How to Watch a Pandemic

Why Watch a Pandemic

Before we look at how to watch a pandemic, let's look at the why. Why should you watch a pandemic?

There are two major reasons:

1. To predict what things are likely to happen and how and when they will impact your business.
2. To determine what measures it may make sense for your business to take and when it will make sense to take them.

Remember, it's always best to learn from other people's ideas and mistakes, so we need to watch what happens elsewhere and try to learn from it.

First let's remind ourselves of some basic terminology:

• An epidemic is the rapid spread of infectious disease to a large number of people in a given population in a period of time. Control measures may confine a disease outbreak to a limited area.
• A pandemic is the rapid spread of an infectious disease to a large number of people in multiple areas (e.g. many continents). The 1918 influenza virus, which is thought have originated in the USA and spread throughout almost every part of the world, is a classic example of a major pandemic.
• A disease becomes endemic if it reaches a steady state. That is, it stays within a population and the number of cases remains stable from year to year. Chickenpox and seasonal flu are both endemic diseases: cases occur from year to year, but the number of cases remains stable.

So when we hear the first reports of an infectious disease somewhere in the world, initially we will always hear about an outbreak or an epidemic. If the disease begins to spread worldwide, it will turn into a pandemic. Unless the disease is totally eliminated, it will end up as endemic in the population.

What impact an infectious disease will have on you, and what governments will do to try and control the spread of the disease, depends on the disease itself. So what do you need to know about the disease?

Watching The Disease…

Even if we are not epidemiologists, we can get some idea of how easy it will be to contain a disease and the likely steps authorities will take by looking at the answers to some simple questions about the disease. Although the questions may be simple, the initial answers will be very uncertain, so it's important to recognize that answers will change over time.

Is it a Virus or a Bacteria?

Bacteria are relatively large and complex, single cell organisms, which can reproduce on their own. Some bacteria are "good" bacteria (they supply essential nutrients or perform other functions for their host), but others can cause serious illnesses. Because of their complexity, bacteria are often susceptible to antibiotics.

Viruses are much smaller, and consist of a protein coating and a core of genetic material. Viruses can only survive and reproduce by attaching themselves to cells in a host organism. There is no equivalent to antibiotic for viruses. The main means of defense are vaccines, which stimulate the host to create defenses against a weakened or inert form of the virus. But vaccines take a long time to develop, and it's not possible to develop an effective vaccine against a virus that hasn't been seen yet. For a novel virus, expect a delay of at least a year before a vaccine becomes available. Vaccines also require extensive safety testing, since they are given to otherwise healthy people. A further problem in some countries is that manufacturers are reluctant to produce vaccines: if people get sick after receiving a vaccine they often believe the vaccine caused the sickness. This in turn leads to lawsuits, and the risk of juries awarding large amounts of damages based on dubious evidence can make producing a vaccine a loss-making proposition.

How is the Disease Transmitted?

The diseases which travel most quickly through society are typically passed through aerosol droplets when you breathe, speak, sneeze, or cough. Depending upon their size, the droplets can hang in still air for a considerable period of time, and depending upon the nature of the disease, the droplets may remain infectious on hard surfaces for hours or days. (More absorbent surfaces may dry out and damage the bacteria or virus in a slightly shorter period). Other easier-to-disrupt mechanisms include contact or exchange with body fluids, the oral-fecal route, and so on.

How easily is it transmitted?

The number used to measure this number in epidemiology is known as the Basic Reproduction Number (or R₀ or R nought or R zero) which is the expected number of cases generated in a population which has no immunity to the disease by one infected person. The higher the number, the more rapid the spread in a vulnerable population. Some estimated numbers for well known diseases gives an idea of how a new outbreak compares. These numbers are taken from Wikipedia:

If the R0 number is below 1, then the disease can be expected to die out on its own. The higher the number the quicker it will spread through a population until most members of the population become immune. Without a vaccine, the only way of controlling the spread of a disease is by changing peoples' behavior so that they come into less contact with each other. The higher the basic reproduction rate, the more drastic behavior changes that may be required. When these measures are taken, the number becomes the Effective Reproduction Number (R). If this can be reduced to one or near one, the epidemic will progress slowly without overwhelming health services.

What are the symptoms and when do they appear?

People won't normally seek medical help until symptoms appear. If the symptoms can be confused with a cold or seasonal flu, people may simply stay at home in bed and (in the West) watch Netflix or read a book. The people who will be recognized as having the disease early on will only be those who had symptoms serious and distinct enough to seek medical attention.

