Issue 6 July 2015

The pandemics edition

Longevity BulletinFrom the Institute and Faculty of Actuaries

Contents

1. IntroductionbyourPresident

2. Summary:JosephLu,ChairoftheIFoA’sMortalityResearchSteeringCommittee

3. Anactuarialperspectiveonpandemics,DrGordonWoo

4. Casestudy:1918Spanishflu

5. Anepidemiologicalperspectiveonpandemics,DrAlisonMartin

6. Casestudy:HIV/AIDS

7. Apolicyperspectiveonpandemics,DrChloeSellwood

8. Casestudy:Ebola

9. Amedicaltechnologistperspectiveonpandemics,DrChristophThuemmler

10.Recentdevelopments

11. Furtherreading

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TheviewsexpressedinthispublicationarethoseofinvitedcontributorsandnotnecessarilythoseoftheInstituteandFacultyofActuaries.TheInstituteandFacultyofActuariesdonotendorseanyoftheviewsstated,noranyclaimsorrepresentationsmadeinthispublicationandacceptnoresponsibilityorliabilitytoanypersonforlossordamagesufferedasaconsequenceoftheirplacingrelianceuponanyview,claimorrepresentationmadeinthispublication.Theinformationandexpressionsofopinioncontainedinthispublicationarenotintendedtobeacomprehensivestudy,nortoprovideactuarialadviceoradviceofanynatureandshouldnotbetreatedasasubstituteforspecificadviceconcerningindividualsituations.OnnoaccountmayanypartofthispublicationbereproducedwithoutthewrittenpermissionoftheInstituteandFacultyofActuaries.

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1. Introduction by our President

WiththeongoingoutbreakofEbola,aswellastherecentMERScoronavirusandH7N9avianfluoutbreaks,theriskofemerginginfectiousdiseaseanditspotentialtocausethenextpandemicisaregularfeatureinthenews.Itisevidentthattheimpactsofapandemiccouldbeveryseriousforsocietyingeneral.Howevertheinsurancesectorcouldalsobesignificantlyaffected,notonlybecauseofextraclaimsbutalsobecauseoftherelatedeconomicreactionsandoperationalriskissues.ThisissueoftheLongevityBulletinassessestheimpactofpandemicsfromthevariousanglesincludingriskmodeling,epidemiology,healthpolicyandtechnology.

IamproudtobegiventheopportunitytointroducethesixthissueoftheLongevityBulletin.Iwouldliketothankallthecontributorsandauthorsfortheirthought-provokingandinformativearticlesonthetopicofglobalpandemics.

Wehopethatthisissuewillbereadwithinterestbyallthosewithatechnical,professionalorpersonalinterestinlongevitymatters.

Bestwishes,

Fiona MorrisonPresident,InstituteandFacultyofActuaries

2. Summary

JosephLu,ChairoftheIFoA’sMortalityResearchSteeringCommittee

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Despitedramaticadvancementinmedicalsciencesandhealthcareinrecentdecades,wearestillnotimmunetopandemics.Apandemiccanbedeadlyandcostly,asshown inthe1918Spanishfluwhichkilledmorethan50million peopleandcosttheinsurancesectorabout£13billionworldwideintoday’smoney.

AtthetimeofwritingthisLongevityBulletin,theWorldHealthOrganisation(WHO)warnsofglobaloutbreaksincluding Ebola(27,609caseswith11,261deaths),MERS-CoV(186cases with36deaths),andAvianInfluenzaH7N9(15caseswith 3deaths)(WHO,2015).Withtheseoutbreaksandincreasingglobaltravel,theriskofpandemiccannotbeignored.Inthisbulletinwehaveaselectionoffourarticleswrittenbyexpertsfromdifferentdisciplinestoreflectcurrentthinkingon variousaspectsofthemodelling,natureandmitigationof pandemicrisk.

Pandemicriskmodellingplaysanimportantroleinriskmanagementandassessmentofregulatorycapitalrequirementsintheinsurancesector.Ourmodellingexpertadvocatesagoodunderstandingofcurrentenvironment,driversandprocessofdeadlyinfectioninmodelling. Thisbulletinalsooffersideastodealwithfutureuncertaintythatmightotherwiseleadtosevereoperationalchallenges.

Forillustration,wehaveincludedcasestudiesonSpanishflu,HIV/AIDSandEbolavirus.Theydemonstratethecomplexityofinfectiousdiseasesastheydifferinorigin,modeoftransmissionandimpactonpopulations.

TheUKgovernmenthaspoliciesandplanstodealwithfuturepandemics.Arangeofinterventionssuchashygienemeasures,social-distancingandvaccinesareavailabletofightinfectioninthepopulation.Recentadvancesinbigdatacapabilityandsocialmediadata,whencombinedwithgenomicsandspatialinformation,shouldprovidenotablyquickerinformationflowstohelpminimisethespreadofinfectionandfacilitatefastertreatments.

Despitethesecontingencyplans,pandemicriskisbeingfuelledbyglobaltrendssuchasincreasedinternationaltravel,urbanisationandimmune-deficiencyduetodiseaseorageing.Ontheotherhand,governmentscanfightcontagionswithvaccination,internationalsurveillanceandimprovedhygiene.Thesechangesinthepandemic‘landscape’maketheactuary’smodellingtaskparticularlychallenging.

Theactuarialcommunitycanaddnotablevaluebyhelpingourstakeholdersunderstandtheriskandimpactofpandemics,throughmodellingbasedonthelatestscientificresearch.

WorldHealthOrganization(2015).AvianinfluenzaA(H7N9)virus.Availableat:www.who.int/influenza/human_animal_interface/influenza_h7n9/en/

WorldHealthOrganization(2015).MERS-CoV.Availableat:www.who.int/emergencies/mers-cov/en/

WorldHealthOrganization(2015).Ebola.Availableat:www.who.int/csr/disease/ebola/en/

3. An actuarial perspective on pandemics

DrGordonWoo

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InfectiousdiseasepandemicssuchasSpanishflu,HIV/AIDSorEbolahavebeenascourgeonhumansocietythroughoutrecordedhistory.Fortunately,severepandemicsarerare,sotheiroccurrenceregistersasanoccasionalspikeindownward-trendingmortalityrates.Thepossibilityofalargespikeissignificantforinsuranceriskmanagementbecauseoftheprematuredeathofsignificantnumbersofinsuredlives,manyofwhommightbeinmiddleageoryounger.Therewouldbesubstantialconsequentvolatilityincashflow.

Inordertoevaluatepandemicrisk,atraditionalactuarialapproachwouldbetoundertakeastatisticalanalysisofpastmortalityexperience.Aswithallextremeevents,whileitispossibletoextrapolatefromhistoricaldata,thereliabilityoftheresultsisseverelydegradedbythepaucityofhistoricalevents,andtheevolutionovertimeofboththehumanpopulationanditsinteractionwiththeinfectiousdiseaseenvironment.

Tounderstandthescopeofpandemicrisk,thespectrumofpossiblefuturescenariosneedstobeconstructedbasedonthecurrenthumanpopulationandbestscientificunderstandingoftheinfectiousdiseaseenvironment.Thisstructuredapproachtodynamicmodellingismoreinsightfulforriskmanagementthanapurelystatisticalmethod,becauseofthesparsestatisticsofpandemics.Suchastructuredapproachishighlycomputer-intensiveandunderpinsthedevelopmentofsoftwareforcatastropheinsuranceriskmodellingoverthepastquartercentury(Woo,2011).Intrinsictothisapproachistheincorporationintothemodellingprocessofscientificknowledgeandunderstanding.Thisextendstotheinclusionofhypotheticalscenariosthathavenohistoricalprecedent,butyetarescientificallyplausible.Asanillustrationofthisforesight,theRiskManagementSolutions(RMS)infectiousdiseasemodelincorporatedEboladisasterscenariosyearsbeforethealarming2014EbolacrisisinWestAfrica(RMS,2007).

TheunderlyingmathematicalframeworkformodellingthespreadofanepidemicderivesfromequationsofbranchingprocessesoriginallyestablishedformallybyKolmogorovandDimitriev(1947).Amongstthepopulationsusceptibletoanepidemic,somebecomeinfected.Ofthese,somerecoverandothersareremovedfromthepopulationthroughdeath.TheacronymSIRmodellingisusedtoreflectthedynamicshiftbetweentheSusceptible,InfectedandRecoveredpopulationgroups,asthecontagionspreads,andeventuallywanes.

The scale of pandemic risk

Eachcountryhasitsownspecifictransmissionvariablesassociatedwiththestandardofitspublichealthcareinfrastructure,quarantiningprocedures,accesstovaccinesandmedicalinterventions.Planningassumptionswhichinformpandemicresponseplansaswellasclinicalandnon-clinicalinterventionsarelistedinSection7ofthisbulletin.Furthermore,thepublicthreatofanepidemicischaracterizedbytwokeyparameters:thecasefatalityrateandthebasicreproductivenumber.Thefirstoftheseistheproportionofthoseinfectedwhodonotsurvive.Thesecondkeyparameteristhenumberofsecondaryinfectionsgeneratedbyaprimaryinfection.

Adegreeofnegativecorrelationbetweenthesetwothreatparametersissuggestedbyanevolutionaryargument:ifaviruskillsoffanexcessivenumberofhosts,thenitwillcurtailitsprospectsforlong-termsurvival.TheavianfluvirusH5N1hasafatalityrate,whichmightbeashighas60%,butispoorlytransmissiblebetweenhumans.LaboratorygeneticsresearchhasbeenundertakentoassesswhatsequenceofgeneticmutationsmightturnH5N1intoaninfluenzavirustransmissiblethroughtheair.However,withoutlaboratorystudiestoforcemutations,thetimeperiodforsuchrandommutationstoappearnaturallythroughchancemightbeextremelylong.

