Notes

1 - Interview with The Fifth Estate special “Black Dawn: The Next Pandemic,” which aired January 11, 2006 on the Canadian Broadcasting Corporation. Interview transcript accessed from CBC.ca in October 2007.

2 - Photo acquired via istockphoto.com. Photo by Lisa Vanovitch.

3 - These numbers are estimates for 2005 as presented in Michael T. Osterholm’s “Preparing for the Next Pandemic,” Foreign Affairs, July/August 2005. All numbers in this book for items such as population, Gross Domestic Product (GDP), etc. ascribed to 2011 and 2012 are actually published figures for 2004, 2005, 2006 or 2007——in short, the latest available up to July 2007. The author did this for simplicity (projections of what these statistics will be in the future are essential irrelevant to the story) and to show what an avian flu pandemic might look like today rather than tomorrow.

4 - All symptoms for infection with the Avian Flu strain of the H5N1 virus are based on accounts of the Spanish Flu of 1918-19, and not the symptoms of the few cases of humans contracting bird flu over the past few years. Some descriptions of symptoms experienced among victims of the Spanish Flu can be found in Collier, R., The Plague of the Spanish Lady: The Influenza Pandemic of 1918-1919, New York: Atheneum, 1974, and Barry, J.M., The Great Influenza: The Epic Story of the Deadliest Plague in History, New York: Penguin Books, 2004.

5 - This public domain image, created in 1978, was acquired from the Centers for Disease Control website.

6 - This occurred during the SARS outbreak of 2003 in China. In Guangdong, reporting about the epidemic and panic buying was banned; only press releases from government departments could be published in the media. (Abraham, Thomas, Twenty-First Century Plague: The Story of SARS, Johns Hopkins University Press, 2005)

7 - Chinese newspapers used this tactic during the SARS outbreak of 2003. For example, the Nanfang Daily used the ruse of reporting rumors to provide a detailed account of how the epidemic had spread through a number of towns before reaching Guangzhou, the provincial capital. (Abraham, Thomas, Twenty-First Century Plague: The Story of SARS, Johns Hopkins University Press, 2005)

8 - An interesting story about Branch is his battle against malaria in Papua New Guinea, which at the time was suffering a major epidemic.
     Malaria is a disease that afflicts South America, Africa and southern Asia. It is not caused by a bacterium or virus, nor is it caused by “bad air,” the literal meaning of the word malaria, as people believed for thousands of years up to the modern age. It is caused by blood parasites. Like the plague bacterium, malaria is transmitted by an insect that bites an infected person and becomes a carrier of a disease agent. In malaria’s case, the insect is the female mosquito. The malaria plasmodium looks like a snake under a microscope. It multiplies in red blood cells, causing them to burst and resulting in a living nightmare of shaking chills, fever, aches, exhaustion and crushing headaches. Alexander the Great is believed to have died from malaria after building an empire that reached from Europe to India, which fell apart after his death. Alaric, conqueror of Rome, died from malaria soon after taking the city. And Africans were shipped to North and South America in huge numbers as slave labor because they were more resistant to malaria than the natives, who fell in large numbers to the disease when forced to work the fields. As early as 2700 B.C., the Chinese knew about malaria and called it “The Mother of Fevers.” Today, a human dies every 15 seconds from malaria, adding up to two million each year. Mosquitoes steadily grow more resistant to pesticides and malaria parasites are acquiring a growing immunity against chloroquine and other treatment drugs. As global warming transforms the climate of the Northern Hemisphere, it may not be long before malaria becomes a common disease in countries such as the United States.
    There are three ways to fight malaria: provide effective anti-malarial drugs to anybody who comes down with it, destroy its vectors to prevent its spread, and provide antibodies to everybody at risk through a working vaccine so as to build immunity and eradicate malaria entirely. Despite a huge investment, the WHO had no working vaccine for malaria, and a stubborn, rugged strain had emerged that resisted treatment with anti-malarial drugs.
    That left only one option: On the WHO’s advice, the government of Papua New Guinea decided to attack its vector——mosquitoes——with pesticides.
    At first, it worked well. Hospital admissions due to malaria dropped from 900 cases per 100,000 population to less than 400. But the pesticides’ introduction into the ecosystem had consequences the WHO hadn’t intended: The pesticides killed the mosquitoes, the disease’s vector, along with other bugs, but also the lizards that fed on the bugs. The cats ate the lizards and they died. The poison ran through the food chain. With no cats, the number of rats exploded. Rats carry diseases like plague. Outbreaks of plague were reported in the countryside, then the cities.
    Plague is caused by a bacterium, Yersinia pestis, the famed germ that some historians credit with the collapse of the Western Roman Empire. Several centuries earlier, in 251-270 A.D., the Plague of Cyprian struck the Empire and is credited with mass conversions to Christianity and the time when Christians first began to wear black as the color of mourning. Later, in the fourteenth century, another plague began in China and spread across the world to Europe, following the trade routes. When the Mongols laid siege to the Genoese town of Jaffa in the Crimea, they gave up when plague decimated their army, but before they left, they fired corpses over the city walls with catapults, possibly the first time that an army engaged in biological warfare. Genoese ships brought the plague back to Italy, and from there it spread throughout Europe, killing an estimated 25 million people, or one-third of the population, and resulting in a labor shortage that some credit with the end of feudalism and the Dark Ages. (In terms of overall mortality, however, influenza still leads all other microbes known to cause disease.) Y. pestis lives in the bellies of fleas that in turn live on rodents and pass on the infection to them. The fleas jump to people and infect them with plague, which may be bubonic, septicemic or pneumonic in type. While treatment drugs are available, all of these can be deadly, pneumonic being the deadliest. It is thanks to plague that we still have the nursery rhyme, “Ring around the rosie [bubonic plague’s skin rash], A pocket full of posie [flowers carried based on the belief that they warded off the disease], Atishoo, atishoo [the respiratory system failing], We all fall down [death].” Plague cases are still reported in many parts of the world today, including British Columbia, Alberta and the western United States.
    Branch knew the only way to stop the plague was to reduce the rat population, and came up with a simple solution——put cats back in the food chain. He drew up a plan and the WHO endorsed it.
    Within a month, a squadron of the Australian Air Force, staging from local airfields, began to airdrop more than 6,000 housecats all over the countryside.
    The cats ate the rats and stopped the plague.
    (The above fictional story is based on an actual incident in Borneo in the 1960s: See Conway, Gordon R., “Ecological Aspects of Pest Control in Malaysia,” an essay published in The Careless Technology: Ecology and International Development, The Natural History Press, 1972. At the time of writing, the book was available for free online at www.iucn.org.)