The key terms to watch for in reports are:

• the incubation period — the delay between a person being infected and showing symptoms,
• the latent period — the delay between a person being infected and being able to infect others,
• the infectious period — the length of time an infected person is infectious to others.

With SARS, the incubation period and the latent period were similar, making it easier to quarantine those infected.

With Covid-19 the latent period is four to five days shorter than the incubation period (and some infectious people never show symptoms). This makes the virus much harder to control because you need to ask people to change their behavior or introduce quarantine measures even if there is no evidence that they are sick.

How Serious is the disease?

Much emphasis is often placed on the Case Fatality Rate (CFR). This is the proportion of people who are diagnosed with a disease who subsequently die from it. Death is obviously not a great outcome, so it's worth comparing diseases to get an idea of where a new disease fits. Remember that this number is based upon available treatments, not what happens if the disease is left untreated.

Once again, Wikipedia can provide some good comparisons:

But the Case Fatality Rate does not tell the full story. It only measures death, and does not take account of the resources required to keep people alive.

With a serious disease we also need to look at:

• What percentage of cases require hospitalization? [Covid-19: 20%] How long for? [Covid-19: weeks]
• What percentage of cases require an intensive care unit bed? [Covid-19: 4%]
• What percentage of cases (for a disease with respiratory effects) require a ventilator?

These determine whether a health system is going to have sufficient resources to treat all cases. If the trained staff, hospital beds, or specialized equipment aren't available, then a proportion of cases are not going to be treated, and the Case Fatality Rate will rise as available resources become overwhelmed. The epidemic may also cause deaths of other patients who cannot be treated because medical resources are not available.

There are also two questions to ask about recovered patients:

1. Are there any lasting effects of the disease?
   Some disease cause permanent damage to a proportion of patients (e.g. reduced lung capacity, disability). Significant lung damage was still found in recovered SARS patients 15 years later.
2. Can patients be infected twice?
   Most diseases offer some degree of immunity to future infection, but some diseases mutate rapidly and an infection offers very limited future immunity. If having a disease does not give long term immunity, then an epidemic may recur in the future.

Where to Find Current Information

When an epidemic breaks out, it's important to use reliable sources of information. New diseases lead to rumor and fear-mongering. The best English language places to look for reliable information are:

• The World Health Organization (WHO). This body is responsible for monitoring diseases world wide.
• The European Centre for Disease Control (ECDC). The European Union equivalent to the CDC.
• The US Centers for Disease Control and Prevention (CDC). The American equivalent of the ECDC.

The WHO site is generally the best starting point. Organizations reporting to a single government can unfortunately be tainted by political motives.

Watching the Disease — Summary

Looking at the Basic Reproduction Rate, the method of transmission, the symptoms, the Case Fatality Rate, and the treatment requirements for a new infectious disease will give us some indication of how likely a disease is to be contained, how serious the disease is, what methods can be used to control an outbreak, and the likelihood of an outbreak becoming an epidemic or a pandemic.

Watching The Official Figures…

Testing for exposure to an infectious disease can be expensive, both economically and politically. Early questions to ask are:

• Is there a reliable test to determine if people have the disease?
• Is there a reliable test to determine if people have been exposed to the disease? (An antibody test)
• Are the tests available?
• Are the tests expensive?
• Do the tests take a long period of time to perform?

With the Covid-19 outbreak, the genome of the virus was sequenced quickly, and tests for the presence of the virus followed soon after. These tests required complex equipment to perform, took several hours to complete, and in most places testing facilities were in limited supply. These tests only tells if someone is infectious, and are thus helpful in determining treatment options. Rather too much emphasis has been placed on these tests in the absence of any others.

Antibody tests determine if a person had been exposed to the disease and is now immune. These tests make it possible to track the disease's progress, determine the percentage of the population still vulnerable to the virus, and identify those immune to the virus who can return safely to work. Antibody tests also work from a small blood sample, and can typically be completed cheaply in minutes rather than in batch operations which take several hours.

Without both types of testing readily available, political agendas will often affect what is measured, how it is measured, and how the results are presented. Health organizations suffering from resource constraints will also restrict testing to certain groups of the population, resulting in highly skewed figures. So we need to be very wary when interpreting figures such as confirmed cases (which will be zero if a country does not do any tests), and deaths (which may only be being counted if the patient was actually tested).

