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There is more than 2% difference between moisture content at the top of boards, and the subfloor. As noted above, by measuring the trowel marks the inspector was able to determine that the installer failed to use a ¼ x ¼ trowel as required by the adhesive manufacturer. The installer used an improper trowel, according to the manufacturer's instructions, as well as applied an insufficient amount of adhesive. Failure to use the proper trowel, and failure to apply the adhesive according to manufacturer guidelines will lead to moisture issues in wood flooring. From the manufacturer’s guidelines: Use DriTac 7300 adhesive with a properly notched trowel. All square footage rates are estimated. Rates will vary based on substrate condition and the angle the trowel is held to the subfloor. Failure to properly flatten the subfloor may result in hollow spots. DriTac warranties do not cover problems caused by improper use of installation products. 5/16” Solid Parquet, 1/4” TR-5 80 sq. feet/gal. Engineered Plank, 1/8” x 1/8” x 1/8” Square Approved Cork/Rubber/Foam Underlayment, Recycled Notch Rubber Flooring Over Porous Substrates See: DriTac 7300 Technical Data Sheet attached as Exhibit B. Inspector notes that the spider-webbed type of foaming pattern observed under boards (see Photo Nos. 33-34) is usually only seen when there is an issue with flatness. The foaming pattern has clearly overtaken most of the trowel pattern marks. This is because of the up and down motion while the glue was curing because the floor is out of flat. Additionally, this sort of bubbling is sometimes indicative of high moisture content. Sanding and Finish Issues This inspector was advised that homeowner, commissioning party, and the installer agreed that installer would complete the installation in the downstairs kitchen. Based upon this inspector’s observations, the floor installed in this kitchen fails to meet NWFA guidelines. Bill Gorton – Photo Narrative regarding 5510 Fulton Ave, Los Angeles, CA 91401 Page 51 of 56

Buffer marks are visible from a standing height under normal lighting. Inspector observed start and stop marks. Drum marks. Some amount of edger marks as well. See Photo Nos. 36-43. This wouldn’t be considered an acceptable job. This would be unacceptable across the entire room. Additionally, the inspector notes that, downstairs, the flooring product is a solid hardwood flooring product. In the basement, the installer has apparently unilaterally elected to install micro-beveled, engineered flooring rather than the square-edge product that was specified and agreed to. This produces undesirable and unsightly lines that are incompatible with the desired aesthetic produced by the downstairs flooring. See Photo Nos. 44-45. After some investigation, this Inspector was informed that neither homeowner nor contractor requested disparate wood flooring be installed at this site. Both homeowner and contractor expected that solid hardwood would be used throughout the entirety of the installation. CONCLUSION The preceding data, the on-site inspection, and the interviews with the involved parties support the following conclusion: Please call if you have any questions or require any further information, regarding this report. Sincerely, ___________________________________________ _________________________ Jeffrey B. Meltzer Date NWFA Certified Flooring Inspector, CR License # CP1980205 Phone: 310-839-9663 Email: [email protected] President Flooring Detective Bill Gorton – Photo Narrative regarding 5510 Fulton Ave, Los Angeles, CA 91401 Page 52 of 56

LIST OF EXHIBITS Exhibit “A” - NWFA Section II Subfloor Guidelines and Specifications Exhibit “B” - DriTac 7300 Technical Data Sheet Exhibit “C” - National Wood Flooring Association Installation Guidelines Wood Flooring – Chapter 3: “Solid Parquet Floor”

EXHIBIT “A” NWFA Section II Subfloor Guidelines and Specifications

Section II Subfloor Guidelines & Specifications Chapter 4 Wood Subfloor Guidelines Page Chapter 5 Concrete Subfloor Guidelines 23 Chapter 6 Installing a Subfloor Over Concrete 26 27 24 National Wood Flooring Association ©2007 l Revised 02.2016

Chapter 4 Wood Subfloor Guidelines Note: Always follow the wood flooring manufacturer’s recommendation for a proper subfloor. Part I Wood Subfloor Specifications A. Subfloor panels should conform to U.S. Voluntary Product Standard PS1-07, Construction and Industrial Plywood and/or US Voluntary PS 2-04 and/or Canadian performance standard CAN/CSA 0325.0-92 Construction Sheathing. Other CSA standards also apply. B. Solid-board subflooring should be ¾” x 5½” (1” x 6” nominal), Group 1 dense softwoods, No. 2 Common, kiln- dried to less than 15 percent moisture content. C. Both CD Exposure 1 plywood and OSB Exposure 1 subfloor panels are appropriate subflooring materials, but the proper thickness of the material will be determined by the factors noted below in Part IV, Panel Products Subflooring, E, Acceptable Panel Subfloors. Part II Subfloor Moisture Note: The National Association of Home Builders’ Green Home Building Guidelines contain the following directive under Section 5.3.8: “NAHB Model Green Home Building Guidelines, Section 5.3.8: Check moisture content of wood flooring before enclosing on both sides. Ensure moisture content of subfloor/substrate meets the appropriate industry standard for the flooring material to be installed.” A. For solid strip flooring (less than 3” wide), there should be no more than 4 percent moisture content difference between properly acclimated wood flooring and subflooring materials. B. For wide-width solid flooring (3” or wider), there should be no more than 2 percent difference in moisture content between properly acclimated wood flooring and subflooring materials. Part III Subfloor Flatness and Integrity A. Wood subfloors must be flat, clean, dry, structurally sound, free of squeaks and free of protruding fasteners. 1. For installations using mechanical fasteners of 1½” and longer, the subfloor should be flat to within ¼” in 10 feet or 3/16” in 6 feet radius. 2. For glue-down installations and installations using mechanical fasteners of less than 1½”, the subfloor should be flat to within 3/16” in 10 feet or 1/8” in 6 feet radius. B. If peaks or valleys in the subfloor exceed the tolerances specified above, sand down the high spots and fill the low spots with a leveling compound or other material approved for use under wood flooring. However, it is the builder’s or general contractor’s responsibility to provide the wood-flooring contractor with a subfloor that is within the tolerances listed above. When possible, check the back of the subfloor panel for American Plywood Association (APA) rating. 25 National Wood Flooring Association ©2007 l Revised 02.2016

