Flu Reports From Around The Nation

Credit CDC FluView 

# 6818

 

While a few states are still reporting low influenza activity, much of the nation has reported significant increases in influenza-like-illnesses during the month of December. Of concern, the predominate strain this year has been H3N2, which tends to produce a more severe season than does H1N1.

 

With the holidays over and schools scheduled to return to session this week and next, many communities are bracing for another spike in flu cases.

 

A brief round up today of some of the news reports of Flu Activity around the country.

 

First stop, Minnesota, where the latest CDC FluView report showed only moderate activity as of the 22nd of last month.

 

 

Flu cases spike in Minnesota

The Associated Press

MINNEAPOLIS —

Health officials predict it could be one of the worst flu seasons in years in Minnesota.

 

Flu patients have been filling urgent care centers and emergency rooms across the state. More than 120 Minnesotans were hospitalized with the flu in the week ending Dec. 22, nearly twice the number of cases in the previous week, health officials said. And it's still early in the flu season.

 

"That suggests this has the potential to be severe," said Minnesota Department of Health infectious disease director Kris Ehresmann.

(Continue . . . )

 

 

From Florida, Sharon Sanders, editor of  FluTrackers, has been in contact with the local health department, and files this report:

 

Influenza Trends Up in Central Florida in December

Sharon Sanders - Editor FluTrackers.com

January 2, 2012

Winter Park, Florida – Reports from sentinel providers indicate that influenza and influenza-like-illness have been trending up since Thanksgiving says Dain Weister who is the Florida Department of Health spokesman for Orange and Seminole counties. “We are reaching the level of activity seen in the 2009 pandemic” he said. Figure 1 on the Florida Flu Review for week 52 in 2010 shows the progression of the 2007-2008, 2008-2009, and 2009-2010 Florida influenza seasons as monitored by three surveillance systems: ILINet, Bureau of Laboratories viral surveillance, and county activity levels.

 

The Florida Department of Health    indicates "Moderate” as the current level of influenza activity in Central Florida on its website (see map 2).

Mr. Weister reported that 2 nursing homes in the Central Florida area have experienced a flu outbreak this season. Most hospitalizations have been in the 55+ age group and most emergency room visits for flu symptoms have been in the 0-19 age range.

 

The prevalent influenza type in the area confirmed by laboratory testing is A/H3 and A/H1N1 (H1N1pdm09) has also caused some illness. Mr. Weister can reached at 407-858-1400 for further inquiries.

 

From Arizona, we get:

 

Cases of flu in AZ, across US already signal busy season

All but two Arizona counties have reported cases of the flu in what is turning out to be an early and busy season.

 

A total of 581 flu cases of the flu have been laboratory confirmed by the Arizona Department of Health Services this season, state data show. At this time last year only 10 cases had been confirmed statewide.

(Continue . . .)

 

And this report (with video from WKYC-TV) from Ohio indicates a 13-fold increase in flu cases this year, over last.

 

Ohio flu season sees rise in hospitalizations

CLEVELAND -- The Ohio Department of Health is reporting a spike in the number of people hospitalized with influenza this year compared to last year.

 

Department spokeswoman Shannon Libby says it's early to see this much flu activity, with cases typically going up in January or February.

 

According to ODH influenza reports, 65 Ohioans were hospitalized with the influenza virus from October to late December 2011. In that same period this year, the number skyrocketed to 867.

(Continue . . . )

 

 

A reminder that there are still plenty of places where you can get a flu shot, and since the peak of the season may still be a month or more away, it isn’t too late to do so.

 

In addition to the shot, the CDC recommends:

 

Take everyday preventive actions to stop the spread of germs.

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub.*
• Avoid touching your eyes, nose and mouth. Germs spread this way.
• Try to avoid close contact with sick people.
• If you are sick with flu–like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.)
• While sick, limit contact with others as much as possible to keep from infecting them.

 

 

These precautionary steps can also help protect against norovirus, which is spreading misery this winter as well -although Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus.

»» Read More

WHO: 2012 World Health Statistics Report

 

# 6329

 

 

The World Health Organization has released the 2012 edition of their World Health Statistics report, an annual compilation of health-related data from its 194 Member States. This report also summarizes progress being made in achieving the health-related Millennium Development Goals (MDGs).

