"Il mio compito è di dirvi cose che non volete sentire, chiedervi di spendere denaro che non avete, per qualcosa che non credete accadrà." Dr Ziad Abdeen, the Palestinian Health Authority
"For the first time in human history, we can prepare for a pandemic in advance of his arrival. E 'then the world community must now be devoted to action." Dr Margaret Chan, Director - Communicable Diseases Section, WHO
"We do not know when a pandemic may come. However, two things are certain: anything that will first appear alarmist, and everything after that will seem insufficient. This is our dilemma, but it should not prevent us to prepare. We must reach everyone with words that inform and not fiery. We must encourage all to prepare and maybe not to panic. " Michael Leavitt, U.S. Department of Health and Human Services, 2007
As you can imagine from these observations, some experts argue that a new influenza pandemic is inevitable. If this happens, the ' impact could be catastrophic as a whole, and most importantly, it is not easy to prepare medically, socially and economically for the event.
This essay deals with four sides of the issue: the medical and epidemiological prediction based on modeling and construction equipment; already social and economic impacts, and emergency planning.
medical aspects and epidemiological
Influence can occur in three forms. That is rather predictable seasonal and occurs mainly in winter. It can be transmitted from person to person, but most of the victims have some immunity. In addition, a vaccine is available and on the whole, the impact on society is less.
Avian Influenza (H5N1) broke out in East Asia in 2004-5. Its potential as a source of disaster is high because people have no natural immunity. Currently, a vaccine is not commercially available. However, it is likely that the virus passes from birds to humans.
Pandemic flu like 'A' is a new virus easily trasmissibilità tra gli esseri umani, i quali non dispongono di immunità naturale. Quindi, essa ha un'ottima propensione di provocare malattie gravi. Si divide in due tipi: Hemagglutinin (H) è composta di 16 sottotipi e agisce per attaccamento e penetrazione; Neuraminidase (NA) dispone di 9 sottotipi di 8 geni virali e cresce in assemblea per replicazione. E' bene notare che l'influenza pandemica
non è uguale all'influenza stagionale, alla SARS o all'aviaria. Comunque, importanti lezioni vengono fornite da ciascuno di questi altri fenomeni.
L'influenza viene trasmessa per via respiratoria tramite gocce e aerosol prodotte quando una persona infetta parla, tossisce o starnutisce, o quando ella tocca una persona or an infected area, including contact between contaminated hands and your face.
Pandemics vary in severity, and then the U.S. Federal Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, authoritative institution epidemiological study, launched an index of severity of the pandemic, such as to help predict the severity and design mitigation strategies. The index is based on the case fatality ratio
(the number of deaths per 100 cases of established disease) and five categories, as follows:
Case fatality ratio Category 1: <0.1 ovvero 1 in 1000
Category 2: 0.1 - <0.5 ovvero 1 in 1000 - 1 in 200
Category 3 : 0.5 - <1.0 ovvero 1 in 200 - 1 in 100
Category 4: 1.0 - <2.0 ovvero 1 in 100 - 2 in 100
Category 5: 2.0 - or 2 in 100 + In addition, the preparation of scenarios
insists on a model of the stages of disease progression in society.
Period interpandemic Step 1. No new influenza virus subtype has been found in humans, although one may be present in animals (but with low-risk persons).
Step 2. No new influenza virus subtype has been found in humans. However, a subtype of the virus circulating in animals and poses a substantial risk to humans.
Period of pandemic alert Step 3. A new subtype is causing infections in people, but without significant diffusion.
Step 4. transmission from one person to another is limited and localized: the virus is not well adapted to human umanil
Step 5. interpersonal transmission occurs more indicative of a better adaptation of the virus human host, without, however, full transferability (the phase indicates a substantial pandemic risk).
period of the pandemic Step 6. It happens increased and sustained transmission of the disease in the general population.
post-pandemic period You return to the inter-pandemic period, which therefore provides an opportunity to launch well-targeted mitigation strategies.
tools to combat the risk of pandemic flu are vaccines (which will probably not be generally available in the first wave), antivirals (probably of limited supply), interventions on transmission, infection control measures, and protocols of social isolation is of sick people than healthy ones.
There are four types of antiviral drugs, reported here with the common trade names of the product in parentheses: Amatadine (Symmetrel), rimantadine (Flumadine), Zanamivir (Relenza) and oseltamivir (better known as Tamiflu). If antivirals are taken within 48 hours of the beginning of the sick, they can help prevent clinical complications. However, questi farmaci potrebbero non funzionare contro un virus influenzale pandemico di tipo nuovamente evoluto. In ogni caso, la loro distribuzione dovrà avvenire secondo una certa priorità premeditata e, si spera, trasparente e eticamente giustificabile. All'inizio dell'ondata di influenza gli antivirali verranno usati, molto probabilmente, per cure, anziché per profilassi.
