportunity to
contain the pandemic from its start to containment or spread. It takes
4-5 days for rural infected patients to show up in clinics, several more
for diagnosis and virus characterization,

Then another 10-15 days for contact tracing and to bring them in for
diagnosis and anti-viral treatment and/or isolation.

International cooperation must be fully organized before an outbreak,
and WHO is the best hope of reaching all the world's 250 nations (of
which only some 50 are believed to have started on response plans.

In the 40 trillion dollar economy, some 10% or \$3 trillion comes from
transportation and travel. The UK estimates that it would reduce air
travel 90% to delay the virus from arriving for 2-3 weeks. Consider the
world impact, costing at least a trillion dollars of just travel and
transport restrictions.

A global stockpile of anti-virals for 20% of the world population (1.3
billion) would cost about \$14 billion. This will take at least 3 years
to achieve, if the necessary investments are made in the next few
months. Here it was good to learn that the US is committing \$8 billion
to bird flu defenses, of which \$3 billion is for anti-virals and \$3
billion is for vaccine development. But we need another \$11 billion for
the global anti-viral stockpile.

That should be affordable and advantageous, given the trillions of
savings in reduced flu pandemic deaths and damage it could yield.

But the other short term measures -- given absence of sufficient
vaccines and anti-virals for the next year -- are more difficult to cost
out, for the added logistic and food prestocking and distribution
necessary to shelter in homes or vital workplaces for several weeks to
avoid contagion. The chief cost would be the labor lost and absenteeism,
and that remains to be calculated. But the cost of ***preparations*** to
shelter in place are relatively modest, consisting mostly of
communications, public education and training, and prestocking of
non-perishable food supplies that are eventually consumed anyway.

III

[**BirdFluPlex:** An Exercise for Planning Emergency Preparedness for an
Avian Flu Outbreak in Greater Boston (Bottom-up / Top-off
Program),]{.underline} by Clark C. Abt

Local & state government, health care communities, media, and
corporations need to do more to prepare for the health, social, and
economic impacts of the coming Avian Influenza Pandemic.

While many government and health care organizations have developed
plans, these plans fail to address practical action items at a community
and individual level (parents of school-age children, school teachers
and principals, transportation workers, food service managers, mayors,
city council members, policemen, firemen, pharmacists, poor singles,
hospital administrators, nurses, clinicians, grandparents, health plan
providers, major employers, shopkeepers, construction workers,
reporters, etc.).

Further, government organizations may not sound sufficiently timely
early warning for fear of producing a false alarm provoking high
political and economic costs. .

Dr. Clark Abt, an expert in developing human player simulation models,
together with representatives from Tufts University, Mass General
Hospital (MGH) and the World Health Organization (WHO), has developed a
human simulation program for the purpose of helping individually and
collectively to prepare for and mitigate the coming Avian Influenza
Pandemic.

The United Nations Association of Greater Boston and BearingPoint's
Health Care Consulting Group will be hosting a series of these
simulations throughout the coming months for leaders of various
communities within Greater Boston.

These simulations models will be packaged and made available to groups
nationwide as an effective and affordable grassroots initiative to
better prepare their local population (at all levels) for surviving an
Avian Influenza Pandemic.

The results of the exercises will be synthesized and brought to the
attention of appropriate state and local government officials.

> *\"These exercises have been regarded as eye-openers, resulting in
> recognition of precise critical weaknesses in day-to-day operations
> and the formulation of precise recommendations for their
> correction.\"*

-   WHO\'s 2005 report, \"Responding to the avian influenza pandemic
    threat: recommended strategic actions\" recommends (p.16): \"Develop
    model pandemic response exercises

# SCENARIOS

# 

# Starting Scenario

# 

Greater Boston: Dec, Jan, Feb, March, April Morning (Real Time duration
periods for each phase of weeks to months to be simulated by hours to
days) 

**Inter-Pandemic Period**

[Phase 1]{.underline} - New animal flu viruses only - no new flu
subtypes detected in humans.

[Phase 2]{.underline} - Circulating animal flu subtype poses risk of
human disease (affects extensive travel/trade links with affected
countries)

**Pandemic Alert Period**

[Phase 3]{.underline} - Human infection with new subtype, no
human-to-human spread, rare spread to close contacts (affects extensive
travel/trade links with affected countries).

