Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

[Thomas Luke]

All,

please see the abstract below for a recent article my colleague and I published. A full text version can be found at: http://people.hofstra.edu/jean-paul_...-2_05-Luke.pdf

We would appreciate comments.

Sincerely

Thomas Luke, MD, MTMH

Luke TC, Rodrigue JP. Protecting public health and global freight transportation systems during an influenza pandemic. Am J Disaster Med. 2008Mar-Apr;3(2):99-107.

The H5N1 influenza threat is resulting in global preparations for the
next influenza pandemic. Pandemic influenza planners are prioritizing
scarce vaccine, antivirals, and public health support for different
segments of society. The freight, bulk goods, and energy transportation
network comprise the maritime, rail, air, and trucking industries. It
relies on small numbers of specialized workers who cannot be rapidly
replaced if lost due to death, illness, or voluntary absenteeism.
Because transportation networks link economies, provide critical
infrastructures with working material, and supply citizens with
necessary commodities, disrupted transportation systems can lead to
cascading failures in social and economic systems. However, some
pandemic influenza plans have assigned transportation workers a low
priority for public health support, vaccine, and antivirals. The science
of Transportation Geography demonstrates that transportation networks
and workers are concentrated at, or funnel through, a small number of
chokepoints and corridors. Chokepoints should be used to rapidly and
efficiently vaccinate and prophylax the transportation worker cohort and
to implement transmission prevention measures and thereby protect the
ability to move goods. Nations, states, the transportation industry and
unions, businesses, and other stakeholders must plan, resource, and
exercise, and then conduct a transportation health assurance and
security campaign for an influenza pandemic.

[sharon sanders]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Welcome Thomas Luke.

I look forward to reading your paper. Great topic.

Moderators, please leave this poll in Current News. Thanks!

[sharon sanders]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Please also see - Notice of Availability of Draft Guidances to Assist in Preparation for an Influenza Pandemic - HHS.

http://www.flutrackers.com/forum/showthread.php?t=70752

[gsgs]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

of course, they should be prioritized.

But how much ? How many ?

[mixin]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Finally, someone from transportation. Welcome Thomas Luke. When the Vaccination Prioritization webdialogs were ongoing, I think the flubies made it clear that the top priority should be keeping the grid intact.

However, after reading the sector-specific guidelines below, it gets so much more complicated than just who gets vaxed. Maybe you are in a position to share with us how any of these sectors are progressing with their planning.

In one of those I read it was suggested that a sector should formulate its plans by going back at least 2 tiers of suppliers. I cannot imagine the success of a plan based on those of suppliers to suppliers.

DOT Pandemic Flu Planning
Aviation, Highway/Motor Carrier, Maritime, Mass Transit, & Railroad Sub-Sector Pandemic Influenza Planning Guidelines (annexes).

These 5 annexes are intended to assist the Transportation Sub-Sectors, and associated public and private sector businesses plan for a severe influenza pandemic.

These Sector-specific guidelines are annexes to the Pandemic Influenza Preparedness, Response, and Recovery Guide for Critical Infrastructure and Key Resources developed by the Department of Homeland Security and posted at: http://www.pandemicflu.gov/plan/pdf/...uenzaguide.pdf.

Aviation Sub-Sector Pandemic Influenza Planning Guidelines (Draft) (218 KB)

Highway and Motor Carrier Sub-Sector Pandemic Influenza Planning Guideline (Draft) (145 KB)

Maritime Sub-Sector Pandemic Influenza Planning Guidelines (Draft) (206 KB)

Mass Transit Sub-Sector Pandemic Influenza Planning Guideline (Draft) (153 KB)

Railroad Sub-Sector Pandemic Influenza Planning Guideline (Draft) (189 KB)

For more information, or if you require an accessible version of any of these documents, please contact Joan Harris at joan.harris@dot.gov.

http://www.dot.gov/pandemicflu/

[Sally Furniss]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Poll: Should critical infrastructure workers have the highest priority for vaccine, antivirals, PPE .....