 

 

While infectious diseases get most of the world’s attention, it continues to be the NCDs (Non-Communicable Diseases) - like high blood pressure, heart disease , diabetes, and tobacco related illnesses – that exact the greatest toll on human health.

 

Some excerpts from today’s press release highlights these findings:

 

New data highlight increases in hypertension, diabetes incidence

News release

16 May 2012 | Geneva - The World health statistics 2012 report, released today, puts the spotlight on the growing problem of the noncommunicable diseases burden.

 

One in three adults worldwide, according to the report, has raised blood pressure – a condition that causes around half of all deaths from stroke and heart disease. One in 10 adults has diabetes.

 

“This report is further evidence of the dramatic increase in the conditions that trigger heart disease and other chronic illnesses, particularly in low- and middle-income countries,” says Dr Margaret Chan, Director-General of WHO. “In some African countries, as much as half the adult population has high blood pressure.”

<SNIP>

Published annually by WHO, the World health statistics is the most comprehensive publication of health-related global statistics available. It contains data from 194 countries on a range of mortality, disease and health system indicators including life expectancy, illnesses and deaths from a range of diseases, health services and treatments, financial investment in health, as well as risk factors and behaviours that affect health.

Some key trends in this year’s report are:

• Maternal mortality: In 20 years, the number of maternal deaths has decreased from more than 540 000 deaths in 1990 to less than 290 000 in 2010 – a decline of 47%. One third of these maternal deaths occur in just two countries – India with 20% of the global total and Nigeria with 14%.
• 10 year trends for causes of child death: Data from the years 2000 to 2010 show how public health advancements have helped save children’s lives in the past decade. The world has made significant progress, having reduced the number of child deaths from almost 10 million children aged less than 5 years in 2000 to 7.6 million annual deaths in 2010. Declines in numbers of deaths from diarrhoeal disease and measles have been particularly striking.

 

(Continue . . . )

DOWNLOAD THE SUMMARY BROCHURE

Available in 3 languages

• English pdf, 381kb
• French  pdf, 389kb
• Spanish pdf, 389kb

DOWNLOAD THE FULL REPORT

Available in 3 languages

• English pdf, 2.47Mb
• French pdf, 2.69Mb
• Spanish pdf, 2.84Mb

 

 

Of considerable interest to those of us who follow disease outbreaks around the world is the lack of disease and mortality information available from many low-resource countries.

 

Among low income countries, only about 1% of deaths (and their causes) are recorded, while just 34 countries – representing 15% of the world’s population – produce high quality cause-of-death documentation.

 

The two most populous countries in the world – India and China – do not have national civil registration systems in place, and instead generate estimates of births and deaths based on smaller population samples.

 

 

All of which helps to explain why, nearly two years after the end of the 2009 H1N1 pandemic, we still don’t have a good handle on how many people died from the virus.

 

This lack of surveillance and reporting extends far beyond just births and deaths, which is why there is so much ambiguity regarding the true prevalence of many diseases (including H5N1) around the world.

 

Much of the data that is available can be accessed via the WHO’s Global Health Observatory, which allows tailored online searches for health information by country or region.

 

Global Health Observatory (GHO)

• Global Health Observatory
• Data repository
• Reports
• Country statistics
• Map gallery
• Standards

»» Read More

USGS: New Real-Time Earthquake Map

 

New Real-Time USGS Earthquake Map

 

# 6289

 

 

The USGS has introduced an impressive real-time earthquake map on their Earthquakes Hazards Webpage, that allows the user to customize how the data is delivered. 

 

The control panel (see below) allows the user to filter out quakes based on minimum display parameters.

 

 

And the map has the ability to pan and zoom, allowing the user to drill down to the local level (including information on cities, streets, and fault lines).

Close up View of seismic activity around Tokyo, Japan

 

The global map display lists the most recent earthquakes (based on your criteria), and you can click on each event to get more information.

 

 

 

For more on the unveiling of this new tool, we have the following press release from the USGS.

 

Enhanced Real-time Earthquake Information Now Online

Released: 4/17/2012 1:53:48 PM

 

New U.S. Geological Survey webpages featuring more robust, real-time earthquake information are now available.  Whether the earthquake is minor or major, earthquake.usgs.gov visitors will see a unique, interactive earthquake map that regularly updates, can be individually tailored, and provides saved settings for future map visits.