9 - Chinese officials attempted the same ruse during the SARS outbreak of 2003. (Abraham, Thomas, Twenty-First Century Plague: The Story of SARS, Johns Hopkins University Press, 2005)

10 - Use of these infrared cameras remains controversial. They offer a screening method that is economical and less disruptive but can produce false positive and negatives. Originally, they had been designed for industrial monitoring. Heat build-up in electrical devices and machinery can cause early equipment failure. Thermal imaging devices enable detection of these heat build-ups, useful for preventive maintenance.
     Although not designed for medical use, the devices first saw deployment for mass passenger screening during the SARS epidemic. They failed to flag 14 people flying into Canada and three flying out of Toronto with SARS. The cameras, apparently, did not catch a single person with the disease.
    On the other hand, their presence may have deterred sick people from flying. Unfortunately, to accomplish mass passenger screening, the only viable alternative to the cameras was to line up all passengers and record their body temperature via a tympanic temperature check——inserting thermometers in their ear canals. And even that likely would not stop a novel pathogen from entering the country, as people could enter the country while infected but asymptomatic.

11 - Ledeux, it appears, is being too hard on herself in discussing the failure of border restrictions to prevent the entry of Avian Flu into Canada. Ferguson et al, writing in “Strategies for Mitigating an Influenza Pandemic,” Nature, April 2006, reported: “We find that border restrictions and/or internal travel restrictions are unlikely to delay spread by more than 2-3 weeks unless more than 99 percent effective.” At the time, no such ideal restrictions existed.

12 - Hospitals consider Dr. Chambers’ infection control role to be critical. Despite technology and antibiotics, the Canadian Hospital Epidemiology Committee, a subcommittee of the Canadian Infectious Disease Society, estimated that 250,000 Canadians get an infection as a result of being in a hospital each year, and between 8,000 and 12,000 of them die from it. This means that hospital-based infection could be considered the fourth leading cause of death in Canada after heart disease, cancer and stroke. Due to public overuse of antibiotics, drug-resistant strains of bacteria have proliferated, making infection control even harder.

13 - This public domain image was acquired from the Centers for Disease Control website. This photo, used to depict a staff scientist at NML, actually shows a scientist at the CDC’s laboratory in Atlanta, Georgia.