Un'altra linea di attacco e la riduzione dell'entità delle infezioni (cioè, gli interventi sulla trasmissione della malattia). Si tratta di incoraggiare tutta la popolazione a lavarsi le mani bene e spesso con sapone, di coprire la faccia in caso di tossi e starnuti, di non sputare e, quando occorre, di portare una mascherina sulla faccia.
Infine, isolation techniques can be divided into two: the quarantine infected people, and social distancing
to uninfected persons, which, as far as possible, you should get rid of the company. In the latter tactic, it is increasing the space between people and decrease the frequency of social contacts, with targeted interventions, particularly on schools and workplaces.
Forecasting, modeling and scenarios
Worldwide, influenza pandemics are recurring such as to be inevitable. They are cyclic intervals (rather irregular) of 30-40 years. In the recent past, the ranges were as follows: 1847-89 (42 years), 1889-1918 (29 years), 1918-57 (39 years) and 1957-68 (11 years). It did not happen for an influenza pandemic for over 35 years and then it is assumed that one may be imminent.
As regards the consequences, the influence of so-called "English flu" of 1918 (H1N1, is, however, was born in China) has hit 25-30% of the world population became ill and 11% of these people are dead . The economic impact was profound: for example, U.S. GDP fell by 5%. The influence called "Hong Kong" in 1968 caused 34,000 deaths in East Asia and Canada. SARS in East Asia in 2003 caused 800 deaths and a fall in GDP in the region of 2%. Finally, the bird flu in East Asia in 2004-5, it has caused 112 people, of whom 57 died (52%).
Based on the analysis of these events, the forecast for the next time you indicate, globally, a mortality rate between 2.0 and 7.4 million people. The people will be hospitalized at least 135 million. World GDP will drop by $ 3 trillion. In the U.S. there will be a 15% increase in the demand for medical services, accompanied by a drop of 80% in demand for recreational facilities and 10% of demand for each kind of product.
A simulation developed for the catchment area of \u200b\u200bCareggi Hospital in Florence, using generally accepted parametric models, indicates a maximum of 5,600 hospitalizations and 1,240 deaths in a wave of influence of duration of 50 days.
generally outweigh the impact on the health system, it can be assumed that, despite the lack of health personnel, equipment and drugs and beds in medical centers, the demand for health services will exceed supply for several months. The vaccine will be available only between 6 and 8 months after the start of the crisis. Given the limited availability of care and the very high demand, most of the wards will be spent at home. The conceivable scenario
medical / health event indicates that in all probability the production and distribution of vaccines will have priority over other health insurance. In addition, to ensure an ongoing and increasingly to the task, some Private services will be controlled or nationalized by the government.
E 'Remember that you may experience, not a single pandemic, but a series of waves of illness of the total length to about two years. The impacts can be divided into those immediately (days to weeks) and long-term (weeks to months). Apart from the purely medical impact, there would be a long line of other effects, as described in the next section.
social and economic impact
In summary, the impacts of pandemic influenza can be divided between those medical and health, socio-economic and psychological ones about politics, the
governance and public administration, and those on the world of commerce and business.
The preparation can not eliminate all elements of uncertainty, unpredictability, fear of the future, sense of loss, psychological trauma, bereavement, disruption of society and need to make difficult decisions. In fact, some experts argue that the psychosocial impact can be much larger than the physical. Given the high probability of becoming ill and even die, the psychological effects that could not be more profound. The fear is mixed with the decline in confidence in the ability of authorities to solve problems and bring security to the company.
The scenario is that individuals and families will devote themselves to amassing food, drugs and money. The closest social relationships will be enhanced, such as between relatives, but less important ones will be neglected. As far as the closest ever, there will be a falling birth rate that will last throughout the period of the pandemic and beyond. At the same time, respect the community, will be the cancellation of many mass meetings, accompanied by a dispersal of population away from urban centers, a phenomenon that recalls Boccaccio's Decameron and the shadow of the plague in medieval times. Under these circumstances it will be difficult to solve the problem of how to provide services to groups of people particularly vulnerable as the handicapped and the elderly.