Welcome Thomas Luke

What infrastructures are included in your definition of critical infrastructure?

[cartski]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Fascinating!

Welcome.

J.

[Laidback Al]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Thanks for joining and posting the abstract here at FT.

The science of Transportation Geography demonstrates that transportation networks and workers are concentrated at, or funnel through, a small number of chokepoints and corridors.

More information about these chokepoints would be beneficial. With high concentrations of transportation workers, these chokepoints might be acutely associated with higher infection rates (larger R0 numbers). Perhaps these chokepoints would be logical locations for pandemic influenza education and training in NPI to avoid infections in addition to other infection control measures such as vaccination.

[mixin]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

He has some great maps of the corridors in his full text version.

[JJackson]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Welcome and thanks for the link.

It is nice to see some numbers attached to what I think most H5N1 watchers view as a one of the great dangers of pandemic plans – namely insufficient attention to the potential for collateral damage in the event of a clinically severe pandemic.
Influenza is a natural pathogen of birds which periodically make a zoonotic transition causing a pandemic in humans. As an avian disease HPAI H5N1 has reached equilibrium with its natural reservoir (mainly wild waterfowl) in which it causes some symptoms but is not generally fatal. Genetically other species, including poultry and humans, are fairly irrelevant as adaption to these hosts does not generally end up getting back onto the gene pool, the corollary of this is that the severity of the illness caused in these species is coincidental and can be anything from negligible to a 100&#37; <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:stockticker>CFR</st1:stockticker> as even instant death is not an impediment to a pathogen as long as it occurs in an evolutionary dead-end host. The upshot of this is that each new zoonotics emergence can start off with virtually any level of clinical severity – from pinkeye in H7N7 to ARDS in H5N1 – and until equilibrium with the new host is reached we must devise plans to cope with both extremes.
Plans should identify those elements (e.g. voluntary absenteeism) which are most sensitive to changes in <st1:stockticker>CFR</st1:stockticker> (as a crude measure of virulence). The paper makes a vital point regarding the unions not having been adequately included in the decision making process. If the <st1:stockticker>CFR</st1:stockticker> is high any plan is much more likely to be adhered to if those putting themselves in harms way were instrumental in its devising and were able to ensure adequate provision was made to meet their concerns. Those concerns are likely to have a lot more to do with providing security for their families than for themselves or some common good. Unless the concerns of the individual workers are addressed and they feel invested in the plan they will not follow it or feel bound by it. The paper also concerns itself mainly with provision of pharmaceutical entitlement but I think this should be a secondary consideration to putting in place systems designed to provide social distancing. Consider the existing arrangements for a driver (pilot, train or truck) on arrival they need to rest, eat and pick up their next route. The existing systems would require human interactions to achieve all of these and with relatively simple planning they could all be achieved without endangering anyone. The paper obviously addresses some of the flow networks involved but I would like you to consider another type of network as a suitable model for protection of workers – the terrorist cell structure. Here the aim is to protect functional units from exposure by other cells with whom they need to have some contact. Limiting the interactions between nodes to only those that are essential and keeping down the size of functional units to the minimum needed to achieve there allotted task is the underlying driver of the nets structure. <st1:place>Mission</st1:place> critical nodes are duplicated as a backup. Analysis of the functional units, unavoidable & avoidable interactions, resources needed to isolate them and cater for their needs etc. must all be done urgently now in conjunction with the individuals effected. Reliance on a non existent vaccine and prophylaxis by an antiviral that may be ineffective against the pandemic strain, subject to resistance and have not been stockpiled in the quantities required for prophylactic use is unwise.
Another point highlighted is the predominately national approach to a problem that is by definition global in nature. This is bound to be other than optimal; it is analogues to writing bits of code to perform individual functions without any attention being paid to interoperability. The maps showing trade routes and port traffic highlights the enormous volume of globalised trade and the significance of <st1:country-region><st1:place>China</st1:place></st1:country-region> as both a global source for manufactured goods and as a sink for the raw materials and energy that created them. Without a commensurate level of worker protection in key trading-partner nations keeping our end of the conveyer belt working will be of limited use. If the global conveyer system does begin to hiccup two categories from Table 1 will be under particular load. Storage, which normally acts as capacitor smoothing flow, will need to hold goods for which there is either no longer a receiving station or a conveyance. Logistics managers will be the other group whose role will change – and vastly increase - as the system evolves from forwarding to finding, prioritising and rerouting items of importance amongst the co-shipped Jacuzzis and patio furniture.
<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
You asked for comments and while I agree with the arguments for prioritising the supply chain and you provide convincing data to backup you argument I am not sure your focus on redistribution of pharmaceuticals is the best cure. My preferred solution is more aid to and integration with the extended supply chain, changed systems to compartmentalise and firewall work teams.
<o:p></o:p>
I note Thomas is military and if there is one thing you guys are really good at it is logistics so a little work experience in the civilian sector's systems now might be very useful later. You also have hardened C2 which may be vital in a very sever pandemic where infrastructural failures incapacitate the civilian systems; again now is the time to practice integration of the military backbone with civilian data structures.
<o:p></o:p>
JJ