14 - Photo acquired via istockphoto.com. Photo by Jeff Leung. The original photo depicts a protest in Hong Kong against Article 23 on July 1, 2003. Basic Law Article 23, proposed by the Hong Kong government, stated: “ The Hong Kong Special Administrative Region shall enact laws on its own to prohibit any act of treason, secession, sedition, subversion against the Central People's Government, or theft of state secrets, to prohibit foreign political organizations or bodies from conducting political activities in the Region, and to prohibit political organizations or bodies of the Region from establishing ties with foreign political organizations or bodies.” After massive protests, the proposed law was withdrawn indefinitely.

15 - Photo by Cynthia Goldsmith, 2005. This public domain image was acquired from the Centers for Disease Control website. This photo, used to depict the 2012 Avian Flu virus, actually shows the 1918 Spanish Flu virus as recreated by Dr. Terrence Tumphey, a CDC staff microbiologist, who was conducting research into the characteristics that made it so deadly. This type of research can help researchers produce new vaccines and treatments for future pandemic flu viruses.

16 - The access control procedures described here are similar to what doctors experienced at a Toronto hospital during the SARS outbreak in 2003. (Vincent Lam and Colin Lee, The Flu Pandemic and You: A Canadian Guide, Doubleday Canada, 2006)

17 - Photo acquired via istockphoto.com. Photo, by Grace Donald, depicts nurses gowning up for surgery.

18 - A survey of employees at Sunnybrook and Women’s College Health Sciences Center after the SARS epidemic revealed that respirator masks were considered the most bothersome type of infection control; the most commonly cited problem with the masks was “physical discomfort” (92.9 percent). (Nickell, Leslie et al, “Psychological Effects of SARS on Hospital Staff: Survey of a Large Tertiary Care Institution,” CMAJ, March 2004)

19 - A study of the psychological effects of quarantine on hospital workers during the SARS outbreak of 2003, conducted by Maunder et al, reported: “Quarantined staff had concerns about their personal safety, about transmitting disease to family members, about stigmatization and about interpersonal isolation. . . . Prominent among the varied responses of individual staff members were themes of fear, anxiety, anger and frustration.” (Maunder, R. et al, “The Immediate Psychological and Occupational Impact of the 2003 SARS Outbreak in a Teaching Hospital,” CMAJ, May 2003)

20 - A survey of employees at Sunnybrook and Women’s College Health Sciences Center reported that 29 percent of respondents experienced emotional distress during the SARS outbreak, more than double than reported among the general adult population of Canada; 45 percent of nurses experienced emotional distress. (Nickell, Leslie et al, “Psychological Effects of SARS on Hospital Staff: Survey of a Large Tertiary Care Institution,” CMAJ, March 2004)

21 - Fiksenbaum et al’s study of nurses working in Ontario during the 2003 SARS outbreak, one-fourth of whom worked directly with SARS patients, reported that “greater levels of perceived SARS threat [resulting from direct contact with patients and being under quarantine] predict higher levels of emotional exhaustion and state anger. . . . In the event of an extended and indefinite outbreak of avian flu, nurses would likely experience higher levels of fear and uncertainty about avian contagion (i.e., avian threat).” C.D. Spielberger, in STAXI-2: State-Trait Anger Expression Inventory-2, defines state anger as “a psychological emotional state or condition marked by subjective feelings that vary in intensity from mild irritation or annoyance to intense fury and rage.” The study further found that strong organization support, which could take the form of emotional support and dissemination of information to dampen the feelings of threat, can mitigate feelings of anger and emotional exhaustion. (Fiksenbaum, L. et all, “Emotional Exhaustion and State Anger in Nurses Who Worked During the SARS Outbreak: The Role of Perceived Threat and Organizational Support,” Canadian Journal of Community Mental Health, Fall 2006)

22 - Saverina Sanchez, RN, CNephC, a nurse who experienced hospital quarantine during the SARS outbreak of 2003, provides a graphic depiction of the emotional stress and hardship suffered by nurses. She says: “Every day, [patients] would say thank you to us. They could see after the first eight hours of work that nurses had no energy left, primarily because of the protective equipment we needed to wear. We were dizzy, nauseated, and generally feeling unwell. . . . You could imagine the tension within our hospitals. Nurses were crying at the drop of a pin.” During a flu pandemic, these conditions would likely be imitated, if not worse. (“SARS in Toronto: Nurses on the Front Lines,” Medscape Nurses, posted June 2003)

23 - According to Phil Hassen, CEO of the Canadian Patient Safety Institute, only 40 percent of Canadian healthcare workers properly wash their hands, as reported in “Only 40 Percent of Healthcare Staff Properly Wash Hands, Expert Says,” The Globe and Mail, Friday, September 14, 2007.