Services basic (such as water, electricity and gas, telecommunications, procurement of food and fuel, waste collection) will be plagued by absenteeism and frequent interruptions. In addition, people who continue to work could be carriers of infection and speakers. To avoid this, schools and universities, for example, would be closed for long periods, giving students the problems of continuity of the study. Because of absenteeism and coupler of the general trade, all the major distributions will be declined.
Due to the vast expansion occurred in the international dependency, globalization will increase the risk of transmission is that the effects of the pandemic. To restrict migration carrier pandemic, borders, airports and stations will be closed to the public for long periods.
about products and services, absenteeism will be accompanied by a drop in productivity that will result in, among other things, a lack of inventory in factories and the disruption of supply chains. Consequently, there will be a reduction in the quality and availability of products, and then a food rationing and various other essential products.
As in industry, agriculture will be a decrease in the production and distribution of its products. If the transmission of the disease affects animals, there will be a great slaughter of chickens, and perhaps other types of livestock. Come risultato di tutto questo, si verificheranno grandissimi aumenti nel costo dei prodotti alimentari.
Insieme al calo nella produzione, per motivi sanitari, economici e sociali, ci sarà un calo della domanda per prodotti e servizi. Questo è stato stimato dell'entità di 10% in genere e fino all'80% per servizi come il turismo, l'aviazione e la ristorazione. In compenso, ci sarà un massiccio aumento della domanda per pubblica sicurezza, servizi di evacuazione, e assistenza medica con associati servizi di trasporto.
Per quanto riguarda il
governance , ci sarà una riduzione del numero di riunioni amministrative e politiche, con appositi rallentamenti dei processi decisionali. Contemporaneamente ci saranno increases in demand for law and security, with equally large increases in public expenditure on health, safety, welfare and support of business, countered by strong lowering spending on functions not directly involved in the crisis.
In the financial sector, is expected to lower tax revenue decline for the economy. With high demand for liquidity, expects a significant increase in the supply of money and a marked decrease in the value of its currency. The circulation of money will be lowered, as will the value of the shares and thus stock prices.
The crisis will be marked by massive increases in insurance payments accompanied by the failure of some insurance companies. Major health problems will occur in prisons and there will be a decrease in the activity of courts and legal services, then the efficiency of the justice system. Finally, in the field of information, for fear of contamination is the most read newspaper and magazine paper, which will be replaced by electronic means. However, the public will remain intensely interested in news, although given the expected decline in the production and circulation of newspapers of all kinds will be difficult to maintain quality and accuracy of journalism.
Emergency preparedness
The problem of the pandemic is considered so serious and urgent that in parts of northern Europe, the planners are devoting up to three quarters of their business to prepare for such an event. Contingency planning should consider some specific aspects, such as:
- the massive increase in demand for healthcare products and services
- the need for ethics and transparency of decisions
- the public reaction to risk, and the event authorities' response
- education, training and information on the crisis for all sectors of society
- the closure of schools, businesses, shops and public places
- the lack of communication, electricity, gas, water, waste disposal waste, telephone service, distribution fuel production and distribution of food
- security and public order
- and the imposition of quarantine restrictions on the movement of the population
- how to communicate with the public and the media.
The objectives that a planner who is interested in this field must keep in mind there are four: how to limit the number of sick and dead, how to maintain the continuity of basic services, how to minimize the disruption of society and the economic losses, and how enhance the appropriate health services.
strategies can be summarized in so-called "three 'P': people, plans, products and practices. Pandemic contingency plans are needed at all levels of government and in other places such as factories, universities and offices. E 'need to create an integrated monitoring and control healthcare. We must develop a capacity to give effective and decisive action, distinguished by transparency and good communication and the extensive involvement of all sectors of the public.
Conclusions
While the likelihood of being faced with a pandemic may seem very remote to many emergency planners, it is not so unlikely. If this happens as described in this article, the consequences could be very deep and the whole "landscape of risk ', and therefore the view of civil protection, would suffer a change net in no time. The priorities would be sharply rearrangement.
will blow out some hot issues related to ethics of the choices made, and the availability and cost of remedies to the problems occurred. In this context, public health is a "power of public policy", or police. In this form, it could infringe the freedom of the individual, but at the same time you must defend the rights of the few efforts were made to protect the safety of all. Choices are difficult but you should start studying now, in "peacetime", instead of having to deal with it for the first time the height of the crisis.
Thanks
I thank Prof. Ziad Abdeen
of Al Quds University, Palestine, and Dr.. William Hancock of Texas A & M University for their valuable notes, on which this essay is based.
In response to Anita, but d ' general interest. 
