1. July 27, 2009 Loma Linda University, California, April 2009

3. What a difference two months makes April 2009 June 2009

5. Distribution of US Cases, July 4, 2009

6. Florida, H1N1v by age

7. World cases, 23 June 2009

8. Australia, H1N1v by age

9. C ONSULTATIONS MADE TO UK G ENERAL P RACTITIONERS Source: Peter Osborn and Dr. Tony Yardley-Jones, UK

10. Global H1N1v fatalities, April-July 2009 Source: Peter Osborn and Dr. Tony Yardley-Jones, UK

12. First wave, Spring- Summer 1918 Second wave, Fall 1918 Third wave, Winter-Spring 1919 The second wave in 1918 was the killer. Between 50 and 100 million people died worldwide in a 20-week period in 1918-19.

13. The Argentina cautionary tale  Case fatality rate higher than global average  Absenteeism in some sectors exceeding 40%  Connected to Florida, US via Miami, Orlando, NY gateways People stand in line to vote in Argentina’s national election. The ruling party (Peronist Party) lost badly, due in part to the government’s perceived mishandling of the swine flu situation, and the Health Minister resigned after the election.

14. Swine H1 Morbidity and Mortality  More Americans died of swine influenza (17) this month (July - 136),than in the entire months of April, May and June combined (127).*  In early July, worldwide, there were more than 60,000 confirmed infections, with roughly 230 deaths.  Today, worldwide, there are over 140,000 cases with over 700 deaths.+ That explosive growth occurred in less than three weeks.  That is a case fatality rate of.5%, placing it in the “moderate” Category 2 pandemic category.  Any shift toward greater lethality could move the virus to Category 3 status.  * Sources: CDC, CBS News  + Source: Associated Press

15. What might this virus do?  It might become resistant to Tamiflu.  It might reassort with other flus and become even easier to catch.  It might reassort with H5N1 in the Middle East (Egypt, Turkey, Pakistan), Africa (Nigeria), Asia (Indonesia, China, Vietnam, Cambodia) and acquire extreme lethality.  Or it could be overpowered by seasonal flu.  “Nearly 100 percent of the influenza viruses being detected now (US) are novel H1N1 viruses.” – CDC, July 17, 2009

16. H1N1v has won King of the Mountain in the US.

17. Official UK estimates for planning purposes, H1N1v (Source and graphic: BBC)

18. Official UK planning estimates of mortality, compared with 1957 and 1968 pandemic deaths. (Source and graphic: BBC)

19. Britain is one-fifth the population of the United States.  Note:

20. The Southern Hemisphere holds the key.  It is their flu season now. It started in April and stretches to October, when ours begins.  If swine H1 gains a strong foothold and becomes the dominant flu strain in the Southern Hemisphere, it will also do so here. DONE.  If the pandemic virus does not defeat seasonal H1N1 and H3N2 in influenza’s game of “king of the mountain” Down Under, it could still emerge triumphant here.  UPDATE: Over 90% of all typed Southern Hemisphere flu cases are the pandemic strain.

22. Tallahassee, FL

23. California

24. Texas

25. New York Bad mask wearing!

26. Camp Modin, Maine, July 22, 2009

27. Mexico City

29. Cancun, Mexico

30. El Salvador

31. Buenos Aires, Argentina

33. Scotland

34. Kuwait City

35. Cairo, Egypt

36. Mecca, Saudi Arabia Umrah

37. Natanya, Israel

38. Bangkok, Thailand

39. Incheon, South Korea

40. Hong Kong

41. Chengdu, China

42. Auckland, New Zealand

43. Australia

44. Shanghai, China

46. BIG rule of thumb:  If your agency or organization has not formulated a pandemic planning team, that organization is NOT PREPARED FOR A PANDEMIC.  If your agency or organization has not exercised its pandemic plan via a tabletop exercise or stronger simulation, that organization is NOT PREPARED FOR A PANDEMIC.

47. What would Ike do?  “The plan is useless – it’s the planning that’s important.”  Ike's point is that events will never go according to The Plan -- but a mature planning process will help you prevail.  Believe me, no one in State government is smarter than Ike on this matter. No one.

48. Add context: What will happen all around us?

49. The pandemic plan for organizations  PLAN ONE CATEGORY HIGHER  Create corporate/agency pandemic planning team  Prepare agency succession plan  Ensure “retail business/government” ops continue  Acquire protective equipment  Monitor employee absenteeism  Cross-train your staff  Design, implement and support Work at Home plans  Prepare for supply chain failures  Prepare Communications Plan  Teach protective actions  Gain an understanding of influenza and how it works  Leverage this planning for similar scenarios  Update DR and COOP plans NOW, as existing COOP plans without pandemic modifications will NOT WORK in a pandemic.