 

In 2011, the website logged almost 48 million unique visitors and nearly 468 million pageviews.

 

"For all citizens of 'Earthquake Country,' whether they reside in our Nation's Capital or near a major global tectonic plate boundary, the new USGS earthquake webpages supply increased functionality to provide more real-time information tailored to the viewer's specific needs," said USGS Director Marcia McNutt. "When the ground shakes and time is of the essence, our goal is to ensure that the most timely information is at the fingertips of those who need to know."

 

From the website, users can access Latest Earthquakes  to zoom into and pan the world map to select different basemaps, as well as overlays such as plate boundaries, faults, and earthquake hazards. Information can be fine-tuned to display earthquakes on the map by time window, magnitude, depth, and maximum recorded intensity.  A list below the map updates for the current map view and settings and is sortable by any data column. Users can also download earthquake lists into other map interfaces like GoogleEarth (KML format) and Excel (CSV).

 

The event page when an earthquake is selected has also been upgraded and it provides interactive features and more information, including downloadable data files in various formats for each earthquake product, such as ShakeMap, Did You Feel It?, etc. This new event-centric view allows the visitor to see all the information associated with each earthquake without having to jump around the website to view each related product.

 

A future product in development will utilize the same user interface to search a comprehensive earthquake catalog populated with all existing USGS earthquake data, presenting a seamless view of recorded world-wide earthquakes current and historic.  It is anticipated that this product will be released in beta later this year.

»» Read More

WMD Center: BIO-Response Report Card

 

 

 

# 5894

 

While I’m personally more concerned over the probability that nature will produce a new, highly virulent pandemic than the possibility that terrorists might develop and unleash a bio-nightmare – I recognize that both are legitimate concerns - and either could deliver a substantial blow to the United States, and to the world.

 

So I’m happy to report that a new analysis outlining America’s ability to respond to either type of bio-emergency has just been released. 

 

The WMD Center, a bi-partisan group formed in 2010 and led by two well respected former Senators (Bob Graham, Chairman & Senator Jim Talent, Vice Chairman) along with an advisory group consisting of some of the nation’s leading biodefense experts, has put together an in depth report card on the nation’s ability to respond to a biological threat.

 

And while much of this report is WMD centric, many of the areas it addresses are equally important during a naturally occurring pandemic.

 

From the executive summary, this report offers:

• An overview of  current and emerging bioterrorism threats,
• Fundamental expectations and evaluations for each of  seven bio-response categories,
• An overview of challenges that affect the entire bio-response enterprise, and
• Recommended priorities that will strengthen the nation’s bio-preparedness and response capabilities.

 

The bottom line, again from the executive summary, is that:

 

The nation does not yet have adequate bio-response capability to meet fundamental expectations during a large-scale biological event.

 

 

As you can see from the color coded report card below, there are a lot of areas where this critical review gives a failing, or near-failing, grade.

 

 

Ten years after the anthrax attacks of 2001, out of 40 categories graded, 15 received an F, 10 received a D, and no area received an A.

 

You can read the entire 73 page report at the link below:

 

Bio-Response Report Card

The idea for this report card project began late last year, when we asked ourselves the question, “If the nation is unprepared for a biological attack, what more can we do?” Since 2001, the United States government has spent more than $65 billion on biodefense, and yet it has done so without an end-to-end, strategic assessment of the nation’s bioresponse capabilities. This report seeks to fill that gap.

View the complete Bio-Response Report Card PDF

 

 

This report indicates that America’s ability to respond to small-scale biological events has improved, but the ability to manage large-scale outbreaks (or worst case scenarios) is severely lacking.

 

This is a sobering report, highly critical in some areas, and will likely ruffle some feathers. 

 

But it does illustrate just how complex, and difficult, preparing for a large-scale biological threat really is. While this report provides that progress has been made, it also reminds us how much work still remains ahead.

 

There is a lot of detail in this report, so by all means, it is worth taking the time to read the whole report.

»» Read More

WHOSIS: World Health Statistics 2011

 

 

# 5570

 

 

The World Health Organization’s 64th World Health Assembly, being held in Geneva (May 16–24), ends today (see WHO Media Centre).