For example, during the first months of the Covid-19 outbreak our local government only tested people with symptoms who had traveled abroad, or had been in contact with people who had already been diagnosed as having the Covid-19 virus. This made sense. But they then happily announced that there was no evidence of community transmission, even though their testing policy effectively eliminated gathering of any evidence of community transmission. Subsequently they changed their story to report that there might already be dozens, hundreds, or even a thousand cases they didn't know about.

When looking at official figures, also be very aware of the delays involved. Known cases depend upon transmission days earlier, deaths and recovery rates may be based upon patients diagnosed weeks earlier. If you want to be your own epidemiologist, make sure you know how to allow for testing practices, delays, growth rates, and uncertain figures in your calculations.

Watching Governments…

Responsible governments will, if they are able, take measures to mitigate the effects of an infectious disease on their citizens. However, the actions they take will be restricted by both economic and political cost.

If we look at what other governments do, we can get an idea of what our own government may do. We will also get an idea of what will happen at various points in the supply chains we are part of and which may therefore affect our business, even if the disease never affects us directly. It's also very revealing looking at what governments have tried with previous infectious disease outbreaks, and any plans they may have published for SARS and pandemic influenza in previous years.

Government actions can be divided into two phases:

• Containment. In this phase actions are taken intended to eliminate the disease or to keep it confine it to a small number of people.
• Delay. In this phase actions are taken to limit the peak effects of the outbreak. If everybody is sick at the same time, this will overwhelm health services, close down industries, and have a major impact on the availability of essential goods and services. However, if the impact of the disease is spread out, health services may not be as overwhelmed and essential goods and services can continue to be provided. This is currently being referred to as flattening the curve.

When looking at other government actions, try to determine what phase they believe they are in, and try to identify any novel actions they are trying that could be tried elsewhere. Successful ideas and strategies are likely to be copied if they are believed to be feasible.

Containment Phase

During this phase efforts are made to limit the disease to a particular area in the hope of eventually eliminating it. Actions often taken at this time include:

• Tracing possible contacts of an infected person, and placing them in quarantine.
• Testing of travelers from affected areas.
• Preventing travel to and from infected areas. (Note that this is often done even though it's not a World Health Organization recommendation; travelers just choose alternative routes and are harder check when entering or leaving an area).
• Education campaigns to encourage healthy behavior (e.g. hand washing)
• Local shutdown of events and places where large numbers of people gather.

Delay Phase

If containment is unsuccessful, then the government's concern is to limit the ability of the disease to overwhelm health services and shut down essential services. Actions at this time typically include:

• Close larger places where people will be near each other and may pass the disease. This includes sporting events, concerts, conferences, cinemas, theatres, pubs, restaurants, etc.
• Restrict all international travel for non-residents.
• Close smaller places where people might meet unless they are deemed essential.
• Require anyone who has symptoms of the disease to stay home.
• Encourage people to stay away from each other. (Most airborne droplets travel about 6 feet or 2 metres, further with coughing and sneezing).
• Ask or require people to stay home if possible.

Or a government could try something else entirely…

The UK government's initial response to the Covid-19 virus was to try to develop "herd immunity" by allowing over 60% of the population (35 million) to become infected by the virus and therefore become immune. This, the public were assured, would prevent future annual outbreaks. Fotunately researchers at Imperial College in London calculated that this approach also meant that the health system would be overwhelmed and might result in 510,000 deaths. Shortly afterwards, the response was changed to the "delay" approach adopted by most other countries…

At the time of writing, the Trump administration is arguing that the number of suicides produced by an economic slowdown caused by the government attempting to slow the disease's progress is worse than the number of deaths caused by Covid-19 overloading the health system, and that therefore lifting most restrictions is justified. The lieutenant governor of Texas, Dan Patrick, has also argued that old people would be happy to die miserably for the good of the United States economy. It remains to be seen whether US policy will change from a "delay" response based on these arguments. Juhana Leinonen (@JuhanaIF) tweet cleverly illustrates this American version of the Trolley Problem.

Watching Businesses…

If you watch what businesses are trying in affected areas, their ideas can help in your own pandemic planning. Things we've observed businesses doing include:

• Communicating with staff, and reminding them of basic hygiene measures (hand-washing, etc.)
• Banning staff international travel
• Restricting or eliminating outside visitors
• Banning in-person meetings
• Special procedures for staff returning from affected areas, or just returning from abroad.
• Changing sick-pay policies to encourage sick hourly-paid staff to stay home.
• Increased cleaning of shared areas and common surfaces to try and limit at work spread of the disease.
• Reminders to staff of the importance of hand-washing, covering your mouth with your elbow if you cough or sneeze, etc.
• Making hand sanitizers readily available in the workplace.
• Supplying protective gear or using protective barriers for staff at higher risk of infection.
• Visibly cleaning surfaces used by customers between each use (e.g. supermarket trolleys)
• Communicating with customers to reassure them about the company's continued operations.
• Introducing practices which minimize in-person customer contact.
• Tooling up production for alternative products.
• Switching to delivery only and shutting down retail locations.
• Shutting down non-essential operations to protect staff.
• Shutting down operations because of lack of demand.
• Expanding operations or setting up new production lines due to increased demand.