24 - Recurrent nightmares were common among Hong Kong doctors treating SARS patients in 2003. One doctor reported dreaming that he had entered a pneumonia ward wearing only one mask—considered insufficient protection against infection from SARS—and was inhaling virus from the air. (“Mystery Illness Changes Life of Hong Kong Doctor,” New York Times, April 13, 2003)

25 - Figures for population and acute care, ICU and ventilator beds are from Pandemic Influenza Response Plan, Calgary Health Region, December 2005. Population in this health plan is listed at 1.2 million; the author arbitrarily adjusted this figure by +1,362 to make the resulting model’s numbers appear less perfectly rounded and therefore seem more “realistic.”

26 - The mortality rate for the Avian Flu virus in this book is based on that of the Spanish Flu virus that resulted in a pandemic in 1918-19. Jeffrey K. Taubenberger and David M. Morens of the U.S. Armed Forces Institute of Pathology in Rockville, MD write, “An estimated one-third of the world’s population (or about 500 million persons) were infected and had clinically apparent illness during the 1918-1919 influenza pandemic. The disease was exceptionally severe. Case fatality rates were >2.5 percent, compared to <0.1 percent in other influenza pandemics. Total deaths were estimated at about 50 million and were arguably as high as 100 million.” (The article, with citations/sourcing provided for these numbers by the authors: “1918 Influenza: The Mother of All Pandemics,” Emerging Infectious Diseases, January 2006.)

27 - Soares, Christine, “Cooping up Avian Flu: Buying Time to Arm for a Pandemic is Possible——Maybe,” Scientific American, April 2005. Other estimates place the R0 of Spanish Flu at 1.8 (Ferguson, NM et al, “Strategies for Containing an Emerging Influenza Pandemic in Southeast Asia,” Nature, 2005;437:209-14) and about 2-3 (Mills, C.E. et al, “Transmissibility of 1918 Pandemic Influenza,” Nature, 2001;432:904-6). The R0 value of Avian Flu in this book is estimated at 2-2.4.

28 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and found that 79-93 percent of respondents would be willing to avoid mass gatherings for one month during a flu pandemic. However, it is the author’s view that this would be unlikely until the threat was perceived as tangible to a large number of people.

29 - During the SARS outbreak in China in 2003, the government of Hong Kong ran a campaign encouraging people to “say hi and wave goodbye.” (“Mystery Illness Changes Life of Hong Kong Doctor,” New York Times, April 13, 2003)

30 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and found that 85 percent of respondents would be willing to keep their children from gathering outside the home while schools closed for three months during a flu pandemic.

31 - The Canadian Pandemic Influenza Plan for the Health Sector (2006) reports that census data suggests 3.6 percent of the Canada’s workforce “would need to make alternative arrangement in the event of school closings.” The 2006 Annual Alberta Regional Labor Market Review estimated 1,870,700 people employed in Alberta, which suggests about 67,000 people would need to make alternate arrangements. An assessment of the impact of a two-week school closing in British Columbia in October 2005 suggests that not all of these people would miss work as a result.

32 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and found that 86 percent of respondents could arrange care for children if schools/daycare closed for three months during a flu pandemic. During a pandemic where difficulties are shared across the entire population, this may be difficult for parents to accomplish, however.
     The author used a fictitious assumption of 2 percent for the portion of the workforce that would have to miss work because of school closings.

33 - Figures for population and acute care, ICU and ventilator beds are from Pandemic Influenza Response Plan, Calgary Health Region, December 2005. Population in this health plan is listed at 1.2 million; this number was adjusted arbitrarily by +1,362 to make the numbers appear less perfectly rounded and therefore more “realistic.”

34 - The known information in this paragraph can be sourced to The Canadian Pandemic Influenza Plan for the Health Sector, (Health Canada, 2006). The effects of antivirals during a Pandemic assume that these drugs will be effective: In The Canadian Pandemic Influenza Plan, Health Canada says oseltamivir and zanamivir “are expected to be effective against pandemic viruses including H5N1.” Anticipated reduction in mortality due to use of these antiviral drugs is right now a guess. Gani et al estimates oseltamivir treatment would “provide a 50 percent protection against death. This estimate was based on the assumption that a 50 percent protection against the more serious outcomes of influenza would translate to equivalent protection against death,” as stated in the Canadian Pandemic Influenza Plan for the Health Sector (original source is Gani, RD, Hughes, H, Fleming et al, “Potential Impact of Antiviral Drug Use During Influenza Pandemic,” Emerging Infectious Diseases, 2005; 11:1355-62). Assuming perfect distribution of these drugs (which is unlikely) and a 50 percent reduction in mortality, the mortality rate is reduced in this book from 2.5 percent to 1.25 percent.