C. Inspect the subfloor carefully. If there is movement or squeaks in the subfloor, refasten the subfloor to the joists in problem areas. D. Protruding fasteners are easily remedied by driving those fasteners deeper into the subfloor. Part IV Panel Products Subflooring A. For panel products subflooring, check for loose panels and renail or screw down loose panels securely. B. Ensure that there is proper expansion space (1/8”) between the panels. If the subfloor panels are not tongue- and-grooved and if there is not sufficient expansion space, use a circular saw to create the specified space. Do not saw through joints on T&G subfloors. C. Also check for delaminated or damaged areas and repair those areas as needed. D. Make sure the subfloor is free of debris before beginning installation. E. Acceptable Panel Subfloors: Truss/joist spacing will determine the minimum acceptable thickness of the panel subflooring. 1. On truss/joist spacing of 16” (406mm) o/c or less, the industry standard for single-panel subflooring is minimum 5/8” (19/32”, 15.1mm) CD Exposure 1 Plywood subfloor panels (CD Exposure 1) or 23/32 OSB Exposure 1 subfloor panels, 4’ x 8' sheets. 2. On truss/joist spacing of more than 16”, up to 19.2\" (488mm) o/c, the standard is minimum ¾” (23/32”, 18.3mm) T&G CD Exposure 1 Plywood subfloor panels, (Exposure 1), 4’ x 8' sheets, glued and mechanically fastened, or minimum ¾” (23/32\", 18.3mm) OSB Exposure 1 subfloor panels, 4’ x 8’ sheets, glued and mechanically fastened. When possible, check the back of the subfloor panel for American Plywood Association (APA) rating. 3. Truss/joist systems spaced over more than 19.2” (488mm) o/c up to a maximum of 24” (610mm) require minimum 7/8” T&G CD Exposure 1 Plywood subfloor panels, (Exposure 1), 4’ x 8' sheets, glued and mechanically fastened, or minimum 7/8” OSB Exposure 1 subfloor panels, 4’ x 8’ sheets, glued and mechanically fastened – or two layers of subflooring. Or brace between truss/joists in accordance with the truss/joist manufacturer’s recommendations and with local building codes. Some truss/joist systems cannot be cross-braced and still maintain stability. a. For double-layer subfloors, the first layer should consist of nominal ¾” (23/32”, 18.3mm) CD Exposure 1 Plywood subfloor panels (CDX), 4’ x 8' sheets or nominal ¾” (23/32”, 18.3mm) OSB Exposure 1 subfloor panels, 4’ x 8’ sheets. The second layer should consist of nominal ½” (15/32”, 11.9mm) CD Exposure 1 plywood subfloor panels, (Exposure 1) 4’ x 8’ sheets. The ½” plywood should be offset by ½ panels in each direction to the existing subflooring. The panels may also be laid on a diagonal or perpendicular, with 1/8” spacing between sheets. Nail on a 12” minimum grid pattern, using ring- shanked nails or staples. F. Fastening and Spacing Specifications 1. Follow the panel manufacturer’s recommendations for spacing and fastening. 2. Typical panel spacing and fastening requirements for truss/joist systems call for approximately 1/8” (3.2mm) expansion space around the perimeter of each panel, with panels fastened every 12” (305 mm) along intermediate supports. 3. Edge swell should also be flattened. This can usually be accomplished by using an edger sander. Part V Solid Board Subflooring A. Solid board subflooring should be: ¾” x 5½” (1” x 6”), Group 1 dense softwoods (SYP, Doug Fir, Larch, etc.), No. 2 Common, kiln-dried to less than 15% MC. Refer to Chapter 2, Acclimation and Conditioning of Wood Flooring, for proper subfloor moisture content at time of installation. B. Solid board subflooring should consist of boards no wider than 6 inches, installed on a 45-degree angle, with all board ends full bearing on the joists and fastened with minimum 8d rosin-coated or ring-shanked nails, or equivalent. C. Some types of wood flooring should not be installed directly over solid board subflooring. 1. Thin-classification solid strip flooring must have a 3/8”or better plywood underlayment installed over solid board subflooring. 26 National Wood Flooring Association ©2007 l Revised 02.2016

2. Parquet flooring cannot be installed directly to solid board subfloors. A parquet installation over solid board subflooring requires 3/8” or better underlayment panels, nailed on 6” minimum grid pattern using ring-shanked nails or staples. D. Some engineered flooring cannot be installed directly to solid board subfloors. (See wood flooring manufacturer’s recommendations.) 27 National Wood Flooring Association ©2007 l Revised 02.2016

Chapter 5 Concrete Subfloor Guidelines Note: Always follow the wood flooring and adhesive manufacturer’s recommendation for a proper subfloor. Part I Concrete Subfloor Specifications A. Subfloor must be flat. 1. Make sure the concrete slab is flat to the wood flooring manufacturer’s specification. Typically, manufacturers will specify a flatness tolerance of 1/8”in a 6-foot radius and or 3/16” in a 10-foot radius. 2. If the slab is out of specification, consider grinding, floating or both. Many high spots can be removed by grinding, depressions can be filled with approved patching compounds, and slabs also can be flattened using a self-leveling concrete product. 3. When sanding or grinding concrete, care must be taken to minimize the amount of silica dust produced. OSHA recommends using dust-collection devices, or applying water to the concrete before sanding. Approved respirators may also be used to minimize the amount of silica dust inhaled. B. Subfloor must be dry. 1. See Chapter 3, Moisture Guideline Testing and Vapor Retarders. 2. Concrete moisture meters and other tests can be useful in identifying moisture problem areas. However, NWFA guidelines specify using relative-humidity testing (ASTM F2170), calcium chloride testing (ASTM F1869) or calcium carbide (CM) testing (ASTM D4944 and MilSpec CRD-C154-77) to identify the moisture content of the slab. See Chapter 3, Moisture Guideline and Vapor Retarders. 3. If a slab tests too high in vapor emission to glue a floor down, consider using a vapor retarder type product, installing a vapor retarder and a plywood subfloor or using an alternative installation method. 4. Concrete slabs with a calcium chloride reading of more than 3 require use of a vapor retarder with a perm rating of 1 or less. It is strongly recommended to use an impermeable vapor retarder with a perm rating of .13 or less, such as 6 mil polyethylene film. C. Slab must be: 1. Minimum 3000 psi. 2. Free from non-compatible sealers, waxes, oil, paint, drywall compound, etc. a. Check for the presence of sealers by applying drops of water to the slab. If the water beads up, there may be sealers or oils. D. Do not attempt to glue a wood floor over a chalky or soft concrete slab. E. Burnished or slick slabs may require screening or sanding with a 30-grit abrasive. F. Specifications for lightweight concrete: 1. Make sure the concrete is well bonded to the subfloor. Check for hollow spots, cracks and loose areas. 2. As with on-grade concrete subfloors, make sure the concrete is clean, flat to specification and dry. 3. Over lightweight concrete (less than 3000 psi), if the flooring adhesive used has a higher shear strength than the concrete, use the floated subfloor installation method. (See Chapter 6, Installing a Subfloor Over Concrete.) If the psi of the concrete is unknown, use the floated subfloor installation method or contact the adhesive manufacturer. 4. Rule of thumb: Draw a nail across the top; if it leaves an indentation, it is probably lightweight concrete. 28 National Wood Flooring Association ©2007 l Revised 02.2016

Chapter 6 Installing a Subfloor Over Concrete Note: Always follow the manufacturer’s recommendation for a proper subfloor. Part I Direct Gluing a Subfloor Over Concrete A. Always follow the adhesive manufacturer’s recommendation for proper application, proper adhesive and correct trowel notch and spread rate. B. If necessary, add vapor retarder recommended by the adhesive manufacturer before applying adhesive. Part II Floated Subfloor A. In on-grade and below-grade applications, always add vapor retarder before applying underlayment. B. In above-grade applications, follow the flooring manufacturer’s recommendations. C. A vapor retarder is recommended anytime solid ¾” wood flooring is installed over concrete. A vapor retarder is required for installation over concrete with a calcium chloride reading greater than 3 pounds, a relative humidity reading of greater than 75%, or a calcium carbide (CM) reading of greater than 2.5%. D. Floated Subfloor System 1. Materials a. 2 layers minimum 3/8” (10mm) minimum CD Exposure 1 Plywood subfloor panels (CDX) 4’ x 8' sheets. 2. Installation method a. Place the first plywood layer with edges parallel to wall, without fastening. Leave ¾” space between wall and plywood. b. Plywood panels should be placed with 1/8” gaps between sheets. c. Lay the second layer perpendicular or at 45 degree angle to the first. d. Plywood panels should be placed with 1/8” gaps between sheets and a ¾” minimum expansion space at all vertical obstructions and wall lines. e. Staple/screw and glue (with urethane or construction adhesive) the second layer to first layer on 12” interior grid pattern (6” on the perimeter). Be careful not to penetrate the vapor retarder. E. Alternate Subfloor System 1. Materials a. Use minimum ¾” (23/32”, 18.3mm) CD Exposure 1 Plywood sheathing, 4’ x 8’ sheets. 2. Installation method a. Cut sheets to 16” x 8’ or smaller panels, scored on back 3/8” deep a minimum of every 12” across width. b. 16” planks oriented perpendicular or diagonally to direction of flooring. c. Panels staggered every 2’, and spaced 1/8” between ends, with ¾” minimum expansion space at all vertical obstructions. Part III Glue-Down Subfloor A. Always follow the adhesive manufacturer’s recommendation for proper subfloor, spread rate and trowel notch. B. If necessary, add vapor retarder before applying underlayment. A vapor retarder is recommended anytime solid ¾” wood flooring is installed over concrete. C. Glue-Down Subfloor System: 1. Materials a. Use minimum ¾” (23/32, 18.3mm) CD Exposure 1 Plywood subfloor panels, (Exposure 1), 4’ x 8’ sheets. 2. Installation method a. Cut the plywood panels to 2’ x 8’ or 4’ x 4’ sections. 29 National Wood Flooring Association ©2007 l Revised 02.2016