. 

 

One of the resources released to their 193 member nations, and to the public, during the past week is a compilation of global health statistics put together by WHOSIS (WHO Statistical Information System).

 

 

World Health Statistics 2011

World Health Statistics 2011 contains WHO’s annual compilation of health-related data for its 193 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets.

Addendum pdf, 45kb

Progress on the health-related Millennium Development Goals (MDGs)

Fact sheet N°290

DOWNLOAD THE FULL REPORT

Available in 3 languages

English pdf, 4.28Mb

French pdf, 5.50Mb

Spanish pdf, 5.89Mb

 

 

This report provides a comprehensive summary of the current status of national health and health systems in the following nine areas:

• life expectancy and mortality
• cause-specific mortality and morbidity
• selected infectious diseases
• health service coverage
• risk factors
• health workforce, infrastructure and essential medicines
• health expenditure
• health inequities
• demographic and socioeconomic statistics.

 

 

You’ll find most of the information provided in tables, charts, graphs and maps.

 

 

While this report cites modest improvements in global health on a number of fronts (malnutrition, vaccines, lower child and material mortality rates, stabilization of number of new HIV infections), progress varies from country-to-country, and many significant challenges remain.

 

You’ll find an overview of some of the progress that has been made in the following Millennium Development Goals FAQ sheet.

 

Millennium Development Goals: progress towards the health-related Millennium Development Goals

Fact sheet N°290
May 2011

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Key facts

• Fewer children are dying. Annual global deaths of children under five years of age fell to 8.1 million in 2009 from 12.4 million in 1990.
• Fewer children are underweight. The percentage of underweight children under five years old is estimated to have dropped from 25% in 1990 to 16% in 2010.
• More women get skilled help during childbirth. The proportion of births attended by a skilled health worker has increased globally, however, in the WHO Africa and South-East Asia regions fewer than 50% of all births were attended.
• Fewer people are contracting HIV. New HIV infections have declined by 17% globally from 2001–2009.
• Tuberculosis treatment is more successful. Existing cases of TB are declining, along with deaths among HIV-negative TB cases.
• More people have safe drinking-water, but not enough have toilets. The world is on track to achieve the MDG target on access to safe drinking-water but more needs to be done to achieve the sanitation target.

(Continue . . . )

 

 

 

The 2011 World Health Statistics report provides us with some sorely needed good news, and serves as a reminder of how much more needs to be done.

»» Read More

WHO: Global Report On Antimalarial Efficacy And Drug Resistance

 

 

# 5067

 

 

The World Health Organization today has released a new report on the drugs used to treat malaria, along with an appeal to nations to monitor and report any emergence of malarial drug resistance.

 

Roughly half the world’s population lives in areas where they risk infection from the malaria parasite.

 

Each year, roughly 250 million people are infected, and nearly a million people die from the disease  (source WHO 10 Facts on Malaria).

 

CDC Malaria Map.

Map Legend:

 

Over the past couple of years, a new artemisinin resistant form of malaria has appeared along the Cambodian-Thailand border, prompting concerns that it could spread.  

 

Hence the call for heightened monitoring and urgent requests that nations halt the use of oral artemisinin alone for the treatment of uncomplicated falciparum malaria, and use it as part of a drug cocktail instead.   

First the news release, then a link to the report.

 

News release

 

WHO calls on malaria-endemic countries to strengthen monitoring of antimalarial drug efficacy

National monitoring essential step in preventing the emergence of malaria drug resistance

18 NOVEMBER 2010 | GENEVA -- WHO is calling on countries to be increasingly vigilant in monitoring antimalarial drug efficacy in order to allow for early detection of artemisinin resistance.¹ This is one among several conclusions of the Global report on antimalarial drug efficacy and drug resistance: 2000–2010, released today. The report is based on 1100 studies conducted by national malaria control programs and research institutes over the ten-year period.

 

The report estimates that only 34% of malaria-endemic countries are complying with WHO recommendations to routinely monitor the efficacy of first- and second-line antimalarial medicines.²

"A greater political commitment to support and sustain national monitoring of the efficacy of antimalarial medicines is critical to prevent a wider emergence of artemisinin resistance", said Dr Pascal Ringwald of the Drug Resistance and Containment Unit, within WHO's Global Malaria Programme and one of the report authors.