35 - Health Canada created the National Antiviral Stockpile in 2004 with an initial quantity of 16 million doses. In the fall of 2005, it was recommended that this be increased to 55 million doses, or 5.5 million treatment courses assuming 10 doses/course, sufficient to cover 17.5 percent of the country’s population. Nova Scotia’s Pandemic Plan, published in June 2007, suggests the recommendation for expansion of the Stockpile had been accepted, but this was not confirmed by the author. The split between oseltamivir (90 percent) and zanamivir (10 percent) is from The Canadian Pandemic Influenza Plan for the Health Sector, 2006.

36 - The Canadian Pandemic Influenza Plan for the Health Sector (Health Canada, 2006) recognizes that higher dosages than the recognized 10-dose treatment may be required for pandemic viruses, as suggested in research of highly pathogenic flu with mice (Yen, H.L., Monto, A.S., Webster, R. et al, “Virulence May Determine the Necessary Duration and Dosage of Oseltamivir Treatment for Highly Pathogenic A/Vietnam/1203/04 Influenza in Mice,” Journal of Infectious Diseases, 2005;192:665-72). The treatment of 15 doses required for treatment of Avian Flu in this book is a purely fictitious assumption with no basis in actual research.

37 - The Canadian Pandemic Influenza Plan for the Health Sector (Health Canada, 2006) assumes 70 percent infection of the public over the course of a pandemic with two waves, with 15-35 percent of the population becoming clinically ill (due to a high rate of asymptomatic infection). Most cases, or 25 percent of the population if assuming 35 percent become infected during the entire pandemic, will occur during the first wave (this book covers a first-wave pandemic, with a second wave a future threat). If the pandemic has mild to moderate severity consistent with the last two pandemics, the Plan assumes up to 50 percent will need outpatient care, 1 percent will be hospitalized and recover, and 0.4 percent will die.
    For a severe pandemic, and in the absence of intervention, the Plan states: “Recently, projections have been made based on a more ‘severe’ scenario. In the severe scenario it is estimated that 2 percent of clinical cases will die and 10 percent will require hospitalization for management of their illness. While these estimates, which are considered to be more consistent with the outcomes of the 1918-1919 pandemic have been used to describe potential impact of a severe pandemic, to date the emphasis has been on national planning for a pandemic of moderate severity.”
     This book is based on a severe pandemic scenario and therefore assumes a hospitalization rate of 10 percent. The mortality rate in this book is assumed to be higher than Health Canada’s severe pandemic scenario estimate, at 2.5 percent, based on the mortality of the Spanish Flu of 1918-19, before pharmaceutical interventions such as antiviral drugs.

38 - Roccaforte, J.D., “The World Trade Center Attack: Observations from New York’s Bellevue Hospital,” Critical Care, December 2001.

39 - Joint Commission on Accreditation of Healthcare Organizations, Surge Hospitals: Providing Safe Care in Emergencies, 2005.

40 - During the SARS outbreak, a doctor in Hong Kong didn’t tell his parents or his in-laws that he worked in a pneumonia ward “lest they shun him.” (“Mystery Illness Changes Life of Hong Kong Doctor,” New York Times, April 13, 2003)

41 - During the SARS outbreak in Toronto, Vincent Lam, MD and Colin Lee, MD report, “Many healthcare workers in Toronto saw friends suddenly cancel all social plans, and in some cases, family members and loved ones became too frightened to be in the same room with them.” (Vincent Lam and Colin Lee, The Flu Pandemic and You: A Canadian Guide, Doubleday Canada, 2006)

42 - Photo acquired via istockphoto.com. Photo by “annedde.”

43 - In 2005, Dr. Ran D. Balicer of Ben-Gurion University of the Negev in Be’er Sheva, Israel teamed up with researchers at Johns Hopkins Bloomberg School of Public Health in Baltimore to survey employees in three health departments in Maryland. One goal of the survey was to determine the likelihood these healthcare professionals would report to work during a pandemic flu-related emergency; 53.8 percent said they would likely report to work during such an emergency, with clinical staff being more willing to report to work than non-clinical staff.
     In another study published in The Journal of Urban Health in 2005, the Mailman School of Public Health conducted a survey among 6,428 workers from 47 healthcare facilities in the New York Metropolitan area, and found that only 64 percent of healthcare workers said they would be able to report to work during a SARS outbreak, and only 48 percent said they were willing to report to work during an influenza pandemic. Barriers to being willing to work included fear for their own personal safety and concern for their families’ safety (“Many Public Health Employees Would Stay Home in a Flu Pandemic,” Reuters story published on Medscape.com, 2006). This book assumes a higher rate would report to work and that healthcare fields would suffer similar attrition rates as other industries—about 20-25 percent over the course of the epidemic. If in an actual pandemic 52 percent of the healthcare workforce were to not report to work, it would be catastrophic for the health system.