50. There should be already in place, a pandemic planning team  Legal  Human Resources  Training Development  Information Technology  Procurement/Purchasing  Communications/Press Secretary  Facilities/Maintenance/janitorial  And at the top….. The CEO, agency head, or second in command.  If there isn’t one… they’re not ready for a pandemic.

51. Have they created a realistic pandemic annex to their DR AND COOP plans NOW? now.  Armed with your information and in conjunction with all agency peers, urge creation of a Pandemic Annex to your organization’s COOP and Disaster recovery plans now.  Additional questions to answer: 1. Does agency COOP Plan have an event horizon beyond 30 days? 2. Within a 30 day – to – 120 day context, does it have a new definition of essential and nonessential personnel? 3. Does it contain a well-defined succession plan for agency leadership? 4. Just for grins, imagine if you had to support agency operations AND a hurricane or terrorist event came during a wave of the pandemic. Recall that 75% of all pandemics occur during hurricane season. 5. What plans would you engage?

52. Audit to ensure “retail” ops continue  Is an organization prepared to engage in core activities even if the following is true:  Loss of raw materials/finished goods due to failures in JIT supply chain.  Everyday drop in workforce from 10% to 40% during a pandemic wave  Loss of customers due to pandemic  Forced closure of certain industries (restaurants, public gatherings such as football games, dry cleaners, boutiques).

53. Ensure “retail government” ops continue  Retail government service delivery offices in the social, medical and law enforcement “safety net” domains will have to remain open, and certain employees will have to remain exposed to citizens while at work.  Keeping offices open will be essential to preserve the integrity of government and to care for its customers.  Can you imagine what will happen if government fails its citizens when they need it the most?  Katrina times 400 in Florida alone.

54. Ensure “retail government” ops continue  What is an agency’s plan to remain open in a pandemic?  Have they done – or even considered doing -- the following:  Focus on data center integrity first.  Focus on your agency public Website a close second.  Inventory business processes with intent to move them to “eGov” operations  Work with business partners to ensure they are “on top of” pandemic planning (“weak link” Y2K example)  Pay more to have priority restoration if networks fail  Have redundant communications plan (cellphones, aircards, broadband wireless, satellite, etc.) if network or Internet fails.

55. Acquired protective equipment?  N-95 masks or surgical masks  3 per employee per workday for 6-12 weeks (you do the math)  Alcohol-based hand sanitizer  Enough for 6 – 12 weeks  Gloves (vinyl – some are allergic to latex)  Same ratio as masks – 3 pairs per workday for the duration of a wave of a pandemic

56. Have you/they decided who gets protective equipment?  Front-line workers with constant exposure to the general public  The social and public safety “safety net” workers (AWI, DCF, HSMV, local equivalents, etc.)  Data center employees “The checks gotta roll.”

57. Working with Procurement  Do they know what to buy?  Do they know the quantities?  Do they know the context?  Everyone and their brother will want the same items and be willing to pay more for them.  Does your agency have the money to increase expenditures on staples?

58. Have you prepared for supply chain failures?  In a pandemic of any severity, the supply chain will falter.  In a 1918-type (or worse) pandemic, the supply chain will fail.  If possible, keep essential supplies/ parts stockpiled in advance (4-6 week supply).  Survey your suppliers. Resurrect the old Y2K adage: If they can’t articulate their plans for pandemic flu preparedness, be wary of their ability to survive.  In fact, go find your Y2K plans, turn to the tab marked “Supply Chain Workarounds,” update it and put it into your DR/COOP Pandemic Annex.

59. Has your agency prepared internal and external communications plans?  How will key managers communicate among themselves?  How will information be conveyed to employees?  How will employees know who to call in specific situations?  How will information be conveyed to business partners?  How will the public know which “safety net” offices are open and which are closed?

60. Communicate with employees and teach preparedness at work and at home  Conduct an awareness campaign within your organization.  Teach employees how to prepare themselves and their families FIRST. And do it now, instead of later – when it is too late  Cover work and home issues  Teach protective actions and personal hygiene  Prepare them for moving from office to office – even from agency to agency.