Resistance to artemisinin

In February 2009, WHO confirmed that resistance to artemisinin had emerged on the Cambodia-Thailand border. Although patients infected were cured following treatment with an artemisinin-based combination therapy (ACT), the recovery took more time. In artemisinin-resistant areas, the high cure rates observed depend heavily on the efficacy of the non-artemisinin component of the combination.

 

Nonetheless, the report found that ACTs currently recommended by national malaria control programmes remain efficacious in treating malaria, with cure rates generally greater than 90%. In countries where the currently recommended ACT has a cure rate of less than 90%, policy change is ongoing to implement an efficacious replacement treatments for malaria.

 

"The emergence of artemisinin resistance on the Cambodia-Thailand border has been a wake-up call to the world to prevent its spread, increase monitoring, and preserve ACTs as the only effective treatment we have for falciparum malaria", said Dr Robert Newman, Director of WHO's Global Malaria Programme. "Prompt action will be critical to sustain progress in malaria control and achieve the health-related Millennium Development Goals."

 

(Continue . . .)

 

Global report on antimalarial efficacy and drug resistance: 2000-2010

Authors: WHO
Publication date: 2010
Languages: English
ISBN: 9789241500470

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Download [pdf 2Mb]
Questions and Answers [pdf 186kb]

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Overview

This report provides a comprehensive, global overview of antimalarial drug efficacy and the resistance of malaria parasites to the antimalarial medicines used between 2000 and June 2010. Policy-makers in national ministries of health will benefit from this document, as it provides both a global and a regional picture of the efficacy of the antimalarial medicines currently used in national treatment programmes. In addition, the report will be a reference for scientists, enhancing their understanding of the complexity of antimalarial drug resistance.

»» Read More

2010 Public Health Preparedness Report

 

 

# 4923

 

 

The CDC released a 192 page report on the nation’s public health preparedness yesterday, citing a number of areas where improvements have been seen.

 

Admittedly, I’ve not had time to look at this report, so I’ll simply provide a link to it, and to a summary by CIDRAP’s  Robert Roos and Lisa Schnirring.

 

 

2010 Report - Public Health Preparedness: Strengthening the Nation’s Emergency Response State by State

A report on CDC-funded preparedness and response activities in 50 states, 4 cities, and 8 U.S. insular areas

Tuesday, September 21, 2010

Public Health Preparedness: Strengthening the Nation’s Emergency Response State by State highlights progress in preparedness and presents data on a broad range of preparedness and response activities occurring at state and local levels across the nation. The report features national data and individual fact sheets for the 50 states and four directly funded localities (Chicago, the District of Columbia, Los Angeles County and New York City) supported by CDC’s Public Health Emergency Preparedness (PHEP) Cooperative Agreement.

 

An overview of the preparedness activities and challenges in the U.S. territories, commonwealths, and freely associated states funded by PHEP are also included. Fact sheet data expand and update those presented in CDC’s first state preparedness report (2008), and cover activities conducted in 2008 and 2009.

The report also highlights state and local preparedness and response activities occurring during the 2009 H1N1 influenza pandemic. All CDC preparedness reports are an important part of CDC’s overall focus on demonstrating results, driving program improvements, and increasing accountability for the nation’s investment in public health preparedness.

 

 

Since this isn’t exactly most people’s idea of light summer reading, we are fortunate to have this overview from CIDRAP.

 

CDC says state and local preparedness improving

Robert Roos and Lisa Schnirring Staff Writers

Sep 21, 2010 (CIDRAP News) – State and local health departments have significantly improved their readiness for public health emergencies in the past few years, with laboratory capacity and emergency operations centers leading the list of improved areas, the Centers for Disease Control and Prevention (CDC) said in a major report released today.

 

"We have some really good news, and there's some nice trend data," particularly in lab capacity and response readiness capacity, Dr. Ali Khan, director of the CDC Office of Pubic Health Preparedness and Emergency Response, told CIDRAP News.