44 - The Canadian Pandemic Influenza Plan for the Health Sector (2006), citing a large number of sources, states: “An increase in mortality in pregnant women, miscarriages, premature births and stillbirths was documented during the 1918-1919 and the 1957-1958 pandemics. The reported mortality rate of pregnant women admitted to hospital with influenza in 1918 was 51.4 percent compared to 33.3 percent in hospitalized influenza patients from the general population.” The Plan goes on to identify pregnant women in their second and third trimesters as a particularly high-risk group.
    While the author found no evidence of pregnant healthcare providers being excused from their duties during a Pandemic, it is possible the health system would transfer them to lower-risk duties.

45 - Monica Schoch-Spana, MD says this about the 1918-19 Spanish Flu Pandemic in “‘Hospital’s Full-Up’: The 1918 Influenza Pandemic” (Public Health Reports, 2001:116, Supplement 2): “ A severe worker shortage curtailed industrial production and government services. At least 25 percent of police officers, postal workers, sanitation workers, and firefighters failed to report for duty. Transportation, food supply, and communication networks were equally in peril.”

46 - This item is invented; the author does not know if the Red Cross has or does not have such plans. However, the Red Cross did provide homecare services during the 1918-19 Spanish Flu Pandemic. (Schoch-Spana, Monica, “‘Hospital’s Full-Up’: The 1918 Influenza Pandemic,” Public Health Reports, 2001:116, Supplement 2)

47 - Decima Research Inc.’s 2005 national omnibus public opinion poll found 36 percent of Canadian respondents believing authorities were exaggerating the level of the risk of an avian flu pandemic so as to encourage people to begin taking precautions; nearly 60 percent of respondents said they either were not very worried, or not concerned at all, that avian flu could threaten their or their family’s health. (Canadian Press, “Most Canadians Don’t Feel Avian Flu is a Threat: Poll,” March 2005)

48 - In Bird Flu: What We Need to Know, A.A. Avlicino (Heritage House, 2006) writes, “…It’s hard to predict how people today will react to such a pervasive threat to public health and how they will judge the reaction of their governments and health authorities. When your family and friends are dying all around you, it takes great self-control not to strike out at a government and a society that can be seen as having failed to take decisive steps to prevent this strategy.” In September 1918, he points out, rioters rampaged in American cities, while the U.S. War Department was so weakened by the Spanish Flu that they could not adequately respond.
     “These riots,” writes Avlicino, however, “were not so much against the governmental health services’ reaction or lack thereof, but were born and fueled by the hysteria of people watching their communities die around them.”

49 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and attempted to determine the threshold of pain for people losing income due to missed work during a pandemic.
     The results: 56 percent of people with an annual income <$25,000, 29 percent of people with an annual income $25,000-$49,999, and 15 percent of people with annual income $50,000 and higher said they would experience serious financial problems if they missed work for 7-10 days. Further, 84 percent of people with an annual income <$25,000, 69 percent of people with an annual income $25,000-$49,999, 50 percent of people with annual income $50,000-$74,999, and 37 percent of people with annual income $75,000 and higher said they would experience serious financial problems if they missed work for one month. And 93 percent of people with an annual income <$25,000, 84 percent of people with an annual income $25,000-$49,999, 71 percent of people with annual income $50,000-$74,999, and 64 percent of people with annual income $75,000 and higher said they would experience serious financial problems if they missed work for three months.

50 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and found that 85 percent of respondents would be willing to keep children from gathering outside the home while schools closed for three months during a flu pandemic.

51 - In Bird Flu: What We Need to Know, A.A. Avlicino (Heritage House, 2006) describes various 1918 flu pandemic folk cures (“emphatically not recommended,” notes the author): inhaling tobacco smoke, eating large amounts of porridge, sleeping over a shotgun to allow the gun’s steel to draw out the fever, standing naked outside in the cold, lying in a tub filled with chopped onions, drinking large quantities of alcohol, inhaling the vapors produced by a pepper stew, sweating continuously for 90 minutes, and others.

52 - Photo acquired via veer.com. Photo by Gregor Hohenberg.