[mixin]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

Just a portion of questions that need to be answered from the draft for the aviation sub-sector.
------------------------------------------------------------
essential services, functions, and processes
? Each airline and airport may be effected and react differently during a pandemic influenza. Each entity is interdependent and its actions will have impacts on the others.
For example, an airline may transfer resources between airports to support shifts in passenger or cargo demand. How would this change affect the airports in question as well as the communities they serve?
? How might a pandemic affect demand for air transportation and how would these impacts affect your revenue and operations?
o Might disease containment strategies (or the? hassle factor ?associated with them) and public fear reduce demand for non-essential travel or constrain the numbers of passengers you can transport safely?
o What are the impacts on passenger demand if air travel-intensive businesses restrict travel, reduce operations, or close temporarily during a pandemic influenza wave?
o Could media attention/public perception affect demand in the first days/weeks of a suspected outbreak, even if no pandemic influenza results (e.g., the outbreak is later proven to be a false alarm, the virus mutates to become less virulent, or the outbreak is contained effectively)?
o What are the potential challenges from multiple pandemic influenza waves lasting two to three months and recurring over a period of 12-18 months? How quickly or not will aviation demand rebound during the recovery period between each wave?
o What are the potential impacts on major tourist and recreational destinations, such as Hawaii and Nevada? How might this impact passenger demand?
o How might geographic and population differences affect passenger and cargo demand levels, routes, frequency, load factors, and/or aircraft size? Would rural isolated areas be more dependent on air service for essential goods and personal transportation? Would residents/businesses in urban/suburban corridors be more likely to shift to other modes?
o How would impacts on international manufacturers and shippers affect domestic as well as international aviation?
? Might there be increases in demand or need for certain services you provide, including:
o on-demand air transportation of essential medical personnel and supplies;
o cargo operations, including the delivery on essential and non-essential retail goods resulting from an increased public use of on-line electronic ordering;
o private aircraft and/or service from small airports from passengers hoping to avoid public contact; and
o cargo aircraft to deliver goods otherwise shipped as belly cargo on passenger airlines where commercial passenger carriers have suspended or reduced operations?
? How can an airline or airport adapt its services to better support the community, region, or nation?
o Can passenger aircraft be used to haul appropriate types of essential cargo?
o Might airlines, with government public health guidance on appropriate spacing and possible economic support, reduce the number of passengers per flight to enhance social distancing and minimize person-to-person close contact?
o Can airports facilitate social distancing in terminals (e.g., blocking off or removing every other seat in waiting areas)?
o If international flights are routed to airports with CDC Quarantine Stations, can other airports shift essential equipment and personnel support to the ports of entry?
o In collaboration with government officials, can airlines, airports and freight forwarders prioritize cargo handling so the most essential goods/products (e.g., healthcare supplies and water treatment utility repair parts) are delivered first?
o How might the sector and the government together ensure that essential air transportation remains available to all regions, including rural areas?
? How will pandemic influenza affect specialty aviation carriers (e.g., air ambulance, fire fighting, fixed/rotary wing safety inspectors, and offshore oilrig support)? How will priority delivery for essential items (i.e., fuel, repair parts) be maintained for these specialty carriers?
Essential Assets and Equipment