Ofparticularactuarialinterestforlifereinsurersarethe extremepandemicscenarios.Howcostlycouldone realisticallybe?Abenchmarkforapandemicofinsurancecatastropheproportionsisthe1918Spanishflupandemic. Thehighcasefatalityrateof2.5%ismuchhigherthanthatoftheotherpandemicsofthe20thcenturyin1957and1968,whichwereoftheorderof0.1%.FarmorepeoplediedoftheinfluenzapandemicthaninWorldWarIitself(TaubenbergerandMorens,2006).InEurope,theexcessmortalityratewasabout1.1%ofthepopulationof250million(Ansartetal.,2009). Bycomparison,accordingtoEurostatdataforHIV/AIDS,atitspeakinthemid-1990sbeforetherewaseffectivetreatment,about0.01%ofEuropeansdiedfromthisdiseaseoftheimmunesystem.In2014,theEuropeanannualall-causemortalityratewasabout1%.ThespectreoftheEuropeanannualmortalityratedoublingduetoaveryseverepandemicisanextremelychallengingriskmanagementscenarioforthehealthsector,civicauthoritiesandcorporations,includinglifeinsurers. Anditcouldbeworse.

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Conflicts and pandemics

Significantlyforriskassessment,thetwoglobaldisastersofWorldWarIandtheSpanishFluepidemicwerecausallyconnected.TheinfluenzawasmostlikelybroughttotheWesternFrontbyacohortof100,000ChineselabourerswhoweredespatchedtherebytheChinesegovernment(Vergano,2014)intheforlornhopethat,byassistingtheAllies,Chinamightberestoreditsnorth-easternportcityofTsingtao,aformerGermancolony.The1918pandemicismistakenlycalled‘TheSpanishFlu’,becauseSpainwasneutralduringtheWorldWarI,andtherewasnonewsembargoonthedeathtollthere.Moreaccuratelyandinformatively,thepandemicmightbetermed‘TheTsingtaoRevenge’.

AsillustratedbytheSpanishFluCaseStudy,standardsofpublichealthandmedicaladvancestodayarefarhigherthanin1918,andactuariesmayponderthepathwaysbywhichapandemicdisasterof1918proportionscouldre-emerge. Thelinkagebetweenpoliticalconflictandaglobalpandemicprovidesoneclearroutetodisaster.Althoughthereturnperiodofarepeatofa1918pandemiclossisgreaterthan200years(RMS,2007),andhencedoesnothaveadominantroleinthecalculationofcapitalrequirements,thereareotherextremescenarios,involvingpoliticalinstability,thatmightbeusedasrealisticstresstests.

Ifanepidemicweretoemergeinoneofthenumerousdevelopingregionsinastateofpoliticalunrest,civilstrifeoranarchy,theabsenceofdiseasesurveillanceandafragilepublichealthsystemcouldwellallowthecontagiontobecomeestablishedthereandthenspreadabroadtoothercontinentsviarefugeesorgeneralglobaltravelwithlittleconstraint.Accordingly,amajorglobalpandemicisasystemicactuarialrisk,beingcoupledwithsupplychainbreakdownsandbusinessdisruption,potentiallyaggravatedbythedestructionarisingfrompoliticalconflict.

ThecurrentcivilwarinSyriaillustratesthepublichealthcrisispotential.TheflowofSyrianrefugeesinLebanonhasledtoasurgeincommunicablediseasesinthatcountry.Table1belowshowsthenumberofreportedcasesfor2011,2012and2013(ShararaandKanj,2014).(Leishmaniasisisaparasiticinfectionthatleadstoskinlesionsresemblingleprosy.)Giventheovercrowdingandlackofmedicalhygieneinrefugeecamps, itisevidentthatanyoutbreakofpandemicdiseasetherewouldspreadrapidlyintothehostcommunity.

Economic Dislocation

InEurope,thereareaboutsixhospitalbedsper1000population,or0.6%,mostofwhichwouldbeoccupiedforcuringpatients.Thisratioiswellbelowthemortalityrateofthe1918pandemic.Soclearlythehealthserviceswouldbeoverwhelmedbyaseverepandemic.

Theimpactontheworkplacewouldinevitablybeextremelydisruptive.Apartfromworkerswhoareinfected,othersmaynotgotoworkforfearofbecominginfectedduringtheircommute,orwhilstatworkitself.Parentsmayneedtoremainathometolookafterchildren,whoseschoolshaveclosedbecauseofthehighrateofcontagionthere.Atabsenteeismratesabove10%,workproductivitydropsoffsteeply;at20%manybusinesseswouldbeunabletofunction,andwouldsuspendtheiroperations.Asaconsequence,theglobalGDPmightdownturnbymorethan5%(CambridgeCentreforRiskStudies,2014),whichwouldcauseasustainedfallinfinancialassets.Forlifeinsurers,themortalityandmorbidityclaimsresultingfromanextremepandemicwouldbethemainconcern,buttherewouldalsobeadeclineinassetvalues.

AsevidentfromtheEbolacrisisof2014,therearesevereoperationalchallengesassociatedwiththecontrolofanemergingpandemic,whichaggravateinsuranceloss.Wherethedeathrateamongsthealthworkersofanemergingpandemicishigh,asitwasforEbola,staffingoffieldhospitalsandmedicalcentresmaybefraught,unlessthemilitarybecomeinvolved.Themilitaryexcelabovetheirciviliancounterpartsindiligentpreparationforfuturemajorcrises,andhaveahighertoleranceofpersonalphysicalrisk.TheireffortswerecrucialinbringingtheEbolacrisisundercontrol.However,infuture,iftherehappenstobeanongoingsignificantpoliticalconflict,themilitarysupportoptionmaybecurtailed.Forexample,theremaybenomilitaryhelicoptersavailabletoevacuatedangerouslyillhealthworkers;aresourceconstraintthatwouldunderminetheirwillingnesstocontinueprovidingemergencyhealthcare.Financialausteritypressureondefenceexpenditureishighlysusceptibletothelawofunforeseenconsequences:thesecurityimplicationsofdefencecutsareverydifficulttoanticipate.OneconsequenceistheerosionofEuropeanresilienceagainsttheravagesofaseverecivilemergency,suchasanextremepandemic.

Table 1: Reported cases of communicable diseases per year between 2011 and 2013 in Lebanon

Disease 2011 2012 2013

Measles 9 9 1760

Leishmaniasis 5 2 1033

HepatitisA 448 757 1551

Typhoid 362 426 407

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TheEbolacrisisof2014haspassed,butitwouldhavebeenfarhardertomanagehaditoccurredduringtheSierraLeonecivilwarofthe1990s.Inaworldofpoliticalinstability,thenextpandemicmayemergeinaconflictzone.TheFirstWorldWarandthegreatpandemicof1918werelinked.Theyearsleadinguptothecentenaryofthispandemicshouldconcentrateactuarialattentiononprudentmanagementofacatastropheriskinanunstableworld.

References

AnsartS.,PelatC.,BoelleP.Y.,CarratF.,FlahaultA.andValleronA.J.(2009).Mortality burden of the 1918-1919 infl uenza pandemic in Europe.InfluenzaandotherRespiratoryViruses.Blackwell.DOI:http://dx.doi.org/10.1111/j.1750-2659.2009.00080.x

CambridgeCentreforRiskStudies(2014).Sao Paolo virus pandemic scenario.JudgeBusinessSchoolReport.

KolmogorovA.andDimitrievN.A.(1947).Branching stochastic processes. Doklady56:5-8.

RiskManagementSolutions,Inc.(2007).Analytical methods for modelling pandemic fl u.PresentedtotheWorldBank.Availableat:https://info.publicintelligence.net/RMS_InfluenzaPandemicRiskModel.pdf

ShaharaS.L.andKanjS.S.(2014).War and infectious diseases: challenges of the Syrian civil war.PLOSPathogense1004438[online].DOI:http://dx.doi.org/10.1371/journal.ppat.1004438

TaubenbergerJ.andMorensD.M.(2006).1918 infl uenza: the mother of all pandemics.EmergingInfectiousDiseases,12(1).[online]Availableat:http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article

VerganoD.(2014).1918pandemic that killed 50 million originated in China.NationalGeographic-January14.Availableat:http://news.nationalgeographic.com/news/2014/01/140123-spanish-flu-1918-china-origins-pandemic-science-health/

WooG.(2011).Calculating catastrophe.ImperialCollegePress,London.

Biography

DrGordonWooisthechiefarchitectoftheRMSpandemicriskmodel,whichwasthefirstepidemiologicalmodeldevelopedforthelifeinsuranceindustry.Heistheauthorofthetwobooks,‘TheMathematicsofNaturalCatastrophes’,(ImperialCollegePress,1999),and‘CalculatingCatastrophe’(ImperialCollegePress,2011).DrWoograduatedasthe

bestmathematicianofhisyearatCambridgeUniversity,completedhisPhDatMIT,andwasamemberoftheHarvardSocietyofFellows.HeisavisitingprofessoratUniversityCollegeLondon.

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4. Case study: 1918 Spanish flu

The1918fluwasanewstrainthattheworldhadnotseenbefore,sofewhumanshadanynaturalimmunity.This flu was one of the deadliest pandemics on record,ultimatelyclaiming 50 million lives.Onethirdoftheworld’spopulationmayhavebeeninfectedanddeathrateswere5–20timeshigherthanexpected.

Spanish flu relative to other pandemics

The1918Spanishflupandemicwasoneofthelargestpublichealthcatastrophesofthepastcentury,causing life insurance losses of nearly $100 million, which is comparable to nearly $20 billion today  (InsuranceJournal,2013). Thegraphontheright,whichisnottoscale,demonstratestheextremenatureofSpanishflu,relativetootherpandemicsoverthelast300years.

Mortality

Spanishfluisregardedasthebenchmarkagainstwhichothersarebeingmeasured.It killed more people in 24 weeks than AIDS has killed in 24 years. Influenzausuallykillstheveryyoungandveryold(alsoreferredtoasUshapeexcessmortality).However,mostofthedeathsfromtheSpanishfluoccurredinthoseaged between 15 and 35, resultinginexcessdeathshavinganoddW-shapeduringthispandemic.

Therateofmedicaldevelopmentsince1918hasbeenhugeandthemedicalinfrastructureisbetterabletocopewithapandemic.Expertsdonotknowwhattheimpactofanewpandemiccouldbe,butthereisageneralagreementthatthe1918scenarioisveryextreme.

The likelihood that a similar scenario to Spanish flu will occur in the future is estimated to be less than 1 in 400. Asyet,thereisnocureagainstthemutatedvirusandthe virus would probably travel much more quickly around the world today with the greatly increased amount of air travel.

TheviruswasrecentlyreconstructedbyscientistsattheCentreforDiseaseControlintheUnitedStates,studyingremainsofbodiespreservedbytheAlaskanpermafrost.ItisbelievedthatatypeofH1N1 viruswasthecauseofthepandemic–variations of which still exist today in swine flu.