53 - This rumor may have originated from an incident that occurred in 2004.
     The College of American Pathologists (CAP) is a professional organization; one of its activities is to help pathology labs improve their accuracy by sending out CAP testing kits containing various germs that the labs had to identify. In 2004-2005, CAP kits, prepared by Meridian Bioscience, were distributed to 3,700 labs in North America, Europe, Asia, the Middle East and South America. The kits were supposed to contain an influenza A strain. Instead of choosing a common seasonal flu then circulating, however, the company chose the virus strain that had caused the 1957 Asian Flu pandemic. The testing kits are not handled the same way dangerous viruses are, which created the possibility of accidental release. Because the Asian Flu disappeared in 1968, anybody born after 1968 is highly susceptible to it. The Asian Flu killed about 2 million people.
    Fortunately, the NML in Canada identified the strain and alerted the CDC and the WHO. Alarms immediately sounded and the labs destroyed the test kits. (Liza Porteus, “Lawmakers Question Biological Security,” FoxNews.com, April 14, 2005)
    The 1968 Asian Flu and 2012 Avian Flu, however, are not closely related. The Asian Flu is an H2 virus, while the Avian Flu is an H5 virus.

54 - Population in this model is based on the 2006 Census. Figures for acute care, ICU and ventilator beds are from Ontario Health Plan for an Influenza Pandemic, July 2007, and based on 2004 data.

55 - In late 2005, The New York Times received an advance copy of the U.S. Department of Health and Human Services’ (DHHS) pandemic response plan. Gardiner Harris, with assistance from Lawrence K. Altman, wrote an article about it, “U.S. Not Ready for Bird Flu, Bush Plan Shows,” published October 8, 2005. The article opens: “A plan developed by the Bush administration to deal with any possible outbreak of pandemic flu shows that the United States is woefully unprepared for what could become the worst disaster in the nation's history.” Later, Harris writes: “As the outbreak peaks, about a quarter of workers stay home because they are sick or afraid of becoming sick. Hospitals are overwhelmed. ‘Social unrest occurs,’ the plan states. ‘Public anxiety heightens mistrust of government, diminishing compliance with public health advisories.’” Note that this text does not appear in the pandemic response plan published on the DHHS website and accessed by the author in August 2007.

56 - Photo acquired via istockphoto.com. Photo by Harald Tjøstheim.

57 - During the Spanish Flu Pandemic of 1918-19, Victor Vaughn, Surgeon General of the U.S. Army, is reported to have said, “Civilization could have disappeared within a few more weeks.” (Barry, J.M., The Great Influenza: The Epic Story of the Deadliest Plague in History, Penguin Books, 2004)

58 - Photo, which depicts riot police in Ottawa, acquired via istockphoto.com. Photo by Taylor Renforth.

59 - In 2005, the Canadian Forces numbered 65,000 with another 36,500 in the Reserves. In 2003, Liberal Defense Minister John McCallum was developing plans to increase the size of the Canadian Forces to 85,000 by 2013. The author could not identify plans by the subsequent Conservative government in this direction, but assumes, somewhat arbitrarily, that by 2012 the Canadian Forces will be increased to 75,000. (Inside Washington Publishers, “Canadian Defense Minister John McCallum Mulls Future Role of Forces,” August 7, 2003, located on Canadian Forces website)

60 - Peter Knaack, a member of the Royal Canadian Military Institute, wrote an excellent article on this subject in HazMat Management, Spring 2007, which may be accessible at hazmatmag.com. “The constitutionally mandated separation of emergency powers in this country with federal and provincial authorities facing off on the one hand of the constitutional divide, and municipal authorities often left to themselves on the other … has had an undeniable impact on the quality and quantity of civil-military cooperation,” he writes.

61 - Photo acquired via istockphoto.com. Photo by Jim Jurica.

62 - Michael Greger, MD points out in his book, Bird Flu: A Virus of Our Own Hatching (Lantern Books, 2006): “After Katrina hit, it took only 48 hours for 20 percent of New Orleans’ police force to disappear and drug addicts in withdrawal to claim the streets with gunfire. FEMA director Brown said his agency was forced to work ‘under conditions of urban warfare.’ And that’s only one city in crisis.”

63 - deleted

64 - The scene depicted in this photo, courtesy of the U.S. National Archives, occurred in Seattle, Washington in December 1918. Seattle public health officials recognized that mass transit systems, where people crowded in close quarters, were likely vehicles of disease transmission.

65 - The photos in this interlude section were acquired via istockphoto.com. The first photo of the women wearing medical masks is by Tomaz Levstek. The photo of the woman at the window is by “Jaymast.” The photo of the woman in front of the tombstone is by Becky Rockwood. The photo of the baby is by Oleg Kozlov.