? How will a change in demand levels affect your need for equipment (e.g., fewer aircraft would be needed if you consolidate routes or reduce flight frequency on certain routes; fewer airport fire and rescue vehicles would be needed if runways shut down)?
? Can you modify typical processes temporarily to sustain essential assets and equipment? For example, can you operate your essential aviation equipment differently to decrease maintenance/repair requirements (e.g., consolidate routes, reduce flights on certain routes, operate in daylight hours only, rotate aircraft in and out of service)?
o Can your organization close its non-essential facilities and consolidate operations and supplies? For example, can airlines consolidate and operate shared aviation maintenance sites at each airport or can major airline hub operators support all others at a large airport?
o What recurring maintenance requirements exist for the facilities used to house passengers, cargo, workers, equipment, and maintenance operations? Do they demand a continuous level of operations, maintenance, and repair?
o What backup options exist in cases where essential equipment such as heating, cooling and ventilation systems (HVAC) break down?
o Have you developed standard operating and emergency procedures for your essential processes and equipment under other types of emergencies? If so, have you distributed them broadly to managers and staff? Can they be adapted to pandemic flu scenarios lasting 6 months or longer?
o Have you considered primary/supporting asset/equipment challenges, including availability of operators, fuel/electricity, emergency part maintenance, critical radar repair parts, de-icing equipment, FAA/TSA security/safety equipment; and data management systems?
o Have you assessed all contractor-managed primary and supporting aviation systems with your contractors and other key stakeholders to identify potential single-point failures in their support networks (e.g., contractors operating intermodal cargo transfer sites, operational support equipment, aircraft catering suppliers, aircraft and airport cleaning and flight-line refueling crews)?
? Do you possess sufficient operational capacity in your essential equipment and assets to sustain functions and reduce demand on equipment and workers? For example, if essential equipment fails and repair parts become difficult to obtain, are there sufficient numbers of aircraft and support vehicles to rotate in service or ?cannibalize??
? What is the frequency for routine maintenance on essential primary/secondary assets and equipment? How critical is it to perform on this schedule? Can you safely defer or accelerate essential equipment scheduled maintenance on short notice?
? What is the frequency and intensity of typical safety inspections for key infrastructure such as aircraft, runways, control towers, radar, and electronics? In an extreme situation, with appropriate government waivers and other safety oversight, can you safely defer any of these to maximize availability of essential equipment and workers?
? Do your emergency equipment operating plans adequately address pandemic influenza conditions? Can you effectively incorporate social distancing strategies for workers and enhanced workplace cleaning into protocols for operating and maintaining equipment?
? With what other entities (airlines, airports, specialty aviation companies, such as air tour operators) can you share maintenance and repair facilities, equipment/supplies and/or workers?

(and then there are: Essential Materials & Supplies, Essential Worker Groups...)

My question: Have you told all your employees they need to be preparing for:

? Susceptibility to the pandemic influenza virus will be universal.
? Once sustained person-to-person transmission begins, the disease will spread rapidly around the globe.
? The clinical disease attack rate will likely be 30 percent or higher in the overall population during the influenza pandemic.
? Rates of absenteeism will depend on the severity of the influenza pandemic. In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members and fear of infection may reach 40 percent during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak.
? Outbreaks will last 8-12 weeks in affected communities.
? Multiple waves (periods where community outbreaks strike across the country) will likely occur with each lasting 2-3 months.