Timeline of influenza pandemics and medical advances during the past century

1

01700 1800

40-50

Year

Deaths(millions)

1900 2000

2

3

4

5

1918

SpanishFlupandemic(H1N1)killsover50millionpeople

worldwide

Influenza-virusisidentified

Asianflupandemic(H2N2)killsover1millionpeople

worldwide

Theantibioticamoxicillinisdeveloped

Swineflupandemic(H1N1)killsmorethan300,000

peopleworldwide

Penicillinis discovered

Massproductionofpenicillin,theworld’sfirst

antibioticbegins

HongKongpandemic(H3N2)killsbetween1-3million

peopleworldwide

Zanamivir,anantiviralthatcanattackbothinfluenzavirusAandBstrains,isdiscovered

19571931 19721928 19681943 1993 2009

PotterC.W.(2001).Ahistoryofinfluenza.JournalofAppliedMicrobiology91(4):572-579.DOI:http://dx.doi.org/10.1046/j.1365-2672.2001.01492.x

InsuranceJournal(2013).AIR Model Estimates Pandemic Flu Losses Availableat:www.insurancejournal.com/news/national/2013/06/27/296967.htm

TaubenbergerJ.andMorensD.(2006).1918Influenza:Themotherofallpandemics.EmergingInfectiousDiseases.12(1)[online] Availableat:http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article

Influenzaisarespiratoryillnesscausedbyseveralfluviruses.

0

500

1,000

1,500

2,000

2,500

3,000

1911-1917 1918

1-4<1 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85

Specificdeathrateper100,000personsineachagegroup

Taubenberger and Morens (2006)

Potter (2001)

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4. Case study: 1918 Spanish flu 5. An epidemiological perspective on pandemics

DrAlisonMartin

Thepreviousarticlereferredtothe1918Spanishfluasthebenchmarkagainstwhichothersarebeingmeasured. TogetherwiththeBlackDeathofthe14thcentury,eachofthesepandemicscausedover50milliondeathsworldwide, yettheysharefewothercommonfeatures.

Thisarticleexploressomeofthecharacteristicsofinfectiousdiseasesthatarecapableofglobaloutbreaks,andthefactorsthatincreaseanddecreasetheriskofapandemic.

Types of micro-organisms that can cause pandemics

Widespreadinfectionscanbecausedbybacteria,virusesorothermicro-organismsincludingparasites.Someonlyinfecthumans,othersuseotheranimalsashostsaswellashumans.Table1summarisesthecharacteristicsofsomeinfectionscapableofcausingapandemic.

Pandemicsareespeciallylikelywherethereishuman-to-humantransmissionbutwhereanimalsalsocarrytheinfection,meaningeradicationismoredifficult.

Table 1. Types of infectious diseases with pandemic potential

Bacteria Viruses Parasites

Onlysurviveinhumans,transmissionhuman-to-human

Cholera

Meningococcalmeningitis

Tuberculosis(pulmonary)

HepatitisB

HepatitisC

HIV/AIDS

Measles

Poliomyelitis

Smallpox

Useotheranimalvectorsashost,transmissionvector-to-humanandhuman-to-human

Tuberculosis(bovine) Ebola

Influenza

MiddleEastRespiratorySyndromeCoronavirus(MERS)

SevereAcuteRespiratorySyndrome(SARS)

Useotheranimalvectorsashost,transmissionvector-to-human

Plague Malaria

Table 2. Routes of transmission of diseases with pandemic potential

Route of transmission, with typical circumstances Examples of infections transmitted this way

Contactwithblood:

• intravenousdruguse

• bloodtransfusion

• needlestickinjuries

HepatitisBandC

HIV

Contactwithotherbodyfluids:

• nursingthesick

• layingoutbodiesofthedead

• touchingcontaminatedsurfaces

Ebola

HepatitisB

Influenza

Measles

SARS

Smallpox

Sexualcontact Ebola(possibly)

HepatitisB(sometimesC)

HIV

Mothertochild:

• duringpregnancyorchildbirth

• breastfeeding

HepatitisBandC

HIV

Dropletspread:

• cough

• sneeze

Influenza

Measles

Meningococcalmeningitis

MERS(possibly)

Plague(pneumonicform)

SARS

Smallpox

Tuberculosis(activepulmonarydisease)

Foodorwatercontamination:

• drinkingwater

• consumptionofcontaminatedfood

Cholera

Poliomyelitis

Animalvectors:

• insectbites

• contactwithinfectedanimal

• consumptionofinfectedmeat

Ebola(initialcases)

Influenza(initialpandemicstraincases)

Malaria

MERS(possibly)

Plague

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Transmissionofinfectiousdiseasescanbebydirectorindirectcontactbetweenpeople,withorwithoutanimalvectors. Themainroutesoftransmissionforpandemic-riskinfectionsareshowninTable2.Dropletorairbornedisseminationisoneofthemosteffectivewaysofspreadinganinfectionwidelyandrapidly.

Thisisonereasonwhyinfluenzahascausedsomanypandemics,whileEbolahasbeenmoreeasilycontainedwithinoneregionoftheworld.However,asillustratedbytheEbolaCaseStudy,thevirushasnowspreadtodenseurbanareas,wherecontrolishardertoachieve.

Routes of transmission

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Prevention and treatment

Muchofthedecreaseincasesandmortalityfrominfectiousdiseaseindevelopedcountrieshascomefromimprovedsanitation,reducedovercrowding,andbetterresilienceofthewell-nourishedpopulation.Vaccinationhasalsohadasubstantialimpact,inparticularagainstsmallpox,polioandmeasles.Vectorcontrolwithinsecticidesanduseofmosquitonetscanpreventtransmissionofmalaria.Animportantaspectinpreventionandtreatmentisalsotheguidanceandpreparednessplans,bothofwhicharediscussedinthenextarticle.

Bacteriaandparasitesarerelativelyeasytocontrolwithantibiotics.Equivalenttreatmentofviruseshasbeenmoredifficult,butantiviraldrugshavebeenverysuccessfulincontrollingHIVinfectionandhavecontributedtotheremarkablefallinmortalitysince1994asshownbytheHIV/AIDSCaseStudyinthisbulletin.

Unfortunately,micro-organismsrapidlydevelopresistancetoantibioticsandantiviraldrugs,especiallywheretheseare

usedatlowconcentrationsthatkillthesusceptiblestrainsbutallowthosewithnaturalresistancetoflourish.Thisoccursfrominappropriateprescriptionofantibioticsandintensivefarming.Antimicrobialresistanceisofparticularconcerninthefollowingpandemic-riskdiseases:

• Tuberculosis:multidrugresistanceaffected480,000peoplegloballyin2013,and9-13%ofthesearethoughttohaveextensively-resistantstrains(WHOTuberculosis,2015)

• HIV:HighlyActiveAntiretroviralTherapy(HAART),combinationtreatmentwith3drugs,hasbeenrequiredtoreduceresistance.

• Influenza:in2011inEurope,3%ofseasonalinfluenzaisolateswereresistanttothedrugoseltamivir(ECDC2012).

• Malaria:antimicrobialresistancetotraditionaldrugs iswidespreadandisincreasingtonewerdrugs (WHOMalaria,2015).

Factors affecting the risk of an outbreak becoming a pandemic

Changesinwhereandhowwelivehavehadasubstantial effectontheriskofpandemicsandtheirimpactonmortality.Somechangeshaveincreasedtherisk,othershavereducedit,

andsomecandoboth,dependingonthecircumstances,andthesearesummarisedinTable3.

Table 3. Factors increasing or decreasing the risk of pandemics

Factor increasing the risk of pandemic

Examples Factor decreasing the risk of pandemic

Examples

Internationaltravelandtourism

Fasterspreadofinfectionswithhuman-to-humancontact,e.g.influenza,SARS.

Migrantsmaycarrychronicinfections,e.g.tuberculosis,HIV.

Increasedexposureto“exotic”infectionsfromreturningtravellers,e.g.newviralhaemorrhagicfevers.

Overcrowding,suchasonpilgrimagesincreasesriskofmeningococcalmeningitis

Vaccination Cankeepimmunityabovethe80%thresholdrequiredtopreventtransmissionofinfection,e.g.measles,hepatitisB.

Caneradicateinfectionswithonlyhumansashosts,e.g.smallpox,polio.

Internationaltrade Cantransmitfood-borneinfections, e.g.cholera.

Animalvectorsmaybetransportedwithcargo,e.g.plague,malaria.

Internationalsurveillance

Facilitatesearlydetectionandcontrolofoutbreaksbeforetheybecomepandemics,e.g.influenza.

Industrialisation Overcrowdinginurbanslumsandpovertyincreasesrisk,e.g.cholera,tuberculosis.

Improvedsanitation Reducestheriskofwater-borneinfections,e.g.cholera,polio.

Antigenchange Rapidlyevolvingvariantsofantigensmeanvaccinesaredifficulttodeveloporquicklyoutofdate,e.g.influenza,HIV.

Antigenchange Virulenceofpreviouspandemicstrainscandecreaseovertime,soriskofsevereinfectionandmortalitymayfall, e.g.H1N1influenza,plague.

Factor increasing the risk of pandemic

Examples Factor decreasing the risk of pandemic

Examples

Ageingpopulation Elderlyhavecomorbidityandreducedimmunitysoatgreaterriskofsevereillness,e.g.seasonalinfluenza,MERS.

Ageingpopulation Residualorpartialimmunityfrompreviousexposurecanprotecttheelderlyfromnewvariantsofestablishedinfections,e.g.H1N1influenza.

Olderpeoplemaybeatlowerriskofimmunesystemover-reactione.g.cytokinestormwithH5N1influenza

Impairedimmunity MalnutritionandHIVincreasetheriskandseverityofotherinfectionse.g.tuberculosis,hepatitisB/C,cholera.

Improvedgeneralhealthandnutrition

Increasesresiliencetoalldisease,soriskandseverityofinfectionarereducede.g.meningococcalmeningitis.

Emerginginfections Newinfectionsmeannoexistingimmunitysoeveryoneisvulnerable,e.g.smallpoxinNorthAmerica(1600s),Ebola(1976),HIV(1980s),SARS(2002),MERS(2012).