[Phase 4]{.underline} - Small clusters with limited human-to-human
transmission but spread is highly localized (travel/trade links with
affected countries affected).

[Phase 5]{.underline} - Larger clusters but human-to-human spread still
localized substantial** **pandemic risk (travel/trade links with
affected country clusters strongly affected).

*More detailed Phase 5 Scenario in process.*

**Pandemic Period**

[Phase 6]{.underline}- Pandemic phase: Increased and sustained
transmission in general population in multiple countries and regions.

 

-   SCENARIO A: WHO and world and local Boston news media in December
    report large clusters of human-to-human-contagious and deadly Avian
    Influenza in Addis Ababa and Nairobi, with local hospitals and
    clinics overwhelmed with hundreds of cases, one third of whom die
    within days. Travel advisories suggest not visiting East Africa.
    Airline passengers from Nairobi to London (preferred route to US,
    Boston) are screened at Heathrow for fever and illness, not
    permitted to board flights to US if febrile until blood tests
    establish they are not ill with bird flu. A run on Paniflu in the UK
    and US quickly established the lack of supply for more than a few
    tens of thousands in the UK and no more than hundreds in the Boston
    area. Governor Romney, Mayor Menino, and MassPort Communications
    Director, with DPH Commissioner, must decide what to do about
    incoming flights from London and Africa, and other precautionary
    measures. Many physicians, journalists and ordinary citizens
    overwhelm public health and hospital authorities with questions
    about how to prevent and prepare for the coming of bird flu to
    Boston, and insist on being answered. CDC and WHO websites do not
    offer specific short-term guidance.

 

-   SCENARIO B: Late December -- Much airline traffic over the Christmas
    holidays. Several clusters of humanly-transmitted Avian Flu have
    emerged in London, Paris, Frankfurt, New York, Washington, Chicago,
    and Boston. State labs and public health epidemiologists are unable
    to keep up with the demand, but have already identified clusters of
    avian flu deaths, usually associated with recent air travel from
    Europe or rail or bus travel from New York. Some stores and movie
    theaters have closed without being asked to do so by the
    authorities. Dozens of diagnosed or suspected cases have filled
    Boston hospital isolation wards. Food stores are crowded with people
    stocking up on canned goods. Mayor Menino must decide whether to
    close Boston public schools, but some teachers are already staying
    home with their families. Governor Romney must decide about curfews
    and quarantine. Hospitals and Public Health Commissioner call CDC
    for anti-virals and advice, media report the increasing death toll
    in Eastern cities and greater Boston. Traffic jams on Mass. Turnpike
    heading west, threatened further by an approaching blizzard, despite
    some media and public health advice to shelter at home.

> Some major employers urge all employees with even mild cases of flu to
> remain at home.
>
> Others in the financial and high tech industries urge professional
> employees to work at home at their computers. Many poor people crowd
> to local clinics, terrified by the news.
>
> Some pharmacies are looted in desperate searches for Tami flu and
> anti-biotic. The governor and mayor must decide on what to announce to
> the public, what orders to give municipal schools, hospitals, police,
> firemen, transport workers, and utility workers.
>
> Discussions between business leaders and state officials concerning
> closing down malls and shopping centers remain deadlocked, as many
> object to shutting down the economy.
>
> There is no help from federal authorities. Many families are
> withdrawing their children from the still open schools, and
> absenteeism from work rises dramatically across Eastern Massachusetts.

 

-   *More detailed Phase 6 Scenario in process.*

 

**Post-Pandemic (Recovery) Period**

BirdFluPlex will initially simulate only Phase 5 and mostly Phase 6.
Subsequent exercises may incorporate pre-and post-crisis situations.

>  

**PARTICIPATING ROLE-PLAYER'S GUIDE**

>  

**Goals**

Goals will vary with different roles, but they all have in common the
accomplishment of the individual role's mission of meeting their
government, professional, work and family responsibilities within legal
and resource constraints and with maximum effectiveness,
efficiency/economy, and fairness.

 

**Decision Making Power**

Formal legal powers, such as declaration of and enforcement of
quarantines and isolation, closing schools and theaters and shopping
centers, allocating transportation resources, food and medical supplies,
controlling ground travel and traffic, controlling surface and air
travel into and out of the area, delegating missions to those not
usually carrying them out, such as competent and willing volunteers,
etc., announcements and warning releases of public information to the
media.