(Continue. . . )

»» Read More

HHS Unveils Emergency Medical Countermeasures Report

 

 

# 4821

 

 

Along with a new report (Public Health Emergency Medical Countermeasures Enterprise Review), the HHS has also launched a new website called:

 

MedicalCountermeasures.gov

 

The site bills itself as:

 

MedicalCountermeasures.gov provides a central source of information regarding research, development, and acquisition of medical countermeasures for public health emergencies, both naturally occurring and intentional.

I’ve included a screen shot of the site’s front page.

 

The centerpiece of this new website is a freshly issued report that discusses a strategy to produce  “medical countermeasures” (vaccines, antivirals, diagnostics, etc) rapidly against an emerging disease threat.

 

You can read the report, press release, factsheet, and HHS blog entry at the following links.

 

Public Health Emergency Medical
Countermeasures Enterprise Review Report (PDF)

• Report
• Factsheet
• Flu Blog

---

Remarks from the Secretary

Press Release

President's Council of Advisors on
Science and Technology Report

 

 

Maggie Fox, Health and Science Editor at Reuters has more detail on all of this in the following story:

 

U.S. proposes wide changes in role fighting disease

By Maggie Fox, Health and Science Editor

Thu Aug 19, 2010 8:56am EDT

WASHINGTON (Reuters) - The U.S. government proposed big changes on Thursday to the way it works with companies to fight new disease threats such as flu, including reform at the Food and Drug Administration and setting up centers to make vaccines quickly.

(Continue . . . )

 

Note: Since I’m embroiled in moving to new digs this week, I haven’t had time to give these documents more than a cursory look, but wanted to pass them along nonetheless.

»» Read More

CSA White Paper: Voices From The Front Lines

 

 

# 4663

 

 

The Canadian Standards Association (CSA) is a non-profit group that serves businesses, Industry, government and consumers in Canada and around the world. 

 

They’ve recently released a 42 page white paper based on lessons learned from a one-day pandemic roundtable, attended by the Health Care and first response sector, which was held last December. 

 

Their recommendations focus on five main areas:

 

Pandemic Preparedness Planning

Personal Protective Equipment

Antiviral Medications

Vaccine Development and Delivery

Communications

 

 

Since these voices come from the front line – Health Care and emergency workers who are expected to have close, ongoing contact with infected individuals during a pandemic – it comes as no surprise that one of the conclusions was:

 

Given that it takes approximately six months to develop a vaccine once the virus is identified, as was the case with the H1N1, roundtable participants felt strongly that more emphasis needs to be put on access to personal protective equipment (such as specialized masks, gowns, and gloves) and antivirals (medications that work by interfering with the ability of the virus to reproduce in the body).

 

 

If you’ll recall, the safety of health care workers was one of the major concerns during the opening months of the pandemic, due largely to confusing and inconsistent guidelines and access to personal protective equipment (PPEs), along with restricted use of antivirals for pre-exposure and post exposure prophylaxis (PEP).

 

 

A few blogs on those subjects include:

 

The Respirator Controversy Continues

ANA Calls Shortage Of N95 Respirators Unacceptable

CNA/NNOC Plan Protest Over Inadequate H1N1 Protection

Report: Nurses File Complaint Over Lack Of PPE

Pandemic PEP Talk

 

Here is the CSA description of the event, followed by a link to the paper.

 

 

About the CSA Roundtable and White Paper

On December 15, 2009, CSA hosted the national Roundtable on Healthcare and Emergency Service Sector Pandemic Preparedness that was moderated by Dr. Allan Holmes, a fellowship-trained emergency physician, president of Global Medical Services, and pandemic advisor to federal and provincial governments and corporations across Canada. This one-day roundtable was possible thanks to arms-length support from Hoffmann-La Roche (Roche Canada).

 

CSA roundtable Participants included representatives from the following organizations: Association of Medical Microbiology and Infectious Disease Canada; Canadian Association of Emergency Physicians; Canadian Healthcare Association; Canadian Nurses Association; Centre for Excellence in Emergency Preparedness, College of Family Physicians of Canada; Hamilton Health Sciences Centre; National Emergency Nurses Affiliation; Ontario Hospital Association; Ottawa Hospital; and Prince George Fire Fighters Union.

 

 

Voices From the H1N1 Pandemic Front Lines: A White Paper on How Canada Could Do Better Next Time

 

 

A hat tip to Arkanoid Legent  for the link to this study.

»» Read More