Rapidandaffordablemoleculartypingofinfectivestrains

Allowsrapididentificationofnewstrains,confirmsoutbreaksofinfection,andfacilitatesdevelopmentofnewvaccines,e.g.identificationofcirculatingstrainsofinfluenza.

Climatechange Increasingglobaltemperatureby2-3°Ccouldincreasethenumberofpeopleatriskofmalariaby3-5%(orseveralhundredmillion)(WHO,2003)e.g.outbreakinGreecein2011.

Warmerconditionsfavourwater-bornebacterialinfections,e.g.cholera.

Climatechangealtersfarmingpracticessocanchangevectorhabitats,e.g.DengueandWestNilevirusareappearinginnewcountries.

Climatechange Droughtcandestroyhumidenvironmentrequiredforinsectvectors,e.g.malaria.

Conflictandnaturaldisasters

Massmigrationcausesovercrowdingandimpairedsanitation,whichincreasestheriskandseverityofinfectionse.g.cholera,measles

Terrorismmayinvolvedeliberatereleaseofinfectione.g.smallpox,SARS.

Farmingpracticesandfoodprovision

Intensivefarmingencouragesnewanimal-borneinfectionsfromcrowding,e.g.influenza,orirrigation,e.g.malaria.

Closehabitationwithfarmanimalsincreasesmixingofvirusese.g.chickens,pigsandhumansincreasesriskofnewstrainofpandemicinfluenza.

ConsumptionofbushmeatinAfricafacilitatestransmissionofanimal-bornevirus,e.g.Ebola.

Inappropriatefarmingmethodscanspreadnewpathogense.g.humanvariantCreutzfeld-Jakobdisease.

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What is the greatest threat for future pandemics?

Thegreatestriskofnewpandemicsislikelytocomefromanewstrainofanexistingvirus,oranentirelynewtypeofviralinfection,thatistransmittedbydropletspreadfromhumantohuman.Theseconditionsaremostlikelywherehumansandanimalscohabitineconomicallydisadvantagedlocationswherehealthservicesaresparseandbaselinehealthispoor.OutbreaksofpandemicinfluenzainAsiaandEbolainAfricahaveshownhoweasilysomeorallthesecriteriacanbemet.Ourbestchancetominimisetheharmfromsuchapandemicistohaveeffectivesurveillancesystemstoactivelylookforsuchinfections,andfortheinternationalcommunitytorespondrapidlyandeffectivelytoemergingthreats.

References

ECDC(2012).Annual epidemiological report: Reporting on 2010 surveillance data and 2011 epidemic intelligence data. Availableat:http://ecdc.europa.eu/en/publications/Publications/Annual-Epidemiological-Report-2012.pdf

WorldHealthOrganization(2003).Climate change and human health: risk and responses. Availableat:http://www.who.int/globalchange/summary/en/

WorldHealthOrganization(2015).Malaria: Fact sheet. Availableat:http://www.who.int/mediacentre/factsheets/fs094/en/

WorldHealthOrganization(2015).Tuberculosis: Fact sheet.Availableat:http://www.who.int/mediacentre/factsheets/fs104/en/

Biography

DrAlisonMartinhasexperienceasajuniorhospitaldoctorworkingingeneralmedicine,nephrology,medicaloncology,cardiology,generalsurgeryandurology.However,mostofhercareerhasbeenspentworkinginthefieldofevidence-basedmedicinefororganisationsincludingDrugandTherapeuticsBulletin,theBritishMedicalJournal

(BMJ)Group,MatrixKnowledgeGroupandEvidera.AttheBMJGroupshewasaSeniorClinicalEditoronevidence-basedpublicationsforcliniciansandotherhealthcarestaffandresearchers,includingBMJClinicalEvidence,BMJBestPracticeandBMJActionSets.AlisonisnowPrincipalMedicalWriteratCrystalliseLtd.

6. Case study: HIV/AIDS

Acquiredimmunedeficiencysyndrome(AIDS)isadiseaseoftheimmunesystemcausedbyhumanimmunodeficiencyvirus(HIV).

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1900s

ThereisevidencethattheoriginofHIVistheSimian Immunodefi ciency Virus (SIV),andscientistsbelievethatthevirusjumpedtohumansintheearly1900s.ThevirusspreadwhenabushmeathunterinCongokilledandateaninfected ape or chimpanzee. Inearlythe1980s,stillverylittlewasknownabouttransmissionandpublicanxiety and fear continuedtogrow.

1987

In1987Zidovudine(AZT)becamethefirstdrugtobeapprovedbytheUSFDA(FoodandDrugAdministration)forthepurposeofprolonginglifeofAIDSpatients.ThegainfromAZTwasverysmallasitonlyincreased life between two to three years. However,sincethenmanyotherretroviraldrugshavehadamuchmoresignificanteffectonlifeexpectancyandonqualityoflifeforthosewithAIDSandHIV.

Death rate in 25-44 year olds

Intheearly1980s,thebiggestkillersof25–44oldyearmenwereaccidents(about36per100,000),cancer(about25per100,000)andhomicide(about15per100,000).By1994,deathsfromHIV/AIDS had overtaken deaths from all the other causes. However,bytheturnofthecentury,deathsfromAIDShadtakenaverysharpdownturn.

Theremarkablefallinmortalitysince1994reflectsthenewdrugtherapiesthathavebecomeavailableoverthepasttwodecades.

1982

1981 1985 1989 1993 1997 2001 2005 2009 2013

0

10

12

4

6

3

5

78 ‘000

20

30

40

1986 1990 1994 1998

AIDS

Homicide

Cancer

Accidents

Trends, 1981 - 2014

TheUKhasarelativelysmallHIVandAIDSepidemicincomparisonwithsomepartsoftheworld.An estimated 98,400 people in the UK – or around 1.5 per 1000 of the UK population – are currently living with HIV.AlthoughHIVandAIDSreceivelessattentionfromthemediaintheUKthantheydidduringtheearlyyearsoftheUKAIDSepidemic,it’sfarfromanissueofthepast.Infact,theepidemichasexpanded,withtheannualnumberof new HIV diagnoses nearly tripling between 1996 and 2005.

New HIV cases in the WHO European Region.AveragenumberofnewHIVcasesper100,000people:

Per100,000population

New

HIVandAIDSdiagnosis

HIV in Europe

22

6.6

1.9

NewHIVdiagnosesAIDSDeaths

In 2013 there were

80% morenew HIV cases compared to 2004 . Alarmingly, around half of those people do not know that they are infected.

CondonB.andSinhaT.(2008).Global lessons from the AIDS pandemic.Springer.

PublicHealthEngland(2014).HIV in the United Kingdom: 2014Report.Availableat:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/401662/2014_PHE_HIV_annual_report_draft_Final_07-01-2015.pdf

WorldHealthOrganization(2013).HIV/AIDS in the European Region.27November2013.Availableat:http://www.euro.who.int/en/health-topics/communicable-diseases/hivaids/news/news/2013/11/hivaids-in-the-european-region

WorldHealthOrganization(2015).HIV/AIDS: data and statistics. Availableat:http://www.euro.who.int/en/health-topics/communicable-diseases/hivaids/data-and-statistics[accessed17July2015]

Condon and Sinha (2008)

Public Health England (2014)

World Health Organization (2013), (2015)

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7. A policy perspective on pandemics

DrChloeSellwood

ManypeoplewillbefamiliarwiththetermandpopularconceptofanapocalypsethroughrecentfilmssuchasI am Legend (2007),World War Z (2013),Contagion (2011)andDawn of the Planet of the Apes (2014)whereaninfectiousdiseaserapidlyspreadsaroundtheworldwipingoutvirtuallyallofhumanity.Howeverthisisnottrueforallpandemicsandwhilethisarticle

willfocusoninfluenzawhenconsideringthepolicymakers’perspectiveofpandemicpreparednessandresponse,manyofthepublichealthimpactsofotherinfectiousagentsarecommonandconsequentlyplansandpoliciesforinterventioncanencompasscommonelements.

Background to influenza pandemics

Influenzaisavirusthatcausesmanydeathsinthousandsofpeopleacrosstheglobeeveryyear.Thenaturalreservoirforinfluenzaiswildwaterbirdswherethevirusisendemic.Howeveritcanreadilyinfectandcauseillnessinawiderangeofanimalpopulationsincludingdomesticpoultry,swineandhumans.Withincreasingclosecohabitationofpeoplewiththeir

animalsthereareevermoreopportunitiesfornovelvirusestocrossspeciesbarrierswhileincreasinglyintensivefarmingpracticesandglobalisationpresentmoreopportunitiesforavirustorapidlyspreadinpopulationsandcauseepidemicsorpandemicsofdisease(Table1).

Table 2: Pandemics in the 20th Century

Year Common name Origin Global mortality Waves Ages/ groups affected

1918 Spanishflu USA/China 20-40million Three Veryyoung,olderpeople,and20-40yearolds

1957 Asianflu China 1million(mainlyolderpeople) Two Schoolagechildren

1968 HongKongflu China 1-3million One Olderpeoplerelativelyprotected

2009 Swineflu Americas 300,000 Twotothree Schoolagechildren,pregnantwomenandmorbidlyobeseatincreasedrisk

Table 1: The Spread of Diseases

Endemic: Anillnessorinfectionthatispersistentlypresentinacertainapopulation.

Epidemic: Thesuddensurgeincasesabovebaselinelevelsofaninfectiousdiseaseinagivenpopulationwithinashortperiodoftime,usuallytwoweeksorless.EpidemicisderivedfromGreekmeaning‘uponpeople’.

Pandemic:Anepidemicofinfectiousdiseasethathasspreadthroughpopulations,forexampleacrosscontinentsorworldwide.PandemicisderivedfromtheGreekpanmeaning‘all’anddemosmeaning‘people’.

Influenzapandemicshavebeenrecordedthroughouthistory,howeveraspreviouslymentionedinthisbulletin,thebestknownpandemicisthe1918Spanishflupandemic.Pandemicpreparednessisinformedbyplanningassumptionsdeveloped

frominformationonpreviouseventssuchasthoseshowninTable2.IntheUK,thepandemicsofthe20thcenturyinformedtheplanningassumptionsthatguidedtheearlyresponsetothe2009/10pandemic.

