Words matter. They matter because they shape thinking and thinking can shape policy. With this in mind, it is worth describing some of the words we use to discuss pandemic mitigation to see if we can define them as accurately and as usefully as possible.

 

There are three words often used to describe different categories of people during a pandemic: infected, recovered and susceptibles. Although these three words would seem to be self-explanatory, I believe they are often used so imprecisely that they lead to bad policy. In addition, there are two other words which are usually left out - the protected and the dead. I will consider each of these words in turn to describe how they have been misused and how I believe they should be used.

 

This group obviously includes people infected with the virus. However, it is often spoken of as a group that can be readily detected at "quarantine stations" by looking for people who obviously ill or who have an elevated temperature as detected with high-tech infrared sensors. This is extremely misleading when applied to flu viruses. People can be infected, and infectious, before they show any signs of illness. Hence, attempts to limit the spread of the virus by looking for symptoms are doomed to failure. Amazingly, the American CDC has reinforced this false hope by suggesting that quarantine stations will be used at airports to screen passengers for infection. This strategy, if actually employed, would do little to stop the spread of a pandemic from Asia to North America. The only way to guarantee the halt of the spread of the virus by the infected is with a 100% stoppage of all long distance travel, especially from Asia to North America. This option is never discussed, perhaps because policy makers have been misinformed about the nature of the infected.

 

It is often suggested that those who recover from infection will be able to play an important role in keeping vital services functioning because they will be immune to further infection. This may be true in part, but there are some important caveats. First, in a high CFR pandemic, this may not be a large group. H5N1 is currently killing over 80% of the infected in Indonesia, even with liberal use of Tamiflu and hospital care. A pandemic virus with that kill rate will leave few survivors. Second, at least some of those who have "recovered" from H5N1 still have serious health problems. It is not clear how many have returned to normal lives. Third, how eager will the recovered be to take on likely dangerous and under-resourced tasks even if they have nothing to fear from the virus? Finally, H5N1 mutates at a ferocious rate. At some point, it will likely change so much that the "recovered" are no longer immune. No-one will know when this will occur making the return to work of the recovered a constant gamble.

 

 

People who have not received effective vaccine and have not recovered from the infection may nonetheless be safe from the virus. There are number of ways this may be achieved: movement restrictions, shelter-in-place (SIP), personal protective equipment (PPE) and prophylactic use of Tamiflu.

 

 

SIP has been embraced by most of Flublogia. Staying in ones home for the duration of a local outbreak will ensure that one does not become infected. The main concern with this strategy is whether the outside world will allow individuals to execute this protective step without interference.

 

PPE is used routinely to protect people who work with dangerous pathogens. During a pandemic, there is no reason why PPE cannot be used by vital workers to protect themselves from infection. However, this approach requires proper training and stockpiling of the necessary supplies before a pandemic begins. Anyone expected to work during a pandemic should be fit-tested for at least an N-95 respirator, and preferably an N-100, and properly trained on how to apply it and other protective equipment (gloves, goggles, gowns, etc.). All exercises should be conducted with full PPE so that when the real event occurs, vital workers know what to expect.

 

There is little evidence concerning the prophylactic utility of Tamiflu, but there is at least anecdotal evidence suggesting that this drug greatly decreases the risk of death if given within 24 hours of infection. It is thus reasonable to provide this additional level of protection to health care workers engaged in high risk activities, i.e., procedures like intubation which may result in aerolisation of the virus.

 

This group is rarely mentioned in discussions of pandemics by public health officials, although mass casualty plans are sometimes provided. In an unmitigated high CFR pandemic, it is highly unlikely that most of the dead will be dealt with by professional morticians. Morticians would have difficulty dealing with a 2% CFR, much less an 80% CFR. Body collection would have to be handled law enforcement, national guard or volunteers. Mass graves would almost certainly be necessary. However, if societal breakdown occurred, bodies would likely be left where they fell. The psychological impact of large scale death and frequent contact with bodies is rarely discussed in pandemic plans. Most humans respond to the prospect of death with an understandable desire to avoid this fate by running away from the danger. Yet, many pandemic plans assume that vital workers will continue to work during a lethal pandemic with no vaccine and with no, or ineffective, PPE. This assumption is unreasonable and almost certain to worsen societal breakdown when large numbers of vital workers seek to protect their lives and those of their families by avoiding contact with the infected. The only way to prevent this compounded tragedy is to lessen the number of dead by moving as many susceptibles to the protected group as possible and by providing high quality protection for vital workers.

 

The historian Arnold Toynbee said that civilisations don't die of murder, but rather, commit suicide. A failure to face the facts regarding a high CFR pandemic and to take commonsense measures to mitigate a potential death sentence for our civilisation would be tantamount to suicide. It is possible for us to survive a high CFR pandemic. But only if we make a conscious choice to protect ourselves from a clear and present danger.