61. Teach protective actions NOW  Hand washing without recontamination  Covering cough, not using hands  Avoid putting hands to face, mouth, nose, eyes.  Staying home if any signs of illness  Proper use of protective equipment  Cleaning hard surfaces, wearing gloves, using hand sanitizer and wearing masks

62. Consider emergency notification services  Companies such as Dialogic Communications, TechRadium, Dell/MessageOne and others have affordable, hosted services that allow an agency to push information to employees via any type of device  Eliminates the old “phone tree” tedium  Includes voice synthesis and fax  Can allow agencies to poll their workforce to see who can work and who is too sick to report  Will be critical when trying to open offices or trying to tell people which office to report for work

63. Janitorial  Stop vacuuming during weekdays as soon as the virus is detected in your community.  Vacuum on weekends only, preferably on Saturdays.  Repurpose those vacuumers to the constant cleaning of all solid surfaces that are touched routinely, such as doorknobs, elevator buttons and elevator rails, staircase rails, and customer countertops.

64. Federal checklists (by sector)

66. Let’s define “work”  Government still runs largely on paper  Forms have to be inputted into computer systems  The business process must be taken apart in order to be streamlined  Tremendous opportunity to further digitize government – and we cannot afford to lose this chance to streamline government ops!  Inventory business processes with intent to Webify them as “eGov” operations

67. Potential failures in work at home plans  Paper must be quarantined, lest employers inadvertently sicken otherwise healthy homes  CDC and St. Jude say virus becomes inert after 12 to 24 hours on paper and porous surfaces  Each stage in the paper handling process requires a day quarantine to prevent infection (learn from the death of Inuits (Eskimos) in 1918).  How will paper get home?  USPS? Irregular deliveries  UPS? FedEx? DHL? They too may suffer loss of dependable service.  Will agencies put together their own delivery routes?

68. SSL VPNs and you  Time for an SSL VPN solution with rigid, unforgiving policy enforcement.  Implement an SSL VPN service and be prepared to scale it radically upward  Be prepared to “lose the Internet,” as network service providers will also experience high absenteeism and be forced to scale back SLAs (Booz Allen)  That is one compelling reason to upgrade to priority restoration.

69. Conclusion, W@H plans:  Government cannot afford to implement “perfect” work at home plans in the current financial and political climate.  W@H plans can be successful, if the process does not involve the moving of paper or constant online access to legacy systems; if applied properly; if created with enough advance planning; and if exercised frequently.

71. IT Issues to consider  Do you have a succession plan in place?  Which services do you turn off or allow to fail?  Data Center operations (lights out operation, automated patching)  Public Website for emergency notices such as openings and closures, if necessary posted by IT staff at home, or even by non-IT staff as needed  Remote Access (Citrix, RAS, Terminal Services) as alternatives to SSL VPN  Don’t forget field staff!!  Maintaining agency cybersecurity in the midst of all this  Do you enable or eliminate Help Desk operations?  PC support for employee personal computers? NO  Ensuring security of access and data while dealing with employee personal computers POLICY ENFORCEMENT via SSL VPN  Videoconferencing as alternative to face-to-face meetings – how will you support it if it malfunctions?  Recovering from cascading emergencies (swine flu on top of hurricanes, terrorism, etc.)

72. IT Services  It is just not practicable to expect to support 100% of all your applications/services.  Now is the time to sit down with leadership and ask which IT services may be turned off in a pandemic, and which can be allowed to fail without restarting.  Doing this now sets the expectation bar, reinforces the urgency of the coming second wave, and allows you to cross-train more efficiently and effectively.

73. Monitor your employee absenteeism, even if no one else does.  Do not rely solely on “actual” totals coming from WHO and CDC. If you see a spike in employee absenteeism, it is probable that the virus has gained a foothold in your workforce.  This can be done without HIPAA violations, and should be performed agency-wide, statewide, and don’t forget field staff.  Encourage an enterprise-wide or agency-wide initiative to monitor for absenteeism which will be critical to track both the spread of the virus (reporting daily roll-ups to DoH) and to determine operational readiness statewide.

74. Have you cross-trained your staff?  Create written instructions/ procedures for critical processes that can be carried out by others  Cross-train your staff, ideally three-deep  Anticipate 30% morbidity (illness) within staff  Assume absenteeism due to closure of other schools, day care centers  Train by TASK, not by what somebody does  Maintain a matrix of staff training and widely distribute and post in disaster recovery books and agency COOP plan  Cross-train inside and outside of Data Center; in other words, cross-train non-data center people in simpler technical tasks such as tape rotation.  Don’t cross-train on services you will disconnect or allow to fail!

76. The High Points  All you can do is all you can do.  COOP and disaster recovery plans must be realigned within an extended event horizon of 8 to 12 weeks per pandemic wave.  Work at home plans require the exact expectation of WORK.  Business processes must be broken down and redefined by task, not by person.

77. New Business Next Meeting