[Thomas Luke]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

I want to thank all individuals who have taken the time to respond to my initial post. I will attempt to address some of your pertinent points and observations.

1. GSGS: The essential fact is that transportation workers are relatively small in number; Mariners 1.5 million (global); Truckers 3 Million (US); Railroad personnel (125,000); Air freight (100,000???). I believe that they should all be covered with available vaccines, antivirals, PPE, Health Support and also detailed plans to use non-pharmaceutical interventions. The problem is that the national strategy is very clear on the need to protect transportation systems and critical infrastructures - unfortunately, it seems as if the strategy has not been incorporated into many local, state or national plans. Hence, many plans are way off the mark (ie prioritization schemes for limited medical resources).

2. Mixin: Thank you for your comments. I have had the pleasure of speaking with Ms. Joan Harris. I am not real happy with the sub-sector plans for reasons that space and time do not permit me to dwell on. However, the ability to reach back through tiers of suppliers is accomplished by transportation - if it can't be moved, all efforts to reach back through the production chain is a worthless exercise.

3. Sally: Please see the 17 critical infrastructures and key resources that I reference in my paper. I strongly agree with the list and the emphasis that the national strategy has placed on transportation, electricity, communications and information technology. If we protect and insure that these key resources are operational during a pandemic, we will have done much.

By the way, here is a quote that my father attributed to Winston Churchill:

"Supply is the stem from which the sweet blossom of victory blooms"

4. transportation Al: We in fact do know the chokepoints and you are absolutely correct that we want the R0 to as close to zero within these locations as practically possible. I absolutely believe in NPI - but if we have effective vaccine, antivirals, Abx, etc., we must prioritize it know.

5. JJackson: Thank you for your comments. I believe that reprioritization of vaccine and antivirals is only one of many changes that pandemic planners must effect. NPI, training, health care support, societal approval and recognition of transportation and critical infrastructure personnel, etc., are all necessary. When I read the strategy and the implementation plan, the objectives seem very clear. However, when I read pandemic plans, a disconnect has occurred.

6. Mixin: Thank you - I believe that the list of tasks that must be accomplished strongly supports my central thesis. If transportation workers are unwilling or unable to work and move during a pandemic (sick, scared, held up at borders, etc), then the system collapses. Please see the section in my paper concerning food security. I am a strong advocate for individual and family preparation and your point about informing workers and subordinates is right on the mark.

[gsgs]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

yes, being small in number is a good argument to receive protection ;-)

the strategy with vaccine, isn't it mainly targeted towards
"herd-immunization", to prevent the spread ?
So everyone would benefit rom vaccinating the
"spreaders", children, sellers,...

the market will dictate : when workers are essential
and require tamiflu, we should have some for them.
Prices for some things will go up and some people will
do the riskier jobs for more money and more protection.
How much more ? Prices/payment will regulate it.

[Thomas Luke]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

GSGS, if you have an adequate supply of vaccine, broad herd immunityis the goal. In the case when vaccine is limited, the goal is to prevent spread by vaccinating those most likely to be exposed and to spread the disease to other non-immunes.

[gsgs]

Re: Article: Protecting Public Health and Global Transportation Systems During an Influenza Pandemic

I just can't believe vaccine would be limited in case of a severe pandemic.

They would produce it, as long as it's paid. (<$20 per dose)

But, if the pandemic is fast (<3 months), there's the priorization issue.

Earlier or later you will vaccinate the whole population in USA anyway, I assume.
And even probably multiple times if there are waves and the virus mutates significantly, which seems likely.

And even then it's unclear how good the protection is in practice,
experience from previous flu-vaccinations or immunization from
natural infection wave-to-wave is not so encouraging.