b. Score the back of the panels ½ the thickness on a 12” x 12” grid. c. Apply an adhesive approved for the installation of plywood, per the plywood manufacturer’s recommendations. d. Lay sections in a staggered joint pattern in the adhesive, with 1/8” spacing between sheets, and ¾” minimum expansion space at walls and all vertical obstructions. Part IV Nail-Down Subfloor A. Always follow the manufacturer’s recommendation for proper subfloor. B. In on-grade and below-grade applications, always add vapor retarder before applying underlayment. In above- grade applications, follow the flooring manufacturer’s recommendations. C. A vapor retarder is recommended anytime solid ¾” wood flooring is installed over concrete. D. Nail-Down Subfloor System Over Concrete 1. Materials a. Minimum: Use minimum ¾” (23/32, 18.3mm) CD Exposure 1 Plywood subfloor panels (CDX), 4’ x 8’ sheets. 2. Installation method Note: Fasteners may be powder-driven pins, pneumatic driven nails, screws, deformed pins, or other fasteners suitable for concrete application. Check with fastener manufacturer for specification such as length, drill size, and/or shot load where applicable. a. Stagger panel joints allowing approximately 1/8” expansion space around all panels to prevent edge peaking due to compression caused by panel swell. b. Allow ¾” minimum expansion space at all vertical obstructions. c. Panels should be mechanically fastened. For powder load or pneumatic pressure information, contact your local supplier. d. Nailing requirements, minimum 32 shots per 4’ x 8’ panel. e. Areas with higher humidity may require additional fasteners. Part V Screed System A. Solid ¾”, 25/32” and 33/32” tongue-and-groove strip flooring may be installed directly to screeds. B. Engineered wood flooring less than ¾” (23/32”) thick, thin-classification strip flooring (including ½”) and solid plank flooring (3” or wider) cannot be installed directly to screeds. C. For engineered flooring less than ¾” thick, thin-classification strip, and for solid plank (3” and wider), the screed system must be overlaid with proper subflooring. The screed system must be overlaid with nominal ¾” (23/32”, 18.3mm) Exposure 1, or nominal 5/8” (19/32”, 15.1mm), Exposure 1, CDX plywood subfloor panels or nominal ¾” (23/32”, 18.3mm) OSB underlayment properly spaced and oriented perpendicular to screed direction. All joints must be staggered. D. Installation method. See Appendix I, Installation Over Screeds. 30 National Wood Flooring Association ©2007 l Revised 02.2016

EXHIBIT “B” DriTac 7300 Technical Data Sheet

7300 SUREBOND Urethane Wood Flooring Adhesive OWNED & OPERATED IN USA TECHNICAL DATA SHEET DriTac 7300 is a contractor grade, urethane wood flooring adhesive that is very easy to spread and dispense from the pail, allowing for increased productivity. It contains no water and provides a permanent bond. ATTRIBUTES • MVER up to 5 lbs./80% RH • Remains Elastomeric • Easy to Spread • Easy to Clean When Wet • Freeze-Thaw Stable • Helps Contribute to LEED Credits • Non-Slumping • Low Odor FLOORING TYPES • M ulti-Ply Engineered Plank • Solid Wood Planks • Parquet • Acrylic Impregnated Wood • Bamboo • R ecycled Rubber Flooring • Plywood • Exotic Woods AVAILABLE CONTAINER SIZE • 4-Gallon Pail • 2-Gallon Pail • 20 oz. Sausage

TECHNICAL DATA SHEET INSTRUCTIONS Read all information before installation. Please contact DriTac Flooring Products at (973) 614-9000 with questions. GENERAL CHARACTERISTICS DriTac 7300 has been formulated for the interior installation of multi-ply engineered plank, solid plank, bamboo, exotic wood, acrylic impregnated wood, parquet, plywood, recycled rubber flooring and cork and rubber underlayments over approved substrates. DriTac 7300 is moisture resistant, however, to prevent damage to the flooring from subfloor moisture, carefully follow the wood manufacturer’s instructions. The time it takes for the adhesive to cure is related to temperature, humidity, porosity of the subfloor, ventilation and air movement. APPROVED SUBFLOORS • Plywood • Terrazzo and ceramic tile • Underlayment grade O.S.B. • Vinyl tile flooring coated with vinyl primer • Concrete; above, on or below grade in the absence of excessive moisture and alkalinity • Non-cushioned fully adhered sheet vinyl coated with vinyl primer • Lightweight concrete/gypcrete (coated with latex primer), per ASTM F2419 Note: If DriTac’s list of approved subfloors is different from the flooring manufacturer, DriTac requires that you must follow the flooring manufacturer’s recommendation. SUBFLOOR REQUIREMENTS • Clean - It is required that all concrete, sheet vinyl, vinyl tile, terrazzo and ceramic tile subfloors be scoured with #3-1/2 open coat sandpaper to remove dirt or any surface contamination such as paint, grease, oil, sealers, waxes and curing compounds. DriTac 7300 adhesive should not be used over these substances. Sweep or vacuum the subfloor before installation. • Preparation - All floors should be flat to within 3/16” in 10 ft. or 1/8” in 6 ft. • Smooth and Flat - Remove any high spots with a terrazzo grinder or Carborundum stone and fill any low spots with a good quality cementitious-based latex patch mix. CONCRETE SUBFLOORS Concrete should be at least 60 days old. Inspect the concrete before installing flooring over it. First inspect for any wetness at the base of the drywall or for visible signs of moisture on the concrete. Second, test for moisture. Use a Calcium Chloride Method Test or Relative Humidity Test for reliable concrete testing. The results should not exceed 5 lbs., per 1,000 square feet over 24 hours, per the ASTM F1869 Calcium Chloride Method Test, or 80% Relative Humidity (RH), per the ASTM F2170 Relative Humidity Method Test. The maximum reading on concrete for wood installations should not exceed the wood flooring manufacturer’s recommendations. Many wood flooring products can be installed over lightweight concrete (less then 3000 PSI) or gypcrete, providing the surface is properly prepared. Follow the concrete manufacturer’s recommendation for the application of a surface hardener/sealer. Radiant heated subfloors should be turned off 24 hours prior to and during installation to prevent premature curing of the adhesive. SHEET VINYL, VINYL TILE, TERRAZZO & CERAMIC TILE SUBFLOORS All tiles or sheet goods must be firmly bonded to the subfloor. Make certain the sheet vinyl is a full spread system, perimeter installations are unacceptable. If materials are poorly bonded to the subfloor remove them down to the original subfloor and sand or scrape off all traces of old adhesive. Do not glue over heavy cushioned (1/4”) sheet goods or rubber tile. New sheet vinyl or vinyl tile must be coated with a primer. Old vinyl must be sanded first, then cleaned with TSP or equivalent cleaner to remove all wax and other coatings. CAUTION: Sanding or removing tile flooring containing asbestos is a health hazard. If there is any doubt concerning the contents, professional advice should be sought. Asbestos has been labeled a carcinogen. PLYWOOD, ORIENTED STRAND BOARD (OSB), OR WOOD SUBFLOORS CAUTION: Subfloors with high moisture content may shrink at a later date causing cracks to appear in the wood floor. Before installing over any one of these subfloors, test for moisture using a reliable moisture meter such as the Tramex Wood Moisture Meter or equivalent. The moisture content should not exceed 12%. If it is over 12%, either wait until the subfloor is drier or stabilize the subfloor with an additional layer of ¼” plywood. All joints in subflooring materials should have 1/8” expansion space around all panels. If expansion space is not present, cut around and through the panel joints with a circular saw. When installing a plywood sheet subfloor over concrete, use a ¼” x ¼” x ¼” square notched trowel to apply adhesive. Score 3/8” deep every 8 to 10 inches on 4’ x 4’ sheets of ¾” exterior. Set 4’ x 4’ sheets into wet adhesive. Apply weight as necessary and allow to cure overnight. WOOD INSTALLATIONS DriTac 7300 flows from the pail very easily. For best results, tip the pail carefully to dispense adhesive. Provide adequate ventilation and air movement. Ideally, installation should not begin until all wet work (painting, dry wall materials, etc.) is complete and the