OutbreaksofavianinfluenzaA/H5N1inhumanpopulationsinHongKongin1997(18cases,includingsixfatalities)andsubsequentlyacrosssoutheastAsiafrom2003to1May2015(840casesincluding447fatalities)aswellastheSARSoutbreakin2003(ParasharandAnderson,2004)gaveglobalimpetustopandemicinfluenzapreparednessactivity,ledbytheWorldHealthOrganization(WHO).Whenthefirstpandemicofthe21stcenturyoccurredin2009,manycountrieshadconsideredissuesthatsubsequentlypresentedduringthepandemic.Thispandemichastypicallybeendescribedasmild,andtherehasbeenanequalamountofcriticismforover-reaction(becauseplanningassumptionsreliedonknowledgefromtheeventsinthe20thcentury)aswellascommendation

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forawell-preparedandmanagedresponse(becausewehadplannedbasedoneventsinthe20thcentury)(Hine,2010).

InJune2013theWHOpublishedrevisedpandemicinfluenzaguidance.Thismovedawayfromtheprevioussixpandemicphases,andinsteadusesarisk-basedapproachrepresentedasacontinuumofglobalphases(inter-pandemic,alert,pandemicandtransition)thatdescribethespreadofanewinfluenzasubtype,takingaccountofthediseaseitcauses,aroundtheworld.Itrecognisestheimportanceofnational,regionalandlocalplansforpandemicinfluenzathatcanbeactivatedwithintheWHOframework(WHO,2013).

UK pandemic influenza preparedness and response

Sincethe2009/10pandemic,theUKgovernmentcontinuestorecognisepandemicinfluenzaasoneofthemostsubstantialriskstotheUK(Figure1)andconsequentlyactivitycontinuesacrossUKorganisationstoprepareforafutureevent.

TheDepartmentofHealth(DH)istheleadgovernmentdepartmentforUKpandemicpreparednessandresponse. Manylessonswereidentifiedfollowingthe2009/10pandemic,

Figure 1. UK National Risk Register of Civil Emergencies (2015)

Risk of terrorist and other malicious attacks Other Risks

Overallrelativeimpactscore

5Catastrophicterrorist attacks

Overallrelativeimpactscore

5 Pandemicinfluenza

4 4

Coastalflooding

Widespreadelectricityfailure

3Cyberat-tacks:

Infrastructure

Terroristattackson

infrastructure

Smaller-scaleCBRterrorist

attacks

Terroristattacksoncrowdedplaces

Terroristattacksontransportsystems

3

Majortransportaccidents

Majorindustrialaccidents

Effusivevolcaniceruption

Emerginginfectiousdisease

Inland flooding

Severespaceweather

Lowtem-peraturesandheavysnow

Heatwaves

Poorair qualityevents

3 2Animaldiseases

Drought

Explosivevolcaniceruption

1

Cyber attacks:data confidenti-

ality

1Disruptiveindustrialaction

Low Mediumlow

Medium Mediumhigh

High Between1in20,000and1in2,000

Between1in2,000and1in200

Between1in200and1

in20

Between1in20and1in2

Greaterthan1in2

Relative plausibility of occurring in the next five years Relative likelihood of occurring in the next five years

CrownCopyright2015www.nationalarchives.gov.uk/doc/open-government-licence/version/3/

andin2011DHissuednewguidancethatreflectedrevisedplanningassumptions,keychangesinthedescriptionofpandemicphases,andade-couplingfromthepreviouslyrigorouslinkintoglobalactivitiesduringaresponsetoensureamoreprecautionary,proportionateandflexibleUKresponse(DH,2011).ThekeyplanningassumptionsusedtoinformpandemicresponseplanningarelistedinTable3,whiletherevisedUKpandemicphasesareshowninTable4.

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2   TheNPFSisawebandtelephonebasedservicethatcanbeusedtoassesspotentialinfluenzapatients,inarapidandsafemannerviaastandardclinicalalgorithm, forantiviraltreatment

Table 3: UK pandemic planning assumptions – adopted from the UK Influenza Pandemic Preparedness Strategy (2011)

• influenzapandemicsareintrinsicallyunpredictable,plansshouldthereforebeflexibleandadaptableforawiderangeofscenarios

• duringapandemic,theassumptionsonwhichtobasetheresponsewillbeupdatedinthelightofemergingevidenceabouttherangeoflikelyscenariosatthetime

• evenpandemicswithonlymildormoderateimpactarelikelytoputconsiderablepressureonservicesandtheexperienceinlocalareascouldbemuchmoresevere

• aninfluenzapandemiccouldemergeatanytime,anywhereintheworld(includingintheUK);itcouldemergeatanytimeoftheyearandregardlessofwhereorwhenitemerges,itislikelytoreachtheUKveryquickly

• itwillnotbepossibletostopthespreadof(oreradicate)theviruseitherinthecountryoforiginorintheUKasitwillspreadtoorapidlyandtoowidely

• fromarrivalintheUK,itwillprobablybeafurtheronetotwoweeksuntilsporadiccasesandsmallclustersofdiseaseareoccurringacrossthecountry

• initially,UKpandemicinfluenzaactivitymaylastforthreetofivemonths,dependingontheseason,andtheremaybesubsequentsubstantialactivityweeksormonthsapart

• itislikelythatinfectedpeoplewillexhibitawidespectrumofillness,rangingfromminorsymptomstopneumoniaanddeath;mostwhorecoverwillreturntonormalactivitywithin7–10days

• allagesarelikelytobeaffectedbutthosewithcertainunderlyingmedicalconditions,pregnantwomen,childrenandotherwisefityoungeradultscouldbeatrelativelygreaterrisk;theexactpatternwillonlybecomeapparentasthepandemicprogresses

• theUKcontinuestomaintainstockpilesanddistributionarrangementsforantiviralmedicinesandantibiotics,aswellaspersonalprotectiveequipment(PPE),sufficientforawidespreadandseverepandemic

• upto50%ofthepopulationcouldexperiencesymptomsofpandemicinfluenzaduringoneormorepandemicwaveslasting15weeks,althoughthenatureandseverityofthesymptomswouldvaryfrompersontoperson

• upto30%ofsymptomaticpatientsmayrequireassessmentandtreatmentinusualpathwaysofprimarycare,assumingthemajorityofsymptomaticcasesdonotrequiredirectassistancefromhealthcareprofessionals

• 1to4%ofsymptomaticpatientswillrequirehospitalcare,dependingonhowseveretheillnessis,andthereislikelytobeincreaseddemandforintensivecareservices

• ifnoeffectivetreatmentwasavailable,upto2.5%ofthosewithsymptomscoulddieasaresultofinfluenzainaseverepandemic,howeverlocalplannersshouldplanfor210-315,000excessdeathsoverthedurationofapandemic.

Table 4: UK pandemic response phases - adapted from the UK Influenza Pandemic Preparedness Strategy (2011)

Phase Activity

Detect

UpondeclarationofaWHOPublicHealthEmergencyofInternationalConcern

• Intelligencegatheringfromcountriesalreadyaffected

• EnhancedsurveillancewithintheUK

• Developingdiagnosticsspecifictothenewvirus

• Informationandcommunicationtothepublicandprofessionals

Assess

UponidentificationofthenovelinfluenzavirusinUKpatients

• Collectingandanalysingclinicalandepidemiologicalinformationonearlycases,toinformearlyestimatesofUKimpactandseverity

• Reducingtheriskoftransmissionandinfectionwithinthelocalcommunitybycasefinding,caseisolation,casetreatment

Treat

Uponevidenceofsustainedcommunitytransmissionof thevirus

• Treatingindividualcasesandpopulationtreatment(viatheNationalPandemicFluService 2ifnecessary)

• Enhancingthehealthresponsetodealwithincreasingnumbersofcases

• Consideringenhancingpublichealthmeasurestodisruptlocaltransmissionofthevirus

• Dependinguponthedevelopmentofthepandemic,preparingfortargetedvaccinations asthevaccinebecomesavailable

Inadditiontotherevisedplanningassumptionsandarethinkofpandemicphasesthatunderpinsnational,regionalandlocalpandemicplanningandresponse,therehavealsobeenmajorchangestotheNHSandwiderresiliencepreparednessandresponselandscapesincethe2009/10pandemicfollowingthe

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Escalate

Whendemandsforservicesstarttoexceedtheavailablecapacity

• Escalatingsurgemanagementarrangementsinhealthandothersectors

• Prioritisingandtriageofservicedeliverywithaimtomaintainessentialservices

• Resiliencymeasures,encompassingrobustcontingencyplans

• Consideringresponsede-escalationifthesituationisjudgedtohaveimprovedsufficiently

Recover

Wheninfluenzaactivityiseithersignificantlyreducedcomparedtothepeakorwhentheactivityisconsideredtobewithinacceptableparameters

• Normalisationofservices,perhapstoa‘new’normal

• Restoringbusinessasusualservices,includingcatching-upe.g.reschedulingroutineoperations

• Sharinglessonsidentifiedthroughpost-incidentreviewanddebrief

• Takingstepstoaddressstaffexhaustion

• Planningandpreparingforaresurgenceofactivity,includingactivitiescarriedoutintheDETECTphase

• Continuingtoconsidertargetedvaccination,whenavailable

• Preparingforpost-pandemicseasonalinfluenza

changeofgovernmentintheUKin2010(seeTable5). Theseofferchallengesaswellasopportunitiesforadifferenttypeofresponsetoafuturepandemicthatpolicymakers mustconsider.

Table 5: Key changes to the NHS and wider resilience landscape in England since 2010

Dis-establishmentofStrategicHealthAuthorities(SHAs),PrimaryCareTrusts(PCTs)andtheHealthProtectionAgency(HPA)–keyrespondingorganisationsduring2009/10withsignificantcommandandcontrolresponsibilities

EstablishmentofClinicalCommissioningGroups(CCGs),NHSEnglandandPublicHealthEngland(PHE)–greaterlocalisationofhealthcarecommissioning(CCGs)coupledwithimprovedopportunitiesforresponsearrangementconsistencyacrossthecountry(NHSEngland)

EstablishmentofLocalHealthResiliencePartnerships–newmulti-healthorganisationcommitteesresponsiblefortheoversightofhealthemergencypreparednessandresilience

RelocationofDirectorsofPublicHealth(DsPH)fromtheNHSintolocalauthorities–improvedintegrationinthewideraspectsoflocalpopulationhealthandwell-being

Interventions

Arangeofinterventionsareavailableforpandemicinfluenza,includingclinical(e.g.vaccinationandanti-microbialtreatment)andnon-clinical(e.g.socialdistancingandhand/respiratoryhygiene)measures.Policymakersmustselectinterventionsthatareappropriatetothescenario,whileconsideringthelikelihoodofacceptanceandeffectivenessintheirpopulation,aswellasassociatedcostandbenefits.Additionally,someinterventionsaremoreeffectiveearlyinaresponse–suchasquarantineorself-isolationbeforeapathogenbecomeswidespread,whileothersmaybebeneficialthroughout–suchashandwashing.Some,suchasaspecificvaccine,maynotbecomeavailableformanymonths(VanTamandSellwood,2012).

