Health Pandemics

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ICRM Symposium 2012 - Black Swan Events

Singapore, 21 22 February, 2012

Health Pandemics: From BlackSwans to . ?

Presented by Pane Stojanovski, Ph.D.with

Mary Chang, Peter Ulrich , Auguste Boissonnade


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2012

Throughout history health pandemics

have been Black Swans not understood

and feared tremendously. With scientific,

medical, and health care advances in

the 20th century they have been tamed,understood, monitored, modeled, .

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Could a pandemic return as a Black Swan today ?


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2012

430 BC: Plague of Athens, killed 1/3 of Athenian population and was a

factor in the downfall of the Greek civilization, unknown cause buthypothesized to be everything from the plague to anthrax to viralhemorrhagic fever

251-266: Plague of Cyprian, measles? 5000 deaths/day in Rome

1347-1350 : Black Death Bubonic plague 25% Europe 25million deaths;16% world, 75 million deaths

1556 and 1560 European influenza epidemic with an estimatedmortality rate of 20%

1518 and 1568 The introduction of smallpox and measles into theAmericas by European explorers caused the population of Mexico tofall from 20 million to 3 million

1793 Yellow fever, U.S. Yellow fever 10% Philadelphia

18th Century Smallpox killed an estimated 60 million Europeans duringthe 18th century, 400,000 a year

19th century, tuberculosis killed an estimated one-quarter of the adultpopulation

A Few Notable Historical Pandemics Black Swans

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2012

Comparative Numbers

Year Event Est. Number of Deaths

14th century Black Plague 75-200 million

1939-1945 WWII 50-70 million

1918 Spanish flu 40-50 million

20th century Smallpox 300-500 million

1980-today AIDS 25 million

1914-1918 WWI 20 million

1852-1860 3rd Cholera pandemic >1 million

1900-today Malaria >1 millionper year

1976 Tangshan EQ 242,000

2004 Aceh EQ, tsunami 230,000

2008 Cyclone Nargis 63,000-100,000

1952 Polio (U.S.) 3145

2005 Hurricane Katrina 1836

2002-2003 SARS 774

Infectious Diseases (ID) 4


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Immunizations

Sanitation Surgical milestones

Sterile techniques

Safer anesthesia

Less invasive methods

Transplantation of organs Diagnostic tools

Blood Tests

X-Rays

CT, MRI

ECG, EEG, EMG Pharmaceuticals

Antibiotics

Antivirals

Health Care Changes In The 20th Century - ReducedInfectious Diseases Risks

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Effect Of Health Care Improvements on Infectious Diseases

Achievements in Public Health, 1900-1999: Control of InfectiousDiseases. MMWR. July 30, 1999 / 48(29);621-6296


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Despite advances in hygiene and medical science, pathogens are

continually emerging and evolving

Scientific advances have reduced the severity of known diseases like

influenza and the risk will continue to diminish with antivirals and

vaccine development improvements. However,

The emergence of H5N1 and antiviral resistant strains demonstratethat extreme mortality and other correlated shocks are still possible

from influenza: 1918 is not a worst case!

We have no immediate medical answer for an emergent viral disease

with characteristics similar to historical causes of excess mortality like

smallpox, measles, and HIV

Global transmission will be faster than it has been historically and

urban populations are likely to be affected first

Challenges Today

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60

80

100

120

140

160

Doses(Millions)

2010 H1N1 Influenza Vaccine Doses Allocated, Ordered, and Shipped inthe U.S.

Allocated

Ordered

Shipped

Lowest virulence of any previously measured pandemicinfluenza virus

Some mortality reduction - pharmaceutical advances,public health measures, and pre-existing levels of immunity

The low number of fatalities can be predominantlyattributed to the genetic characteristics of the virus

Vaccine distribution primarily through public healthchannels with widespread shortages were reported

Government public health organizations slow to declare apandemic

Demonstrated inadequacies of categorization systems

2009 Pandemic A/H1N1

0

10

20

30

40

50

60

70

80

90

100

H1N1 Days until outbreak


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H5N1 Avian Flu

The virus high virulence resulted in a redefinition of whatwe knew about flu viruses

As of March 2010, 489 Cases in 15 countries resulting in289 deaths (60% death rate)

It is likely that migratory birds are spreading the H5N1 virus

and according the WHO, further spread to new areas isexpected.

Since 1997 the virus has adapted to infect moremammalian species and has become more virulent

A reassortment or adaptive mutation of the virus to amore transmissible form could result in a highlyvirulent virus that would be nearly impossible to control

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Moderate

Severe

VerySevere

Mild

Pandemic Viruses - Infectiousness & Virulence

InitialDeathsperCase

30%

10%

5%

2.5%

1%

0.5%

0.1%

7

6

5

4

3

2

1

1.25 1.75 2.25 2.75 3.25 3.75

R0 Basic Reproductive Number

Seasonal Flu

1957

1968

1918

1.0 1.5 2.0 2.5 3.0 3.5 4.0

PandemicSeverity

0%

0.2%

0.75%

2.0%

3.5%

7.5%

20%

50%

Infectiousness

Virulence

ModeledScenario

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Direct Pandemics Risk Quantification