TECHNICAL DATA SHEET heating/air conditioning system is in operation. Jobsite temperature should be between 55 and 90 degrees Fahrenheit. Trowel only the amount of adhesive that can be covered in 30 minutes. Install wood flooring into wet adhesive only. Secure the first row with edge blocking or top nail with finishing or sprig nails. Tighten side and end joints and reduce scooting by securing the flooring together with a manufacturer-approved method (painters tape, side blocking, strapping, etc.). Occasionally check for transfer to back of wood flooring. If adhesive transfer is less than 90% to the back of the plank scrape up the adhesive and apply fresh DriTac 7300. Apply weight to any bowed flooring and all floor mounted trim moldings. Remove all defective or unsightly boards immediately. The adhesive is very tenacious and flooring is difficult to remove after the adhesive has cured. Roll the floor with a 100 lb. roller every two to three hours during and immediately after installation. RECYCLED RUBBER FLOORING INSTALLATIONS This product is approved for installing all recycled rubber flooring products that are recommended for installation with a moisture cure urethane adhesive. Check with the flooring manufacturer for installation recommendations. APPROVED CORK & RUBBER UNDERLAYMENT INSTALLATIONS • Cut underlayment to length and lay loosely over the area to be installed. Both ends of the roll must curl down towards the subfloor. If the ends curl up, turn the underlayment over. • Pull the loose laid material back at least half the length of the roll. Using the recommended trowel, apply DriTac 7300 to the subfloor. Place underlayment into adhesive utilizing wet-lay method. Upon placing underlayment into the adhesive, roll both ways with a 100 lb roller. Repeat the installation for the other half of the subfloor, insuring all joints are butted together tightly. • Allow adhesive to set prior to proceeding to flooring installation. It is highly recommended to allow at least 18 hours prior to installation of the flooring. TR-1 TR-6 TR-11 GLUE/NAIL ASSIST INSTALLATIONS This adhesive can be used for glueTRa-1nd nail assisTtR-i6nstallationsT,R-w11hen recommended in writing by the wood flooring manufacturer. DriTac 7300 adhesive sausages areTR-a2vailable forTRg-l7ue assist inTsRt-1a2llations. TROWELS AND CTOR-2VERAGE TR-7 TR-12 Floor Type DriTacTTRRT--r31owel TTRR--86Coverage TR-13 TR-11 Multi-ply Engineered Plank TR3-/216- ”3x/1-16a/”4lsx”ox1kT/5TTn4R/RRo”1---6wo634n”nF1ala/s2t-”VCNeonttcehrs TR6-80 sq. feet/gal. TR-13 TR-11 3/8” up to 1/2” TR-1 TR-14 TR-9 TR-12 Multi-Ply Engineered Plank TR-2 TR-7 3/8” up to 1/2” (when TR-4 TR5-90 sq. feet/gal. TR-14 additional adhesive is required) TR-6 TR-12 TR-13 and 5/16” to 3/8” Solid StTrRip-2 3/16” x 5TT/R3R-2-75” V Notch TR-3 TR-10 TR-8 5/16” Solid Parquet, 1/4” TTRR--65 TRT-R1-110 Engineered Plank, ApprovTeRd-1 TTRR--85 TR-1830 sq. feet/gal. 1/8” x 1/8” x 1/T8R”-4Square Notch Cork/Rubber/Foam TR-3 TR-6 TR-9 TR-11 Underlayment, Recycled Rubber TR-14 Flooring Over Porous SubsTtRr-a1tes TR-1 TTTRRR--4-26 TTTRRR--1-971 TR-12 3/4” Solid Wood Plank/ 1/4” x 1/4” x 1TT/R4R-”-45Square Notch TR-14 Shorts, 4’ x 4’ Plywood TR-7 30 sq. feet/gal. TR-8 TR-2 TTRR--1120 TR-10 TR-12 GreateTrR-t2han 1/2” TR-3 TTRR--78 TR-13 TTRR-5-7 1/4” x 1/4” x 1T/R8-”9Square Notch Engineered Plank, TR-13 3/4” Parquet and Solid TR-3 TR-1335 sq. feet/gal. Plank greater than 3/8” TR-14 up to T9R/1-36” TR-4 TR-8 Bamboo up to 5/8” to TR-4 TR-9 TR-14 3/16” x 3/16” x T3TTRR/R1---19614”0Square Notch 35 sq. feet/gal. 9/16” TinR-t4hickness TTRR--59 Recycled Rubber FlooringTR-5 TR-10 100 sq. feet/gal. over Non-Porous Substrates TR-15 TR-5 TR-10 3/32” x 3/32” x 3/32” Square Notch Trowels diagrams are not to scale. Use DriTac 7300 adhesive with a properly notched trowel. All square footage rates are estimated. Rates will vary based on substrate condition and the angle the trowel is held to the subfloor. Failure to properly flatten the subfloor may result in hollow spots. DriTac warranties do not cover problems caused by improper use of installation products. Follow flooring manufacturer’s written installations instructions.

TECHNICAL DATA SHEET LIMITATIONS Adhesive will not prevent moisture-related damage to wood flooring installations. DriTac 7300 adhesive is affected by humidity more than temperature. High humidity will cause the adhesive to cure faster and low humidity will slow the curing process. Do not use on wet, contaminated or friable substrates. Due to dimensional stability, only engineered plank wood flooring can be installed below-grade, when proper moisture testing has been conducted and the results do not exceed limitations. After 8 to 12 hours, light traffic is allowed. Do not use as a leveling material. Cutback residue must be removed or encapsulated prior to applying adhesive. REUSE OF PARTIAL CONTAINERS Cover adhesive in the pail with a plastic trash bag or two layers of plastic film. Put lid on tightly. Turn over pail. This will seal contents from outside air. To open container, take off lid, cut plastic and remove thin layer of cured adhesive on surface. SHELF LIFE 12 months when stored at 75° F and 50% relative humidity. CLEAN UP • Remove excess urethane adhesive as soon as possible before it dries on the flooring surface. Clean up as you go. Cured urethane adhesive is very difficult to remove. • Never attempt to remove DriTac 7300 adhesive from tools or flooring with water as this will cause the adhesive to cure more rapidly. • Remove residue before it dries with DriTac Urethane Adhesive Remover or other flooring manufacturer-approved cleaning method. • Clean DriTac 7300 adhesive from floor and tools while still wet with DriTac Urethane Adhesive Remover or other flooring manufacturer-approved cleaning method. PRECAUTIONS • Contains Methylene Diphenyl Diisocyanate. May cause skin and/or eye irritation. May cause dermatitis and allergic responses. Potential skin and/or respiratory sensitizer. Inhalation of vapors may cause irritation and intoxication with headaches, dizziness, and nausea. See Safety Data Sheets for further information. Ingestion may cause irritation. • KEEP OUT OF REACH OF CHILDREN. Avoid contact with skin, eyes and clothing. Wash thoroughly after handling. Avoid breathing vapors. Use only with adequate ventilation. Use impervious gloves, eye protection and if TLV is exceeded or if used in a poorly ventilated area, use NIOSH/MSMA approved respiratory protection in accordance with applicable federal, state and local regulations. DO NOT take internally. Empty container may contain hazardous residues. FIRST AID In case of eye contact, flush thoroughly with water for at least 15 minutes. SEEK  IMMEDIATE MEDICAL  ATTENTION. In case of skin contact, wash affected areas with soap and water. If irritation persists, SEEK MEDICAL ATTENTION. Remove and wash all contaminated clothing. If inhalation causes physical discomfort, remove to fresh air. If discomfort persists, SEEK MEDICAL ATTENTION. INSTALLER RESPONSIBILITY These directions are general guidelines for flooring installations. It is the responsibility of the installer to determine proper drying time of the adhesive, trowel size to be used and acceptability of subfloor conditions. Installations must also be in accordance with flooring manufacturers recommendations. Only flooring that is approved for glue down installations by the flooring manufacturer can be used with DriTac 7300. Floors installed with DriTac 7300 are not warranted against damage caused by wet mopping, flooding, plumbing leaks or other extraordinary circumstances. For any installation not herein recommended, contact DriTac Flooring Products before proceeding. WARRANTY This product is warranted to be free of manufacturing defects. If a manufacturing defect is found within one year from the date of purchase, such defective product shall be replaced. No warranty either expressed or implied is made regarding the performance of this product since conditions under which these goods are transported, stored, used or applied are beyond our control. This warranty is made in lieu of all other warranties either expressed or implied and the seller shall not be responsible for consequential, incidental, special or other damages no matter what the cause. GHS label elements: Hazard pictograms: Signal word: Warning. Hazard statements: Causes skin irritation. Causes serious eye irritation. May cause an allergic skin reaction. May cause respiratory irritation. Precautionary statements: Wear protective gloves: butyl rubber, Ethyl vinyl alcohol laminate (EVAL), nitrile rubber, neoprene rubber. Wear eye and face protection. Wear protective clothing. Avoid breathing vapor. Avoid release to the environment. Wash hands thoroughly after handling. Collect spillage.