66 - Between 1917 and 1928, the world suffered a major epidemic of encephalitis lethargica, which directly or indirectly caused more than 5 million deaths. Research has produced some evidence that this epidemic was caused by viral brain damage in survivors of the Spanish Flu (1918-19). (Ravenholt, R.T. and Foege, W.H., “1918 Influenza, Encephalitis Lethargica, Parkinsonism,” Lancet 320(8303):8604-4, 1982)

67 - Population in this model is based on the 2006 Census. Figures for acute care, ICU and ventilator beds are from the Nova Scotia Health System Pandemic Influenza Plan, June 2007; the acute care bed figure is based on 2006 data and the ICU and ventilator-supported bed figures are based on 2005 data.

68 - At the height of the SARS epidemic in April 2003, airline passenger arrivals to the city of Hong Kong had fallen by nearly two-thirds relative to March levels. Such losses would follow the Pandemic’s progress around the world. (Congressional Budget Office, The Congress of the United States, A Potential Influenza Pandemic: Possible Macroeconomic Effects and Policy Issues, July 2006)

69 - Oxford Economic Forecasting has estimated a pandemic could last two years with an annual cost that easily reaches 5 percent of world GDP, losses of about $2 trillion per year. (Oxford Analytica, “Bird Flu Could Shrink Global GDP,” Forbes.com, November 11, 2005)

70 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and found that 19 percent of employees said their workplace has a plan for an outbreak of pandemic flu. Further, 22 percent said they were worried their employer would make them go to work if they got sick, and 50 percent said their workplace would not shut down if recommended to do so by public health officials.

71 - Jesse Semko’s article, “Pandemic Planning Fever,” Calgary Inc, November 2006, is an excellent discussion of pandemic flu planning and business. Other sources to consider are Canadian Manufacturers & Exporters’ Influenza Pandemic: Continuity Planning Guide for Canadian Business, March 2006, and the International Facility Management Association (IFMA) Foundation’s Pandemic Preparedness Manual, developed by Environmental and Occupational Risk Management, December 2006.

72 - According to The Canadian Pandemic Influenza Plan for the Health Sector (Health Canada, 2006). Note that vaccine and vaccine technology is rapidly advancing, with some new technologies currently developing but still so new they could not be included in this book.

73 - According to The Canadian Pandemic Influenza Plan for the Health Sector (Health Canada, 2006), “It is assumed all persons who lack previous exposure to the pandemic virus subtype will likely require two doses of vaccine, but the dosage is unknown (e.g., two 15-microgram doses or higher).”

74 - In 2007, GSK announced that its H5N1 vaccine may be able to protect humans against genetically different versions of the avian flu strain, potentially countering future drifted mutations of the strain, a s reported by Helen Branswell, “GSK’s Bird Flu Vaccine Protects Against Drifted Strain of H5N1 Virus,” Canadian Press, March 2007. She writes, “GSK has declared it intends to position its H5N1 vaccine as a pre-pandemic product, useful both for national stockpiles and for individuals who want to protect themselves against a possible pandemic … As of the time of writing of this book, Canada has decided to forgo stockpiling vaccine, believing a combination of stockpiled antiviral drugs and first access to vaccine from GSK’s Quebec plant are a better bet, given that there is no way of predicting whether H5N1 or another flu subtype will cause the next pandemic. [Dr. Theresa Tam, head of respiratory diseases at the Public Health Agency of Canada] said [GSK’s testing results for its vaccine] are not likely to change that position. But she admitted that as more research is conducted, the argument for stockpiling vaccine for priming purposes might gather strength.” This technology and its implications were still developing at the time of writing, so the author has not included mention or application of it in this book.

75 - “Canada May Not Have to Stock Pandemic Vaccine,” Canadian Press, March 2005.

76 - According to The Canadian Pandemic Influenza Plan for the Health Sector (Health Canada, 2006), “The current domestic pandemic vaccine production capacity is 8 million 15-microgram (ug) doses per month as specified in the current contract with this supplier. The possibility of increasing this capacity is being explored.”

77 - For more information, see The Canadian Pandemic Influenza Plan for the Health Sector (Health Canada, 2006).

78 - Photo acquired via istockphoto.com, showing a boy being vaccinated, is by Liza McCorkle.

79 - The Harvard School of Public Health Project on the Public and Biological Security conducted a poll among a national representative example of 1,697 U.S. adults in September-October 2006, and found that 94 percent of respondents said they would be willing to stay at home for 7-10 days if sick during a flu pandemic. Further, 85 percent said all members of their household would stay at home for 7-10 days if one member of the household got sick; the author assumes that for the latter, actual compliance during a real pandemic will likely be lower than promised.

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