Watching People…

It's easy to assume that it's just governments and businesses making all the decisions. But people react according to what they hear and know too. What are people doing in other countries, and will they do similar things in other places? Although there may be major cultural differences, people share the basic needs to protect their families and themselves, and to preserve their own livelihood. People in different societies may, however, be more or less interested in acting for the common good.

• Are people complying with government requests or ignoring them? If they are ignoring requests, what types of request are they ignoring?
• What are people buying or not buying? Are they panic buying and hoarding? Are they stopping buying other goods and services. Their behavior may not be entirely rational: why do people stock up on certain items like toilet paper? Why do they stop buying Corona beer?
• What are people doing and not doing? Even without government regulation, fear of infection results in changes in where people go and what they do.
• Are people still reporting for work, or are staff refusing to work if a colleague is sick?
• What is being done to raise people's morale? Is it working?
• Is the additional stress on the population lead to xenophobia? Racism? Discrimination against segments of society?
• Are people being laid off in large numbers? How will this affect demand for your goods and services?

Watching Your Supply Chain…

Very few businesses are truly independent: they either depend upon a supply chain or are part of another businesses's supply chain. It's important, therefore, to understand not just what the effects may be on your own business, but what effects it might have on your suppliers and customers.

To watch your supply chain, you need to know:

• Who are your suppliers, and where are they? What about your supplier's suppliers?
• Who are your purchasers and where are they? Who do they sell to?
• What effects are government restrictions and market changes likely to have on the supply chains you are part of?
• Will suppliers shut down?
• Will buyers continue buying?

Watching Market Consequences…

Government, business, and personal actions may have severe economic consequences:

• Companies forced to shut down by government restrictions or by rapidly falling demand may lay off staff or go bankrupt.
• Employees who are laid off may have difficulty finding alternative employment, and stop buying non-essential items.
• Laid off employees may be unable to meet debt obligations, and go bankrupt.
• Companies that supply other companies will in turn shut down.
• Companies that sold non-essential items to the laid-off employees will in turn shut down.
• Lenders may become reluctant to lend because of the higher risk of default.

The effect may be a major economic collapse. This is one of the reasons governments may be reluctant or late reacting to a possible pandemic, and may introduce economic measures to prop up individuals or selected industries.

Update Your Pandemic Plan

You do have a plan by now, don't you? You didn't just ignore H1N1 Flu (2009), SARS (2002), and Ebola (2013), did you? If not, you have some strategic thinking to do about how you monitor emerging threats.

With what you have seen going on elsewhere, you should now be constantly reviewing and updating your plan with what you have learned.

Some basic questions you might want to ask about your plan include:

• Which parts of the plan ever been tested or are testable, even with a desktop exercise?
• Have any technical assumptions been tested? Is it really possible for part of the workforce to work from home using the existing technical infrastructure?
• Does the plan define what is going to be done and under what conditions actions are going to be taken?
• Does the plan prioritize the safety of workers and customers?
• Does the plan relax or change sickness policies so that sick workers do not have an incentive to work while sick?
• Do actions in the the plan have appropriate approvals and budgets so that they can it be put into action with minimal delay?
• Does the plan address any effects on production if some workers become sick? (These may be particularly onerous for sterile production facilities.)
• Does the address likely economic effects? If not, who is responsible for addressing these?
• Does the plan define any end points when temporary measures will be stopped?
• When a new normal is established, how will the plan be updated with any lessons learned?

And Finally…

The future is always uncertain. We can never know exactly what will happen. There are limits to what we can plan for and the budgets we have available. But, even within those limits, we can improve our planning and response if we watch carefully and intelligently what is going on elsewhere.

Please don't trust any numbers I've given here. By the time you have read this, numbers related to Covid-19 will be out of date, and numbers for other diseases may have been updated. Refer to Wikipedia for older disease information, and the World Health Organization for the current Covid-19 outbreak.

Stay safe and good luck.