EXHIBIT “C” National Wood Flooring Association Installation Guidelines Wood Flooring – Chapter 3: “Solid Parquet Floor”

SECTION II PRODUCT SPECIFIC INFORMATION CHAPTER 3 SOLID PARQUET FLOORING 3/4” & Thinner Unfinished/Factory Finished/Impregnated I. Minimum Acceptable Jobsite Conditions and Checklist See Section I II. Acclimation Guidelines NOTE: Always follow the manufacturers recommendations for acclimation. Upon delivery check wood flooring moisture content (Section V, Appendix AB, AD and AE) to establish a baseline for required acclimation (Section 1, Chapter 1). Acclimation depends on geographic location, interior climate control and time of year. See Definition of Acclimation under Section VI. Refer to Section V, Appendix AD and AE. III. Flooring Grade Levels (Section V Appendix AF) Above Grade: Solid parquet wood floors can be installed successfully above grade level. On Grade: Solid parquet wood floors can be installed successfully on grade level. Below Grade: SOLID WOOD FLOORS ARE NOT RECOMMENDED FOR BELOW GRADE INSTALLATIONS. NOTE: The entire flooring level is considered to be BELOW grade where soil is present along any perimeter wall and is more than 3” above the installed wood flooring level. IV. Subfloor Guidelines – Wood Joist Systems – panel products or solid boards NOTE: Always follow the manufacturers recommendation for proper subfloor. NOTE: Subfloor/Underlayment panels should conform to the USVoluntary Product Standard PS 2-92 or PS 1-95 and/or Canadian performance standard CAN/CSA 0325.0-92 Construction Sheathing. Check underside of boards for codes. 1 Revised June 2002

Chapter 3, Solid Parquet FLoor NOTE: Solid board subflooring should be: 3/4” x 5 1/2”, Group 1 dense softwoods, (SYP, Doug Fir, Larch, etc), No. 2 Common, Kiln dried less than 15% MC. Check subfloor for performance stamp and/or specification agency. Subfloor must be flat,clean,dry, structurally sound,free of squeaks and free of pro- truding fasteners. Test subflooring for moisture according to Moisture Testing Procedures in Section V, Appendix AB. Moisture content should be within 4% of average area environ- mental conditions. Section V, Appendix AD and AE. For installations using mechanical fasteners of 1-1/2” and above, the subfloor sould be flat to within 1/4” in 10’ or 3/16” in 6’. For gluedown installations and installations using mechanical fasteners of less than 1-1/2”, the subfloor should be flat to within 3/16” in 10’ or 1/8” in 6’. For paneled subflooring/underlayment – nailing schedule must be adequate,typ- ical-every 6” along panel ends and every 12” along intermediate supports; all panel edges should exhibit spacing; edge swell should be flattened as necessary. For board subflooring – Boards should be no wider than 6”; installed at 45 degree angle with all board ends full bearing on joists and nailed with 2, 8d nails; 1/4”- 1/2” space should be present between board edges. PREFERRED SUBFLOORING: 3/4” (23/32”, 18.3mm) CDX Plywood subfloor/underlayment (Exposure 1), 4’ X 8’ sheets; OR 3/4” (23/32”, 18.3mm) OSB subfloor/underlayment, with joist spacing 19.2”(475mm) on center or less. MINIMUM: 5/8” (19/32”, 15.1mm) CDX Plywood subfloor/underlayment (Exposure 1) 4’ X 8’sheets, maximum 16” (400mm) on center joist construction Follow panel manufacturer recommendations for spacing and fastening. Typical panel spacing and fastening for joist systems, 1/8”(3.2mm) around perimeter and fastened every 6” (150mm) on bearing edges and every 12” (300 mm) along intermediate supports. For 3/4” (18.3mm) CDX Plywood and 23/32” (18.3mm) OSB, with joist systems spaced over maximum 19.2” (475mm) o/c requires an additional layer of ply- wood. Minimum requirement; 1/2” (15/32”, 11.9mm) CDX plywood subfloor/underlayment,(Exposure 1) 4’X8’sheets. The 1/2”plywood should be off- set by 1/2 panel in each direction to the existing subflooring. The panels may also be laid on a diagonal or perpendicular, with 1/8” spacing between sheets. Nail on a 6” minimum grid pattern-using ring shanked nails. Or brace between joists with 2X6 or wider boards every 24”. Revised June 2002 2

Chapter 3, Solid Parquet FLoor NOTE: Parquet cannot be installed directly to solid board subfloors Board subfloors must have additional underlayment. Preferred requirement; 1/2” (15/32”, 11.9mm) CDX plywood subfloor/underlayment, (Exposure 1) 4’x8’ sheets. Minimum thickness 3/8” underlayment panels. Panels nailed on 6” minimum grid pattern using ring-shanked nails or staples. NOTE: With minimum specified materials , at maximum span and spacing (i.e. greater than 19.2”) flooring will exhibit minimum performance. Minimum per- formance may result in the following conditions: movement, gaps, noises , and with site finished flooring finish delamination. V. Subfloor Guidelines – Concrete Slab NOTE: Always follow the manufacturers recommendation for proper subfloor. Concrete must be flat, dry, structurally sound and clean. Test concrete for moisture according to Moisture Testing Procedures in Section V, Appendix AA. Excess moisture should not be present. Tolerance should be flat to within 3/16” in 10’ or 1/8” in 6’. Substrate should be flattened to tolerance Lightweight concrete (less than 3000 psi) where adhesive used has a higher psi rating than concrete, use with a Subfloor-Floated. RULE OF THUMB: Draw a nail across the top and if it leaves an indentation, it is probably lightweight concrete. Before moisture testing begins, the slab must be cured for a MINIMUM of 30 days. Direct Glue Application NOTE: Always follow the manufacturers recommendation for proper application, proper adhesive and correct spread rate. If necessary, add moisture retarder before applying adhesive. (Section V, Appendix AG) Typical – 3/4”thick parquet requires a vapor retarder over the concrete slab,and spread rate for adhesives 30 – 50 sq. ft. per gallon. Typical – 1/2”and thinner parquet does not require a vapor retarder, and spread rate for adhesive is 40 – 60 sq. ft. per gallon. 3 Revised June 2002