IntheUK,specificnationalworkstreamsareconsideringhow toensuresymptomaticmembersofthepubliccanrapidlyaccessantiviralsinamannerthatisreliableandacceptable, aswellashowapandemic-specificvaccinationcampaignmaybedeliveredtothepopulation.Workisalsounderwaytoconsiderthemanagementanddistributionofstockpilesofitemsofpersonalprotectiveequipment(PPE)thattheNHSwouldneedwhencaringforanincreasednumberofrespiratorypatientswithinfluenza.ThisworkisledbyNHSEngland,inpartnershipwithPHEandDH,andisbuildinguponlessonsidentifiedin2009/10.

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Prospects and conclusions

Whilethemechanismsbywhichpathogensspreadaredifferent–e.g.bloodbornevsrespiratory–manyofthestrategicpoliciesandprinciples,operationaldecisions,andtacticalinterventionsarecommon.Allhavetheultimateoverarchingaimsofreducingharmtopopulationsandminimisingdisruptiontosociety.Lessonswillcontinuetobeidentifiedfrominfectiousdiseaseoutbreaks,epidemicsandpandemics,andpolicymakerswillusethesetoinformthepreparednessandresponsetofutureevents.Itisessentialthataresponseispromptenoughtoensuremaximumimpact,butequallythatdueconsiderationisgiventoensureanypreviousmistakesarenotrepeated.

References

BrilliantL.B.andHodakevicL.N.(1978). Certification of smallpox eradication. BulletinoftheWorldHealthOrganization56(5):722-33

UnitedKingdom.DepartmentofHealth(2011). UK Influenza Pandemic Preparedness Strategy. Availableat:www.gov.uk/government/publications/responding-to-a-uk-flu-pandemic

UnitedKingdom.CabinetOffice(2015). National Risk Register of Civil Emergencies. Availableat:www.gov.uk/government/uploads/system/uploads/attachment_data/file/419549/20150331_2015-NRR-WA_Final.pdf

HineD.(2010).The 2009 influenza pandemic: an independent review of the UK response to the 2009 influenza pandemic. CabinetOffice,PandemicFluReviewResponseTeam. Availableat:www.gov.uk/government/uploads/system/uploads/attachment_data/file/61252/the2009influenzapandemic- review.pdf

Nguyen-Van-TamJ.S.andSellwoodC.(2013).Intervention strategies for emerging respiratory virus infections: policy and public health considerations.CurrentOpinioninVirology3(2):192-8. DOI:http://dx.doi.org/10.1016/j.coviro.2013.02.004

NHSEngland(2014).Operating framework for managing the response to pandemic influenza. Availableat:www.england.nhs.uk/wp-content/uploads/2013/12/framework-pandemic-flu.pdf

ParasharU.M.andAndersonL.J.(2004).Severe acute respiratory syndrome: review and lessons of the 2003 outbreak. InternationalJournalofEpidemiology33(4):628-634.

Van-TamJ.andSellwoodC.(2012).Pandemic Influenza.2nded.CABI,Wallingford,Oxford.

WorldHealthOrganization(2013).Pandemic influenza risk management: WHO Interim Guidance. Availableat:www.who.int/influenza/preparedness/pandemic/influenza_risk_management/en/index.html

Other infectious disease

Howeveritisn’tallaboutinfluenza.Anotherrespiratoryinfectioncouldeasilyemergeorre-emergeandcausehumandisease(Nguyen-Van-TamandSellwood,2013).Inrecentyears,MERS-CoV(avirussimilartoSARS)hascausedmanycasesandfatalitiesacrosstheMiddleEast,andasyetthereservoirofthisvirusremainsunconfirmed.InMay2015,thelargestoutbreakofthisvirusoutsideoftheMiddleEaststartedinSouthKorea,andtodate(13July2015)almost186caseshavebeenidentified,includingover36fatalities(WHO-MERS-CoV,2015).Althoughthisdevelopmenthasnotchangedglobalriskassessment,itdoesservetoillustratehoweasyitisforvirusestospreadacrosstheworld.

TheeradicationofsmallpoxfollowingaWHO-ledcampaignsawtheendtoapproximately3,000yearsofepidemicsacrosstheglobewhichcausedincalculableamountsofmorbidityandmortality.ThiswasendorsedbytheWorldHealthAssemblyin1980afterthelastnaturallyoccurringcasewasdiagnosedinSomaliainOctober1977(BrilliantandHodakevic,1978).Inpartnershipwithotherorganisations,WHOisleadingtheprogrammetoeradicatepolio,withonlypocketsremaininginpartsofAfricaandAsiaandthecampaignisclosetoachievingsuccessfuleradicationofthewildvirus(WHO,2015).

ArguablyoneofthebiggestpandemicsofrecentyearsistheHIV/AIDSpandemicthatcametopublicattentioninthe1980sfollowingdiagnosesofcasesintheUSandhassincecausedinnumerablecasesacrosstheworldandmillionsoffatalities.TheHIV/AIDSCaseStudyprovidesfurtherinformationontheoriginofthevirus,mortalityandtrends.

Morerecently,theEbolaepidemicinWestAfricathatcontinuesinto2015hasraisedconcernthatapandemicofthishighlyfatalbloodbornepathogencouldoccur.TheunprecedentedsizeofthisepidemicisillustratedbytheEbolaCaseStudywherefromthestartoftheoutbreaktoendMay2015,over27,000casesincludingover11,000fatalities,largelyinSierraLeone,GuineaandLiberiahavebeenreported.TheresponsetoEbolahadseenclosecollaborationofinternationalgovernments,non-governmentalorganisations(suchasWHO,RedCrossandSavetheChildren),militaryforces,andpublicsectorhealthcareproviders.Manyoftheinterventionshavebuiltontriedandtestedprocessesdevelopedthroughrespondingtootherinfectiousdiseases.Thereisalsoanenormouspotentialinsmartalgorithmsleadingtoprojectionsofdiseasespreadandvelocity.Thisisfurtherdiscussedinsection9thatfocusesonbigdataandtechnology.

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WorldHealthOrganization(2015).MERS-CoV. Availableat:http://www.who.int/emergencies/mers-cov/en/

WorldHealthOrganization(2015).Status Report: July – December 2014: Progress against the polio eradication and endgame strategic plan 2013-2018. Availableat:www.polioeradication.org/Portals/0/Document/AnnualReport/2014/GPEI_StatusReport2014Jul-Dec.pdf

Biography

ChloeSellwoodBSc(Hons)PhDFRSPHDipHEPisthePandemicInfluenzaResilienceManagerforNHSEngland,withintheEmergencyPreparedness,ResilienceandResponse(EPRR)Team.SheleadsNHSEnglandinternalpandemicinfluenzapreparednessasasubjectmatterexpert,andiscoordinatingnationalpandemicpreparedness

acrosstheNHS,withaspecificfocusonLondon.Sheistheco-editorof,andacontributingauthorto,twotextbooksonpandemicinfluenza,aswellasmanyotherarticlesandpapersoninfluenzaresilience.ShehasworkedwithWHOandECDConinternationalconsultations,aswellasonsecondmenttotheDH(England)PandemicInfluenzaPreparednessProgramme.

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8. Case study: Ebola

Ebolavirusdisease(EVD)comesfromthefilovirusfamily,whichoccursinhumansandotherprimates.

Unprecedented size

Ebolavirusdisease(EVD),formerlyknownashaemorrhagicfever,wasfirstdiscoveredin1972inwhatisnowtheDemocraticRepublicoftheCongonearEbolaRiver.ThecurrentoutbreakdwarfsthelargesthistoricaloutbreaksinAfrica,whichwereruralandrelativelyeasytocontrol.Ebolahasnowspreadtodenseurbanareas,wherecontrolishardertoachieve.Since1994Ebolaoutbreakshavebeenoccurringwithincreasingfrequency .

Transmitting disease

Ebolaisspreadbycontactwithaninfectedperson’sbodilyfluids,butislesscontagiousthanmanycommondiseases,suchasmumpsandmeasles.Inthecurrentoutbreak,each person with Ebola will infect 1 - 2 other people. However,thedeathratefromEbolaisveryhigh,therearevery limited treatmentsavailableandeffectivevaccinesarestillonlyjustbeingdeveloped.

1976, Zaire318cases 280deaths

1976, Sudan284cases 151deaths

Numberofcases Numberofdeaths *DemocraticRepublicofCongo

HepatitisC(2)

R0morecontagious

Ebola (2)

Global reach

HIV(4) SARS(4) Mumps(10) Measles(18)

1995, Zaire315cases 250deaths

2000, Uganda425cases 224deaths

1994, Gabon52cases 31deaths

1996, Gabon37cases21deaths

2001, Gabon65cases53deaths

2007, DRC*264cases187deaths

2003, Congo143cases 128deaths

2007, Uganda149cases 37deaths

2014, Guinea, Liberia, Nigeria,

Senegal, Sierra Leona27,609cases11,261deaths

Modellingofhistoricalair-passengervolumesandflightnetworkscanpointtointernationaldestinationswhereatravellerwithEbolamightendup.