 

 

**Resources**

[Knowledge resources]{.underline}: expert knowledge of biomedical,
health, logistics, police

[Physical resources]{.underline}: vaccines, antivirals, medications, lab
equipment, hospital beds and equipment, transport vehicles (cars,
trucks, buses, helicopters) food and shelter supplies, communication
equipment (radios, cell phones, 2-way radios, etc.)

>  

**Activities**

-   Asking and answering questions

-   Resources allocation decisions and their communication to
    implementers

-   Professional communications

-   Public communication

-   Physical interventions within your responsibility, powers,
    capabilities, & resources

-   Recording (however briefly) all major decisions and public
    communications on audio tape or brief written note form, for later
    evaluation

 

 

**DESIGN CHECK LIST**

1.  **Selection of the Role-Playing Simulation Approach**

    1.  Pandemic Emergency Preparedness Planning and Training

    2.  Participant Needs for Knowledge, Education, Communication,
        Training

    3.  Time, Place and other Resources Availability and Constraints

    4.  Role-Playing Simulation Advantages of Speed, Impact, & Economy

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1.  **Decide Simulation Objectives**

    1.  Select Simulation Subject: Bird Flu Pandemic Preparedness

    2.  Determine Scope in Reality Time, Space, and Function: 10 days,
        Boston, All emergency responses; and in equivalent Simulation:
        5-10 Hours, Large room, 7 most relevant communities of
        participant stake-holders.

    3.  Differentiate and specify Objectives: Recognition of weaknesses
        in

    4.  Current pandemic flu emergency planning and operations,

    5.  Identification of corrective actions, testing of corrective
        actions,

    6.  Awareness, decision-making, communications and action training.

2.  **Collect Simulation Data**

    1.  Data Needs: Avian Influenza epidemiology in animals and humans,
        health

    2.  care and other emergency response capacities, government and

    3.  Individual knowledge and decision-making capacities, public and
        professional and government crisis communications capacity.

    4.  Identification of Data Sources: WHO, CDC, FAO, UPMC, University

    5.  Schools of public health, HMO's, Hospitals, Research Institutes

    6.  Identify and review relevant models: Timely literature search
        complete.

3.  **Design Simulation Model**

    1.  Identify Actors (done)

    2.  Actor Goals (done)

    3.  " Actor Resources (in process)

    4.  " Actor Interactions ( " )

4.  **Develop Simulation Materials**

    1.  Write Scenarios (for Pandemic Alert and Pandemic Periods)

    2.  Refine Role Profiles with specific goals, resources, activities

    3.  Prepare Simulation Game Rules

    4.  Prepare supplementary materials (data sheets, forms, etc.)

5.  **Operate the Simulation**

    1.  Arrange logistic support: Facilities, communications, etc.

    2.  Review all materials and procedures, recruit role-playing
        participants

    3.  Brief and orient all simulation game participants

    4.  Operate the Simulation

    5.  Debrief participants

6.  **Evaluate the Simulation**

    1.  Provide Post-Simulation Analysis

    2.  Review records, notes, tapes

    3.  Assess Simulation learning vs. objectives

    4.  Redesign and/or modify Simulation for replication

**DISCUSSION GUIDE**

 

1.  Have we (local & state government, health care community, media,
    financial community, business and employers)  done all we can to
    prevent, be prepared for, and mitigate the health, social, and
    economic impacts of the coming Avian Influenza Pandemic?

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1.  How far are we (local & state government, health care community,
    media, financial community, business and employers) falling short?

2.  What can we do, individually and collectively, to better prepare for
    and mitigate the coming Avian Influenza Pandemic?

3.  What is the role of public education, authoritatively and most
    completely informed by the UN\'s WHO, in achieving better
    preparation of greater Boston\'s population (at all levels) for
    surviving and mitigating an Avian Influenza Pandemic?

 

-   \"Several countries have already conducted table-top exercises to
    rehearse their pandemic response plans. These exercises have been
    regarded as eye-openers, resulting in recognition of precise
    critical weaknesses in day-to-day operations and the formulation of
    precise recommendations for their correction.\"  \-- WHO\'s 2005
    report, \"[Responding to the avian influenza pandemic threat:
    recommended strategic actions]{.underline}\" recommends (p.16):
    \"Develop model pandemic response exercises." 