Chapter 3, Solid Parquet FLoor Subfloor – Floated NOTE: Always follow the manufacturers recommendation for proper subfloo.r If necessary, add moisture retarder before applying underlayment. (Section V, Appendix AG) PREFERRED: Subfloor system: 2 layers 1/2” (15/32”, 11.9mm) CDX plywood sub- floor/underlayment, (Exposure 1) 4x8 sheets. MINIMUM Subfloor system: 2 layers 3/8” (10mm) CDX Plywood subfloor/underlayment (Exposure 1) 4’ X 8’sheets. Place first plywood layer with edges parallel to wall, without fastening. Plywood should be placed with 1/8” gaps between sheets Lay second layer perpendicular or at 45 degree angle to first Plywood should be placed with 1/8” gaps between sheets 3/4” minimum expansion space at all vertical obstructions and wall lines Staple, screw, or nail second layer to first layer on 12” grid pattern. Glue Down Subfloor NOTE: Always follow the manufacturers recommendation for proper subfloor. If necessary, add moisture barrier before applying underlayment. (Section V, Appendix AA) PREFERRED: Subfloor: 3/4” (23/32”, 18.3mm) CDX Plywood subfloor/underlayment (Exposure 1),4’x8’sheets. MINIMUM Subfloor: 5/8”(19/32),15.1mm) CDX Plywood subfloor/underlayment, (Exposure 1), 4’x8’ sheets. For single layer system; Apply adhesive per manufacturers recommenda- tions (typical spread rate – 30-35 sq.ft.per gallon with a 1/4”x 1/4”notched trowel), cut plywood to 2’X8’ or 4’X4’ sections; score on the back 1/2 the thickness on a 12”x12” grid; lay sections in a staggered joint pattern in the adhesive; 1/8”spacing between sheets; 3/4”minimum expansion space at all vertical obstructions. Nail Down Subfloor NOTE: Always follow the manufacturers recommendation for proper subfloo.r If necessary, add moisture barrier before applying underlayment. PREFERRED Subfloor system: 3/4” (23/32”, 18.3mm) CDX Plywood subfloor/under- layment,(Exposure 1), 4’X8’sheets. MINIMUM Subfloor: 5/8” (19/32,15.1mm) CDX Plywood subfloor/underlayment (Exposure 1), 4’x8’ sheets Revised June 2002 4

Chapter 3, Solid Parquet FLoor 1/8” spacing between sheets with staggered joints Fasten every 12” and 6” from edge along the border for a minimum of 32 shots per 4’x8” sheet. For load (shot) information, contact your local supplier Areas with higher humidity may require additional nails (shots). 3/4” minimum expansion space at all vertical obstructions NOTE: Fasteners may be powder driven pins, pneumatic driven nails, hand nails, screws, deformed pins, or other fasteners suitable for concrete application. Check with fastener distributor for specification such as length, drill size, and/or shot load where applicable. VI. INSTALLATION NOTE: The styles and types of block and parquet flooring as well as the recom- mended procedures for application vary somewhat among the different manu- facturers. Detailed installation instructions are usually provided with the flooring or are available from the manufacturer or distributor. Test wood subflooring for moisture according to Moisture Testing Procedures in Section V, Appendix AB. Moisture content should be within 4% of average area environmental conditions. Section V, Appendix AD and AE. Test concrete for moisture according to Moisture Testing Procedures in Section V, Appendix AA. Moisture indicators should be within the adhesive and flooring manufacturers specifications. A minimum expansion space equal to the thickness of the installed product must be left around the perimeter and all vertical obstructions. Some 3/4” slat parquet can be nailed down, as long as the pattern continues to have an exposed side tongue in which to nail Lay both blocks and the individual pieces of parquet in adhesive. Use the wood manufacturer’s approved adhesive. Follow the spread rate,trowel size and installation procedure as recommended by the adhesive manufacturer. If recommended by manufacturer, roll floor with proper roller. The most common layout of parquet is with edges of parquet units and the lines they form square with the walls of the room. (see figure 1-1) 5 Revised June 2002

Chapter 3, Solid Parquet FLoor Start by snapping a chalk line through the center of the room (line Y (see figure 1-1). The next line (X)must be exactly 90 degrees to line Y to form a perfect square corner. To ensure this angle, do the following: 1. From the center point (A) of line Y, measure figure 1-1 4 feet along line Y and mark that point (B). 2. From the same center point, measure 3 feet in the general direction of where line X will be and scribe an arc. 3. Return to the original 4-foot mark on line Y and measure 5 feet, scribing an arc that crosses (point C) the 3-foot arc you made in the previous step. 4. Verify all measurements before proceed - ing. 5. If correct, snap a chalk line through the conjunction of the two arcs and the center point of line Y. This will be line X, at an exact 90-degree angle to line Y. An alternate layout is a diagonal pattern,with lines at a 45-degree angle to the walls. For diagonal layout you will start with a diagonal working line in the center of the room.(see fig - ure 1-2) To establish a 45-degree working line: 1. From the center point, measure 4 feet down in each direction on lines X and Y. figure 1-2 2. From each of these points, measure 4 feet and scribe an arc. The conjunction of these arcs creates points D and E. 3. Snap a chalk line between points D and E, and the center point. This line represents a 45-degree angle. Most special patterns can be laid out with the above two working lines. Herringbone will require two lines, one at 90 degrees and the other at a 45-degree angle. These lines must be adjusted to properly center the points of the pattern. Herringbone direction should be installed in accordance with consumer preference. If the pattern is to be installed in the direction of the length of the room, the herringbone working line should be laid out parallel to line Y. (see figure 1-3 and figure 1-4). Line B in this instance must run parallel to line Y and represent the center of he herringbone material. To determine the center of the herringbone material and establish line B: Revised June 2002 6

Chapter 3, Solid Parquet FLoor X axis LINE A Y axis LINE C LINE C LINE B figure 1-3 figure 1-4 1. Begin by laying out a few alternating slats. (see figure 1-4) 2. Snap line A and line B through the corners of the alternating slats. 3. Measure the distance from line A to line B. LINE B The working line should be one-half that dis - tance and run parallel to line Y. Herringbone installation: To begin installation on line B (see figure 1-5),cut a square piece of plywood the size of the herringbone pattern figure 1-5 you are installing. For example, if the herring - bone is 3 inches by 12 inches, cut a 12-by-12 inch piece of plywood. Nail this piece of plywood at your starting point on line B, with one corner of the square pointing in the direction of your layout. VI. EXISTING FLOORING GUIDELINES NOTE: Always follow the manufacturers recommendations for installation over existing flooring. Glue down parquet applications that require the use of PVA adhesives is not rec- ommend over existing sheet vinyl or vinyl and cork tile flooring unless an under- layment is put down first. Underlayment should be in accordance with preced- ing NWFA guidelines. Other types of adhesives may require the use of a primer or vinyl blocker when installing over sheet vinyl or vinyl and cork tile flooring. 7 Revised June 2002

Chapter 3, Solid Parquet FLoor Nail down applications may be successful over existing sheet vinyl or vinyl tile if fastener penetration is not significantly diminished and the subfloor meets mini- mum requirements. NOTE: Particleboard is not generally an acceptable underlayment. Some man- ufacturers approve particleboard as an acceptable underlayment. In such cases follow manufacturers recommendation. Sand off old finish and high spots on existing wood floor and prep to clean, dry, sound, flat subfloor. Repair, re-nail or replace loose flooring products. Wood Flooring can be installed over existing ceramic tile, terrazzo, or marble with prop- er underlayment or adhesives only on manufacturers recommendation. Revised June 2002 8