Number of passengers per week

6000+

3000-60001500-3000

CentresforDiseaseControlandPrevention(2014).Outbreaks chronology: Ebola haemorrhagic fever. Availableat:www.cdc.gov/vhf/ebola/resources/outbreak-table.html[Accessed17July2015]

AlthausC.L.(2014).Estimating the reproduction number of Ebola virus (EBOV) during the 2014 outbreak in West Africa.PLOSCurrentsOutbreaks,September[online]DOI:http://dx.doi.org/10.1371/currents.outbreaks.91afb5e0f279e7f29e7056095255b288

GomesM.etal.(2014).Assessing the international spreading risk associated with the 2014 West African Ebola Outbreak.PLOSCurrentOutbreaks,September[online]http://dx.doi.org/10.1371/currents.outbreaks.cd818f63d40e24aef769dda7df9e0da5

CDCP (2014)

Althaus (2014)

Gomes et al. (2014)

9. A medical technologist perspective on pandemics

ProfessorChristophThuemmler

3InternetofThings–Physicalobjectsareseamlesslyintegratedintotheinformationnetwork,andwheretheycanbecomeactiveparticipantsinbusinessprocesses.

4m-Healthisthedeliveryofhealthcareservicesviamobilecommunicationdevices

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Detailedinformationonprevalence,incidence,andvelocityofthevectorarecrucialtocontainmentandpreventionofviralandbacterialepidemics.Typicallyinformationisbasedoncrispmedicaldatawithhighreliabilityinordertoachieveahighlevelofspecificity.Providingdiagnosticinformationin“realtime”inthiscontextmaymeanaconsiderabledelayduetothefactthatmoreorlesscomplexdiagnosticprocedureshavetobecompletedinordertoconfirmadiagnosisandcorrectlyidentifythosepatientswhosufferacertaincondition.Localmedicalinfrastructuresareheterogeneousandofdifferentstandardssothereissubstantialvariationintheprovisionofreliable“realtime”information.AtraditionalapproachemployedbytheUSCentersforDiseaseControlandPrevention(CDC)includescollectinginfluenza-likeillness(ILI)activitydatafrom“sentinel”medicalpractices.Typicallythereisa1-2weekdelaybetweenthetimeapatientisdiagnosedandthemomentthatdatapointbecomesavailableinaggregateILIreports(Achrekaretal.,2011).

Alternative measures of monitoring pandemics

Thewidedistributionofsocialmediaandthefreeavailabilityoftimelyinformationhasgivenrisetodiscussionsonalternativemeasuresofthemonitoring,managementandpreventionofrapidlyspreadinginfectiousdiseasessuchasinfluenza.ArecentreportissuedbyCiscohashighlightedthefactthatthenumberofsmartphonesubscriptionshasnowovertakentheworldpopulationandthatmobiledatawillincreasetenfolduntil2019(Cisco,2015).Therecanbenodoubtthatpersonalisationandvirtualisationofhealthcarewillcontinueandthatsmartphonesandothermobiledeviceswillplayanincreasingroleinallareasofhealth.Itisreasonabletoassumethathyper-connectivitybasedonsuperfastaccesstotheInternetwillimprovetheoutcomesforpatientsasrecentlyhighlightedinareportbytheUKNationalInformationBoard,alsointheareaofinfectionpreventionwithregardstoinfluenzaandothercontagiousandfastspreadingconditions(UnitedKingdom.DepartmentofHealth;NationalInformationBoard,2015).

Inseveralstudiesitcouldbedemonstratedthatitwaspossibletotrackflupandemicsbymonitoringthesocialwebusingdatacompletelyindependentfromthatcommonlyusedforfludetection.Theflu-scoredetectorsuggestedbyLamposand

Cristianiniin2010showedasignificantcorrelation(greaterthan95%)withdatafromtheUKHealthProtectionAgency,whileAchrekaretal.wereabletodetectflutrendsbyusingTwitterdata.Infacttheuseofsmartalgorithmstoextractinformationfromthesocialwebhasbeenusedsuccessfullyduringthe2014Ebolaoutbreak.AccordingtoanarticleinScientificAmericanhealthcareofficialsreliedheavilyonthedataglutcreatedbycountlessnewsarticles,socialmediafeeds,medicalreportsandemailedon-sceneaccounts(Greenemeier,2014).ThisisachievedthroughanewbreedofhealthwebpagessuchasHealthMap.HealthMapcontainsservices,whichareabletoscreenandanalyzetensofthousandsofwebpageshourlyin15languagesleadingtoprojectionsofdiseasespreadandvelocity(HealthMap,2015).HealthMapalreadyplayedaroleduringthe2009H1N1flupandemicbutsincethenevolvedmassivelymakinguseofcuttingedgewebservicetechnologyadvances.

Thereareclearindicationsthat“Bringyourowndevice”(BYOD)strategiescombinedwiththepoweroftheInternetmightbesuperiortostandardproceduresinthespeedydetectionandthemonitoringofflupandemics.However,itisunclearwhatlevelofsensitivity(theabilityofatesttocorrectlyidentifythosepatientswithoutthedisease)andspecificity(theabilityofatesttocorrectlyidentifythosepatientswiththedisease)withregardstotheanalysisofbigdataoriginatingfromthesocialwebmightbeachievable(LalkhenandMcCluskey,2008).InfactInternetofThings 3(IoT)Analyticsinhealthandsocialcareisanareaofmajorfutureinterestduetotherapidpickupofm-healthtechnology 4andthegrowthofthemobilenetwork.DeepIoTanalysiswillinthefutureextendtheavailableinputbeyondthescopeofthesocialwebandwillbeabletoaccessdirectlydatapushedbydevicessuchaslocationtrackers,smartpharmaceuticalsandsmartphones.Thiscouldcomplementtheinformationobtainedfromthesocialwebandalsomayprovideinformationontheimpactoftheuseof(smart)pharmaceuticalsorcertainbehaviourpatternlongbeforethiswasmanuallyextractedfrompatientrecords.

Next generation technology

AccordingtotheEuropeanCommissionglobalm-healthturnoverwillgrowto18billionEurosby2017withmorethan100,000

21

m-healthapplicationsalreadyonthemarket(EC,2014). Ontheotherhandthereisaglobaltrendatthemomenttowardssuperfastbroadband.Theroll-outof4G-LTEtechnologyisinfullswing,whilethereisastrongpushtowards5Gnetworkswhichwillconsiderablyimprovetherapidexchangeofinformation,reducelatencyandincreasethenumberofdeviceswhichareabletoconnectatanygiventime.Amajorapproachtowardsahyper-connectedsocietyiscurrentlyunderwayintheCityofMunich,whichexplicitlyincludesamajorteachinghospitalinthecitycentre(Huawei,2015).

Oneoftheobjectivesistoestablishmoreintelligentnetworksinordertoenablecontextawarecollaborationofmachinesandhumansinordertoimprovequalityofcareforpatientsandqualityofexperience(QoE)formedicalpractitioners(Nunnaetal.,2015).Therecanbenodoubtthatcross-matchingoftheresultsofbigdataanalysisofthesocialwebdataandgenomicsobtainedfromgeneticanalysisofbacterialstrainsorvirusesmightbeoftremendousvalueinthefuturetorapidlyrespondtooutbreaksofinfectiousdiseases.Clearlyspatio-temporalbigdataanalysiswouldbeapowerfultooltosupportthismulti-dimensionalanalysisofmillionsofdatasetsinnexttorealtime.

However,itisnecessarytoconsiderethicalandlegalaspectsinordertocreateanappropriateframeworktoadministerandpolicethispowerfultechnologyinawaythatsystematicallybuildsconfidenceandtrust.Althoughtherighttobeforgottenneedstobecarefullyweighedagainstthepublic-healthrequirementsofmodernsocietiestheback-trackingofcrossmatcheddatatoindividualsmustbetightlyregulated(EC,2015).

Newandupcomingbigdataanalysisstrategieswillimprovedataminingcapabilitiesinthesocialwebandwillenableadetailedassessmentofincidenceandprevalenceofinfectiousdiseases.Advancedcloudstrategiesand5Gnetworkswillinterlinkmoredevicesthaneverandincreasethegranularityandreliabilityofnewscreeningtools.

References:

AchrekarH.,GandheA.,LazarusR.,YuS.H.andLiuB.(2011).Predicting flu trends using Twitter data.IEEEConferencePublicationonComputerCommunicationsWorkshops.10-15April2011,p.702-707. DOI:http://dx.doi.org/10.1109/INFCOMW.2011.5928903

Cisco(2015).Cisco Virtual Networking Index (VNI) Global Mobile Data Traffic Forecast 2014-2019. Availableat:http://www.cisco.com/c/en/us/solutions/service-provider/visual-networking-index-vni/index.html

EuropeanCommission(2015).Ethics. Availableat:http://ec.europa.eu/programmes/horizon2020/en/h2020-section/ethics

EuropeanCommission(2014).mHealth, what is it? – Infographic. Availableat:https://ec.europa.eu/digital-agenda/en/news/mhealth-what-it-infographic

GreenemeierL.(2014).Smart machines join humans in tracking Africa Ebola outbreak.ScientificAmerican,September2014.

UnitedKingdom.DepartmentofHealth;NationalInformationBoard(2014).NHS NIB Report: Personalised health and care 2020: a framework for action[policypaper]. Availableat:https://www.gov.uk/government/publications/personalised-health-and-care-2020/using-data-and-technology-to-transform-outcomes-for-patients-and-citizens

Huawei(Europe)(2015).Huawei build a large scale 5G testbed in a real-life environment in Munich. PressRelease,26February2015. Availableat:http://huawei.eu/press-release/huawei-builds-large-scale-5g-testbed-real-life-environment-munich

LamposV.andCristianiniN.(2010).Tracking the flu pandemic by monitoring the social Web.IEEEConferencePublicationson2ndWorkshoponCognitiveInformationProcessing. DOI:http://dx.doi.org/10.1109/CIP.2010.5604088

LalkhenA.G.andMcCluskeyA.(2008).Clinical tests: sensitivity and specificity. Continuing Education in Anaesthesia,CriticalCare&Pain,8(6):221-223. DOI:http://dx.doi.org/10.1093/bjaceaccp/mkn041

NunnaS,KousaridaA,IbrahimM,DillingerM.etal.(2015).Enabling real-time context-aware collaboration through 5G and mobile edge computing.ProceedingsofInformationTechnologyNewGenerations,13-15April2015,p.615-605. DOI:http://dx.doi.org/10.1109/ITNG.2015.155

Biography

DrChristophThuemmlerisaProfessoratEdinburghNapierUniversityandTechnicalUniversityMunichandisoneofthepioneersofE-healthinEurope.AsaninternationallyrecognisedexperthehasbeeninvolvedinexpertcommitteesfortheEuropeanCommissionsuchasEU/ChinaroundtableontheInternetofThingsandothergroups.Hehasworked

inGermany,theUSandtheUKbeforefocusingmoreandmoreonsmartdevicesandserviceorientedarchitecturesinhealthcare.HisresearchinterestslieintheareaoftheFutureInternetincludingtheInternetofThings,workonsocialtechnologicalalignmentinhealthcareandthegovernanceofe-Healthinawidercontext.