**ROLES**

Select Minimum of 7 - at least one from each of 7 categories, Max.5x7=35

 

**Public Schools**

-   Public high school teenage student(s)

-   High school nurse, mother of 2 children

-   Elementary school teacher, mother of 3 children

-   Single mom on welfare with 2 teenagers & 2 infants

-   Day care center director, mother of 2 children

-   High school principal with working wife & 2 teenagers

-   School superintendent, father of 2 adult children

-   Teacher's Union president, mother of 2 teenagers

 

**Public transportation**

-   Transport worker - Subway motorman - Father of 2 teens

-   Transport worker - Airport air controller- father of 4

-   Transport worker - School bus driver - Mother of 1 child

-   Transport worker - Bus driver - Father of 3 children

-   Transport worker - Garbage truck driver - Father of 2

-   Transport worker - Interstate truck driver - single

-   Transport worker - Taxicab driver - Father of 2 children

-   British airways captain/pilot, stewardess

-   MBTA Transit Police Chief  ‑ Father of 4 teens

-   Teamster's Union President - Father of 3 teens

-   Mass Port CEO, Amtrak CEO, USAir Logan airport US customs
    inspector - father of 5

 

## *Food Services and Public Restaurants*

-   McDonald's cook - Single male

-   McDonald's manager - Single mom with one infant child

-   Howard Johnson's food services manager

-   Stop & shop meat counter butcher - Father of 2 teens

-   Stop & shop store manager

-   Legal seafood chain owner/CEO, pizza shop chain CEO

-   Ritz-Carlton Hotel dining room manager, chef

-   Meals-on-wheels manager - Mother of 2 children

-   Wilson Farms CEO, pet shop owner

>  

## *Local and State Government*

-   Boston Mayor

-   City Council President

-   Boston Chief Of Police

-   Boston Head Of Emergency Medicine

-   Boston City Hospital Director

-   State Epidemiologist, Asst. Cmr. Public Health

-   Massachusetts Commissioner of Public Health

-   Massachusetts Commissioner of Public Safety

-   Governor Romney, Lt.Gov. Healy of Massachusetts

-   U.S. Senators Kennedy, Kerry

-   Congressman Capuano, State Rep. Alice Wolf

>  

## *Medical and Health Care Communities*

-   Children's hospital nurse - Mother of 2 teens

-   Roxbury Clinic, GP/internal medicine MD - Mother of 1

-   Mass general hospital ER Surgeon - father of 2 toddlers

-   Brigham & Women's Hospital intern - Single female

-   State public health lab director - Father of two teens

-   State public health lab technician - Single

-   Partners, Tufts HMO CEO's

-   Mass. Blue Cross/Blue Shield CEO

-   Mass. Medical Society President

-   Harvard School of Public Health Dean

-   Harvard Medical School Dean

-   Nobel-Prize Winning Virologist

 

## ***Major employers***

-   Major real estate firm CEO, major landlord

-   Boston gas & electric line repairman - Father of three

-   Bank clerk, mother of two elementary school children

-   Bank branch manager, South End - Single mom with 1 child

-   Bank of America, Boston CEO

-   John Hancock insurance co. CEO

-   New England Telephone CEO

-   Boston Gas & Electric CEO

-   Filene's, Jordan Marsh CEO

-   Fidelity Investments CEO

-   Loews Theaters, Boston Symphony CEO

-   Tufts Medical Center CEO

-   Boston Consulting Group CEO

-   B.U., B.C., U. Mass. Boston Presidents

-   Northeastern University, President

-   MIT, Harvard University President

-   Biotech Industry Council President

>  

## *Media/communications*

-   Boston Globe/Herald Reporter

-   Boston Globe Editor

-   Boston Tab Reporter

-   TV News Anchorman/Woman (R.D. Sahl, N. Jacobson)

-   Channel 2 Public TV/Radio Commentator (Ms. Rooney)

-   Radio News Commentator (WBUR "The Connection")

-   New England Journal Of Medicine Editor

-   Atlantic Monthly Editor, Boston Magazine Editor

-   B.U. School Of Journalism Dean

-   Local Mystery Story Writer (Robert B. Parker?)