54 The Historical Threat of Pandemic Influenza understanding by two outstanding authors and their painstakingly re- searched books. These books are The Great Influenza: The Story of the Deadliest Pandemic in History, by John M. Barry published in 2004, and America’s Forgotten Pandemic: The Influenza of 1918, by Alfred W. Crosby, Second Edition, published in 2003. These writings greatly helped us to understand the severity of the events a century ago and we have heavily referenced these works in the next few chapters to help the reader understand how important it is for the United States to have an effective pandemic influenza plan. Every major human crisis has some type of a preliminary starting point and the one involving America’s disaster with Influenza began on June 30, 1918 when a British cargo ship named the “City of Exeter” docked in Philadelphia. Upon retrospective examination, although the first wave of the 1918 pandemic seemed to have ended several weeks earlier, an unusual out- break of Influenza had broken out among this ship’s crew during their transatlantic voyage from England. This outbreak was marked both by the severity of its onset and the catastrophic pneumonia that it caused. There were other strange signs and symptoms in the infected crew members as well. This included epistaxis (bleeding from the nose). While nosebleeds are a rather common occurrence, when they are se- vere and when they occur in patients suffering from an infectious dis- ease, it can be a very serious sign. There were also some central nervous system signs. Again, very worrying because of the possibility of menin- gitis. This is a very serious, potentially lethal infection of the mem- branes around the brain. While in transit, the City of Exeter had radioed its developing med- ical problem back to England and when the ship docked in Philadel- phia, the British Consulate had arranged for a special U.S. quarantine team to meet it. The dock had been cleared and the entire crew were

THREE SECONDS UNTIL MIDNIGHT 55 taken off and placed in a special isolation ward in a hospital. There, more crewmembers died.1,2 This should have prompted the U.S. health authorities to rapidly spin up into overdrive to initiate strict quarantine inspections as well as other arrangements for future incidents of this type. In addition, the conditions at the ship’s point of departure should have been immedi- ately investigated with possibly blocking future departures from this British port. None of this was apparently done. In 1918, Dr. Rupert Blue was the 4th Surgeon General and as such, he was the head of the U.S. Public Health Service. He had extensive experience in epidemic control and had been involved in containing an outbreak of Bubonic Plague in San Francisco during 1900-1904. He was also a skilled diplomat and that may have been the problem.1,2 Most likely pressured by President Wilson, he issued no instructions with respect to ordering ships with suspected Influenza cases to be quaran- tined. The Surgeon General would continue to demonstrate an almost complete lack of leadership throughout the events that would soon transpire. He would step down from his post in 1920. The doctors at the quarantine hospital attending the ill sailors sus- pected that something unusual was occurring and their suspicions would soon prove to be correct. Through trial and error, the Influenza virus had finally found its way out of the confining genetic bottleneck that developed after its first lethal outbreak months earlier in Haskell County, Kansas. The predominant quasi-species of the virus that was now circulating had become fully human-adapted. Precisely how this process occurred and whether it was due to mutations in the viral RNA Replicase enzyme or to a new plasticity in the Influenza hemagglutinin protein, would be a question that scientists would still be trying to an- swer a 100-years later.3 Across the Atlantic, fatal cases of Influenza were now appearing in London. Many of these cases were typified by the victims dying from an unusually rapid disease course that ended in massive respiratory fail- ure.2 Over the next few days, an additional 120 victims died in the

56 The Historical Threat of Pandemic Influenza important English industrial center of Birmingham.1,2 The autopsies performed on these cases revealed a severe type of lung damage never before seen with Influenza. Clinical records showed that before dying, the patients had turned blue from a buildup of carbon dioxide in their blood. This condition is called cyanosis and it was caused by the victim’s lungs losing their ability to perform a normal gas exchange with the air.1,2 On July 8, England reported the severe nature of the Birmingham outbreak to the U.S. Public Health Service. In response, the U.S. Sur- geon General issued an urgent national warning to all State Public Health departments. However, he did little else and his alert would have no impact on the biological carnage that was soon to come.1 Already a focal point for the previous milder Influenza outbreak dur- ing the first part of April, by late July the French seaport of Brest was infected with this new modified strain of the Influenza virus. By mid- August, its large port naval hospital was overwhelmed with cases. In- credibly, there were few measures put in place for infection control and the disease quickly spread to the entire civilian region around the port. At the same time, thousands of American soldiers continued to flow into Brest before being quickly shipped off to the front lines, predicta- bly transporting this new lethal Influenza strain with them.4 During the end of August, an ever-increasing number of troop transport and cargo ships suffered lethal Influenza outbreaks during their Atlantic transit. The virus spread through the British Common- wealth to countries as far away as South Africa and New Zealand. In late August, an infected troop transport docked for coal at Freetown in Sierra Leone. A few weeks later some 3-6% of the African population in the area were dead from Influenza.5 With America’s direct involvement in the fighting of the First World War, a single mindedness had taken over President Woodrow Wilson. Following his own divine inspiration, he determined that the fighting in Europe would take place over everything else. He ignored the American Bill of Rights, ruthlessly controlled the press, and he di- rected an extensive national propaganda campaign. An ineffective

THREE SECONDS UNTIL MIDNIGHT 57 Congress let this happen. Wilson’s Justice Department established the Enemy Alien Bureau, which was authorized to arrest and jail allegedly disloyal foreigners without trial. The first job of the controversial J. Ed- gar Hoover after his completion of law school was to head this effort.2,6 Hoover would later to go on to be the first and only life-time Director of the new Federal Bureau of Investigation (FBI). Based on his abuses of power, FBI directors are now limited to one 10–year term, subject to extension by the United States Senate. Even this has been shown to be problematic in recent times. Throughout 1918, thousands of American soldiers continued to cross the Atlantic and disembark into the middle of this new lethal In- fluenza outbreak in Europe. The new seed had now found its ideal soil. With the high density of humans around it, the new Influenza strain was free to reproduce as fast as possible without any worry over killing its host before it could spread further. Wilson’s fixation would result in more deaths of American soldiers due to Influenza than would be killed by enemy weapons. Long-distance passenger air travel across the United States or to Europe was unknown in 1918 (Charles Lindbergh would not make his historic solo flight across the Atlantic until 9-years later). Therefore, long-distance continental travel was mainly by lengthy railroad jour- neys. This factor had helped to minimize the earlier spread of the more moderate Influenza pandemic that had swept the world earlier in April through July. Outside of the Influenza cases in the military cantonment camps and their surrounding urban areas, the civilian population of the United States had been largely spared. However, at the end of August, America’s luck finally ran out. As discussed previously, on Tuesday, August 27, 1918, a transport ship ferrying U.S. soldiers back from Europe docked in Boston Harbor. There the soldiers were transferred over to the Receiving Ship at the Commonwealth Pier building. The Receiving Ship was in fact, the dockside barracks that served as a central point for both freight and pas- senger traffic, with nearby transportation by rail, truck, and bus. Here,

58 The Historical Threat of Pandemic Influenza these soldiers were given temporary overcrowded accommodations while they awaited their transfer to other destinations all over the United States. Over the next two days, 58 cases of the new Influenza developed among the arriving soldiers and they were transferred to the nearby Chelsea Naval Hospital.7 Within 48-hours, the three medical officers who had seen these patients also fell ill. Influenza had arrived back in the United States in a new, mutated, and much more deadly form. Although the infected men were immediately isolated at the Naval Hospital, it was already too late. On the 3rd of September, a civilian was admitted to the Boston City Hospital suffering from severe Influ- enza. The next day, military students attending a specialized Naval Ra- dio School also began falling ill.8 This was the start of a severe Influenza epidemic in Boston that would expand for another six-weeks, generat- ing a horrific final death toll in the city. Schools and draft boards were closed, and stores reduced their business hours. The congested subways and above-ground rail transportation system helped spread the airborne Influenza virus among Boston’s civilian population. On September 7, as the Boston epidemic continued to increase, some 300 sailors at the Commonwealth Pier were transported from Boston to the Philadelphia Navy Yard. The new Influenza strain would accompany them on this journey. Unlike its narrow escape at the end of June, the City of Philadelphia would soon feel the full wrath of this new Influenza, more so than any other major metropolitan area in the United States. As the epidemic began to rage in Boston and transfer to Philadel- phia, a large 5,000-acre military cantonment area lay just thirty-five miles north of the city. Formally named Camp Devens, it was named after the Civil War General Charles Devens. Initially constructed to hold 36,000 soldiers, the Camp was severely overcrowded with over 45,000 men.9 On September 8, the new Influenza struck with a vengeance. Over the next 10-days it infected almost 20% of the soldiers in the Camp. Some 75% of these cases were serious enough to be hospitalized. This was clearly not a normal Influenza outbreak. In one single day, some 1500