Epidemiological Model

0.0

0.5

1.0

0 10 20 30

$Bn

Probability

of

Exceedance

Exceedance Probability Output

Pathogen Characteristics

Probabilistic model of virus characteristics: Frequency of antigenic shift mutations Virulence: Death per Case (DpC)

Infectiousness: Initial Reproductive Number (R0) Other qualitative factors including

pathology mechanism (e.g. cytokine storm)

Incubation time and symptomatic period

Population Spread Model International Spread

Age response

Background immunity

Behaviour assumptions

Antibody

VirusHA Antigen

Susceptible, Infected, Recovered (SIR) Modelling

National Government Response Model Public health capability and strategy

Anti-Viral Administration

Vaccine Development

Non-Pharmaceutical Interventions

Portfolio-Specific Impact Modeling

0.000

0.050

0 20 60 80 Age

AgeMortalityCurves

General Population Age Distribution

Total Risk Capital by Age

40

Portfolio

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0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728293031323334353637383940414243444546474849505152

All New Cases by Week in Working Population

Brazil Indonesia

China Rest of Asia

Rest of Middle East, including North Africa Rest of South America, Central America & Caribbean

Rest of Sub-Saharan Africa. United States of America

Direct Impact Modeling Caseload Timelines in Populations

Modeled Scenario:R0 = 3.25;DpC = 0.5%;Outbreak location = Vietnam

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l d d li l b l l


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2012

Correlated Impact Modeling Global GDP, Employment,Exports

-7.0

-6.0

-5.0

-4.0

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

2009Q4 2010Q2 2010Q4 2011Q2 2011Q4 2012Q2 2012Q4 2013Q2 2013Q4 2014Q2 2014Q4 2015Q2 2015Q4

Global GDP

Global employment

Global exports

G Verikios. M. Sullivan, P. Stojanovski, J. Giesecke and G. Woo, The Global Economic Effects of Pandemic Influenza.)14th Annual Conference on Global Economic Analysis, Venice, June 16-18, 2011.

Modeled Scenario:R0 = 3.25;DpC = 0.5%;Outbreak location = Vietnam

~$2.8 trillion lost inglobal GDP

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Correlated Impact Modeling Tourism

-6.0

-5.0

-4.0

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

2009Q4 2010Q2 2010Q4 2011Q2 2011Q4 2012Q2 2012Q4 2013Q2 2013Q4 2014Q2 2014Q4 2015Q2 2015Q4

tourism shocks health services shocks

labour producitivity shocks population and labour supply shocks


Modeled Scenario:

R0 = 3.25;DpC = 0.5%;Outbreak location = Vietnam

~ 330 billion lost

in tourism andtravel sectors

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Travel and tourism industry about 9% of total GDP

235 million jobs


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2012

-12.0

-10.0

-8.0

-6.0

-4.0

-2.0

0.0

2.0

4.0

2009Q4 2010Q2 2010Q4 2011Q2 2011Q4 2012Q2 2012Q4 2013Q2 2013Q4 2014Q2 2014Q4 2015Q2 2015Q4

China

Singapore

USA

Germany

Rest of Asia

Japan

Correlated Impact Modeling GDP for Selected Regions


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~ $33 billion lostin Singapore GDP

Modeled Scenario:

R0 = 3.25;DpC = 0.5%;Outbreak location = Vietnam


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2012

Thinking of Expanded Correlations - Pandemics, EconomicShocks and Financial Capital Shocks

Unpublished research communications

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2012

With advances in public health, global preparation,medicine, sanitation, .., vector control, . could a

pandemic Black Swan return?

Long historical record and experienceAdvances in science , sanitation, .. ., prevention

Global watch (WHO)

Ability to model pandemics and correlated impacts for risk

quantification and management

Pandemics do not appear to be in the unknown unknowns

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Could a Pandemic Black Swan Return?


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2012

Nature, Volume:481,pp: 417418, January 26 , 2012

Caution Urged For Mutant Flu Work (H5N1)

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Ongoing creation of mutated strains of the H5N1 virus for surveillance of flu

viruses could allow health organizations to monitor birds and other animals forthe mutations early warning of a pandemic

Surveillance of H5N1 in poultry worldwide is patchy, particularly in poorer

countries, where the virus is prevalent, and the mutated strain may not be

caught early enough

Just five mutations allowed avian H5N1 virus to spread easily among ferrets

(good proxy for flu behavior in mammals, including humans). Mutations

spotted individually (not together in wild viruses); .

Risk of accidental or intentional release of similar mutant viruses

New research shows that H5N1 seems capable of evolving the ability tospread rapidly among humans

Existing vaccine technologies incapable of supplying vaccine earlier than six

months after a pandemic starts.

Why Caution ?

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New strain

High InfectiousnessHigh virulence

Compromise / failures of response / defenses

Pandemics - Black Swans ?

-40.0%

-35.0%

-30.0%

-25.0%

-20.0%

-15.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

0 5 10 15 20 25

"Experienced"

Black Swan 2

Black Swan 3

Black Swan 1

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Black Swan WILL HAPPEN, it is

only matter of time

Health Pandemics: From Black Swans to . ?

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GLOBAL impact

Human Fatalities and HUGEeconomic and financial impact

Further research in related scientific fields to be betterprepared (medically and economically)

Correlated catastrophe shocks (stress tests) for betterstrategic foresight, planning and response


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Health Pandemics

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