10. Recent developments

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Who, when and why? Mortality datasets provide a wealth of information for actuaries

Theuseofmortalitydataliesatthecoreofmuchoftheresearchcarriedoutbytheactuarialprofession.Intheareaofhealth,longevityandmortalitymanyreaderswillbeawareofcommonlyuseddatasetssuchasthosefromtheOfficeofNationalStatistics(ONS)orWHO.Thereis,however,awealthofmortalitydataavailable,muchofitfreetoaccessandavailableonline.TheInstituteandFacultyofActuarieshascompiledadirectoryofdatasetswhichcovertheUKandIrelandaswellasthosethatgiveanoverviewofEuropeanandworlddata.Thedirectorynotonlyliststhedatasetsandprovideslinkstoeachbutalsoprovidessomedetailondatapointsofinteresttoactuariesandthetimeframeoverwhichthedatawascollected.

Itishopedthatgreateraccesstoandawarenessofthesedatasetswillenablemoreaccuratemodelling,allowingactuariestomakeinformeddecisionsregardinglongevityandmortalityinrelationtolifeassurance,pensionsandlongtermcareproducts.

To access this free resource please visit: http://bit.ly/1JD9sPx

The Life Conference Celebrates its 30th Year in 2015! 18-20 November, Dublin

TheIFoAisproudtohosttheir30thLifeConferenceandExhibitionin2015andweinviteyoutobepartofthislandmarkevent.TheLifeConferenceistheleadingeventforprofessionalsinvolvedinlifeinsurancewhogathertogetherannuallytoanalysethecurrentandfuturestateoftheinsuranceindustry,examinepotentialnewopportunitiesanddiscuss emergingtrends.

Hearfromsubjectexpertsandengagewithfellowprofessionalsontopicalissuesfacingtoday’sinsuranceindustry.Offering70workshopsontopicssuchasUKandEuropeaneconomicupdates,capitalmanagementunderSolvencyII,IFRS4PhaseII,tomorrow’sconsumerneedsandMasterclasssessions– tonameafew–theprogrammehasbeendesignedtostimulatedebateandencouragethoughtprovokingdiscussions.

WhetherUKbasedorinternational,theconferenceisopentoanyonewithaninterestinthelifesector.Itoffersanidealforumtomeetandexchangeideaswithabroadrangeofprofessionals.Ifyouwanttogetuptodateonthelatestthinkingandinnovation,thisistheeventforyou.

Find out more details and register on:http://bit.ly/1e1g2EP

Save the date: 21 September 2015. BAJ 20th Anniversary Sessional Meeting

Tocelebratethe20thyearoftheBAJandgeneratediscussionaroundthefutureofIFoAresearchthePresident,FionaMorrison,willchairaspecialsessionalmeetingon21September2015atStapleInnHall,London.PlansfortheeventincludeapanelandaudiencediscussionontheroleoftheIFoAjournals(AnnalsofActuarialScienceandBritishActuarialJournal),disseminationofresearchandhowwepromotethevalueofactuarialscienceresearch.IfyouareinterestedinthefutureofIFoAresearchandhowitcanachieveimpactthroughdisseminationandwouldliketoshareyourviews,orsimplyhearwhatothershavetosay,pleasefollowthesessionalprogrammeontheIFoAwebsite.

To follow the sessional programme, please visit: http://bit.ly/1InKhnu

Networking Event: Telematics in Health and Care Insurance - Slave to the Machine(s), 17 September 2015, London

Theinsuranceindustryistryingtoadoptnewtechnologiesandadvancedservicesbutmanyinsurersdonotknowwheretostartorwhattofocusonfirst.Wewillbeexploringaspectsoflifeandhealthtelematics,whatthesecouldlooklikeintheinsurancemarketoftomorrowandmostimportantly,whatthismeansfortheactuariesoftomorrow.

This event will take place from 17.30-19.00 on 17 September 2015 and bookings can be made at: http://bit.ly/1BHZcpo

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Research in Longevity Basis Risk

TheInstituteandFacultyofActuaries(IFoA)andLifeandLongevityMarketsAssociations(LLMA)jointlycommissionedaresearchprojecttodevelopareadily-applicablemethodologyforquantifyingthebasisriskarisingfromtheuseofpopulation-basedmortalityindicestomanagelongevityrisk.

WithmembersfromtheIFoAandLLMAtheLongevityBasisRiskWorkingGroup(LBRWG)isresponsibleforprovidingoversight,direction,reviewandqualityassurancetothethirdpartyresearchteamwhohavebeenappointedtodotheresearch.

Theresearchcomprisedareviewofexistingtwo-populationmortalitymodelsandthedevelopmentofamethodologyfordeterminingtherelationshipbetweenthepopulationandportfoliomortalityratesinthefuture.

To download the research paper and user guide please visit: http://bit.ly/1KsI3mP and http://bit.ly/1GGijM9

Continuous Mortality Investigation (CMI) update

TheCMI,supportedbytheInstituteandFacultyofActuaries,hasalonghistoryofprovidingauthoritativeandindependentmortalityandsicknessratetablesforUKlifeinsurersandpensionfunds.TheCMItableshaveunderpinnedtheprudentialandfinancialreportingofalmostalltheseinstitutions.

For news on mortality projections, annuitant mortality, assurance and others, please visit: http://bit.ly/1O3p9B8

Refl ecting on International Mortality and Longevity Symposium 2014: Explaining the past, exploring the future

Thisconferenceprovidedamulti-disciplinaryforumfortheexchangeofinformationonthelatestrelevantresearch,aswellasanopportunitytolearnaboutestablishedknowledgefromarangeofdifferentdisciplines,allwiththeaimofbetterunderstandingandmanagingthiscomplexyetcriticalsubject.

Thethemesforthiseventwere:

1. MedicaladvancesaretheimpactofGeneticprofilingonmedicineandlongevity

2. Theinternationalperspective:whatcanwelearnfromelsewhere?

3.Newsourcesofinformation:“bigdata”,riskfactors

4. Practicalmortalityandmorbidity:pricing/reservingforthelong-term,underwriting,criticalillness,long-termcareandunderwrittenannuities.

Antimicrobial resistance

UnitedKingdom.DepartmentofHealth(2013). UK Five Year Antimicrobial Resistance Strategy 2013 to 2018. Availableat:www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018

HawkerJ.I.,SmithS.,SmithG.E.etal.(2014). Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995–2011: analysis of a large database of primary care consultations. JournalofAntimicrobialChemotherapy69(12):3423-3430

The Economist: the spread of superbugs. Availableat:http://econ.st/1Bl5rjd

LaxminarayanR.,DuseA.,WattalC.etal.(2013). Antibiotic resistance – the need for global solutions. TheLancetInfectiousDiseases13(12):1057-1098. Availableat:http://dx.doi.org/10.1016/S1473-3099(13)70318-9

LeshoE.P.,WatermanP.E.,ChukwumaU.etal.(2014). The Antimicrobial Resistance Monitoring and Research (ARMoR) program: the US Department of Defense response to escalating antimicrobial resistance. ClinicalInfectiousDiseases,59(3):390-397. Availableat:http://dx.doi.org/10.1093/cid/ciu319

Smith,R.D.andCoast,J.(2012). The economic burden of antimicrobial resistance: Why it is more serious than current studies suggest. TechnicalReport.LondonSchoolofHygiene&TropicalMedicine.38p. Availableat: http://researchonline.lshtm.ac.uk/639028/

WorldHealthOrganization(2014). Antimicrobial resistance: global report on surveillance. Availableat: www.who.int/drugresistance/documents/surveillancereport/en/

11. Further reading

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Pandemics

InternationalActuarialAssociation-HealthCommittee(2015).Analysis on the Risk of Ebola. Availableat:www.actuaries.org/CTTEES_HEALTH/Documents/Risk_of_Ebola_Paper.pdf

Breban,R.,Riou,J.andFontanet,A.(2013). Interhuman transmissibility of Middle East respiratory syndrome coronavirus: estimation of pandemic risk. TheLancet382(9893):694-699. Availableat:http://dx.doi.org/10.1016/S0140-6736(13)61492-0

Feng,R.andGarrido,J.(2011). Actuarial applications of epidemiological models. NorthAmericanActuarialJournal,15(1):112-136. Availableat:http://dx.doi.org/10.1080/10920277.2011.10597612

HaywardA.C.,FragaszyE.B.,BerminghamA.etal.(2014). Comparative community burden and severity of seasonal and pandemic influenza: results of the Flu Watch cohort study. TheLancetRespiratoryMedicine,2(6):445-454. Availableat:http://dx.doi.org/10.1016/S2213-2600(14)70034-7

Huynh,A.,Bruhn,A.andBrowne,B.(2013). A review of catastrophic risks for life insurers. RiskManagementandInsuranceReview,16(2):233-266 Availableat:http://dx.doi.org/10.1111/rmir.12011

The Lancet Ebola Resource Centre. Availableat: www.thelancet.com/campaigns/ebola

Morens,D.M.,Folkers,G.K.andFauci,A.S.(2009). What is a pandemic? JournalofInfectiousDiseases,200(7):1018-1021. Availableat:http://dx.doi.org/10.1086/644537

Sharp,P.M.andHahn,B.H.(2011). Origins of HIV and the AIDS pandemic. ColdSpringHarborPerspectivesinMedicine,1(1)[Online](22p. Availableat:http://dx.doi.org/10.1101/cshperspect.a006841

TaubenbergerJ.K.andMorensD.M.(2006). 1918 influenza: the mother of all pandemics. EmergingInfectiousDiseases,12(1):15-22. Availableat: http://dx.doi.org/10.3201/eid1209.050979

Worobey,M.,Han,G.-Z.andRambaut,A.(2014). Genesis and pathogenesis of the 1918 pandemic H1N1 influenza A virus. PNAS,111(22):8107-8112. Availableat:http://dx.doi.org/10.1073/pnas.1324197111

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