THREE SECONDS UNTIL MIDNIGHT 59 soldiers were admitted to the Camp’s large and efficient hospital.10 Several hundred Army doctors, nurses and support staff were quickly brought in by train to assist with the developing crisis, and they worked until they themselves became ill with some dying from Influenza. Over- whelmed by the developing civilian outbreak in Boston, the Red Cross could only send 12 nurses to Camp Devens to assist. Within a few days, eight of these nurses were severely ill with Influenza, and two quickly died.1 A few days later, a small but expert Army medical/scientific team was sent to Camp Devens to investigate the situation. Leading this team was Dr. William Welch, one of the most distinguished pathologists of the early 20th century. Welsh had been on the Board of the pioneering Rockefeller Institute. Highly patriotic, he had left this position to join the staff of the Army Surgeon General where he had been given the rank of Colonel.1 Figure 7. Boston Red Cross volunteers assemble gauze influenza masks for use at Camp Devens. Eight of these Nurses would soon become infected and two would die from Influenza. 1918 Historical Image Gallery | Pandemic Influenza (Flu) | CDC. Sixty-three soldiers died the day Colonel Welsh and his team ar- rived at Camp Devens and what they found was horrendous.

60 The Historical Threat of Pandemic Influenza The camp was falling apart, and the large military hospital designed to hold 1200 patients was overflowing with over 6000 cases of Influ- enza.1,2 All hospital beds were filled. Hundreds of sick and dying sol- diers were lying on cots in the hospital’s hallways and porches. Out of the 200 nurses in the Camp, 70 of them were severely ill and medical care for any of the patients was almost nonexistent.1 The grounds of Camp Devens had become a biological battlefield with an enemy that was invisible to the microscopes of the time. Inside the hospital, the scene was reminiscent of the “Vestibule of Hell” in Dante’s Inferno. Lying in dirty bedding and bloodied clothing, many of the patients were crying out in delirium. Previously fit, active, healthy young men just a few days before were now bleeding from their noses, coughing blood, and turning blue from cyanosis. Corpses could be found in every hallway and dead bodies were stacked on top of each other outside of the overflowing hospital morgue. Amid the increasing chaos around them, the investigative team poured over the records of the first victims, made when record keeping was still possible. They visited the hospital laboratory and ignoring the danger, they went to the wards to interview and examine patients.2 Desperate to understand what was happening, Colonel Welsh and his team began to conduct autopsies in their frantic search for clues. As highly trained doctors and scientists, what they found inside the dead far surpassed the horrors they had witnessed on the wards. Blood- tinged fluid poured from the body openings of the cadavers and upon cutting open the chest cavity, it was the shocking appearance of the lungs that attracted the team’s first attention. Normal lung tissue is light in weight, spongy, and a relaxing pale pink in color. In the patients that had died quickly from the disease, the scientists found evidence of rampant tissue destruction. The normal pink color of the lungs was replaced by multiple large, angry, dark red and purple hemorrhagic areas of destroyed tissue. A foamy tan-colored froth exuded from the lung tissue when it was cut open with a knife. Inside, the air passages had been stripped of their normal lining of epithelial cells.

THREE SECONDS UNTIL MIDNIGHT 61 The entire pulmonary system appeared to have been damaged by an acute inflammatory process generated by the body’s own defenses. The lungs were heavy and filled with fluid, blood, and damaged tissue debris that blocked the normal exchange of oxygen with carbon dioxide. To- day, this condition would be called ARDS, or the Acute/ Adult Res- piratory Distress Syndrome. Even with modern intensive care, ARDS can lead to death in 40-60% of cases. There were other unusual signs as well in the victims. The heart muscle in some of the cases appeared to have been severely damaged and the tough pale-grey membranous sack that enclosed the heart (called the pericardium), was red and inflamed. In every case, there was damage to the kidneys. Highly unusual for a respiratory disease. The small adrenal glands located above each kidney also showed areas of destruction with tiny hemorrhages. The liver in some patients was damaged and, in some cases, the brain as well. Whatever was causing this disease was affecting the major organs throughout the body.11 Shaking their heads in wonder, the team struggled to put together what is now called a Case Definition. This included the symptoms and timelines of the disease combined with what they had learned from the autopsies. They found that the victims of the new disease had a variety of different symptoms. Some developed excruciating pain in their joints along with fever, chills, and intense headaches. Some 41% of cases had a severe infection of the middle ear, and 5-15% of cases developed se- vere nosebleeds while the victims were still alive. Some patients had signs of brain damage with paralyzed eye movements or partial body paralysis in the final stages of their disease. Bleeding from the mucous membranes was common and intestinal bleeding with bloody diarrhea could also be a part of the death process. One shocking thing was soon apparent……the disease appeared to affect the younger adults the worse. Men in their late teens and early 20’s were the cases struck the most violently by the infection. These were the ones that died within 48-hours of their first cough.12 What the team was seeing was a complete reversal of everything that

62 The Historical Threat of Pandemic Influenza was known about Influenza at that time. Even today, Influenza nor- mally causes only a mild to moderate illness in adults in the 19 to 35- year old age group. Somehow the biological agent causing the 1918 outbreak had become adapted to the specific age group of the popula- tion that was facilitating its spread. The investigative team were in total agreement on one thing. If this was Influenza, it was a type that had never been seen before. That evening, the team consolidated their findings and Colonel Welsh contacted the Office of the Army Surgeon General to outline their data. He recommended that Camp Devens be quarantined and he gave his team’s recommendations for other immediate actions that needed to be taken. In response, Welsh learned that it was already too late. Similar large Influenza outbreaks in other military cantonment camps had already begun. The spillover of infection into the major met- ropolitan areas of the United States was now inevitable. Promoted by war and facilitated by the global movement of humans in the form of transcontinental trains and international ocean transport, this new lethal Influenza strain would now sweep around the world in a matter of weeks. Without a vaccine or treatment, the death toll would be unremitting. In South Africa, some 4% of the city of Cape Town’s population were dead within 30-days. Entire villages were annihilated in West Africa with the bodies left unburied. In Germany, Influenza would demonstrate a shocking fatality rate of 27% in some cities. In Paris, 10% of all who contracted the infection died. Areas of Mexico would lose 10% of their total population within days. In South America, 50% the population in the capital of Argentina contracted the new disease.1 The new Influenza also struck China and while there are no precise known statistics, it is estimated that half the population in the city of Chungking contracted the infection. However, the infection seemed to have had a much lower mortality in China. One explanation is that Influenza had struck the nation hard during the first milder pandemic wave that occurred weeks before and this had provided the population some degree of immunity. This makes sense, especially because

THREE SECONDS UNTIL MIDNIGHT 63 scientists now know that China is a site of constant new Influenza virus generation because of its agricultural practices. Therefore, the popula- tion of China may have had some cross-immunity to the new, lethal, 1918 Influenza strain.13 Elsewhere, even the isolated Pacific islands were not safe. In Fiji, 14% of the population died within 14-days and it became impossible to bury the dead. In contrast, the American Territory of Eastern Samoa initiated immediate total quarantine measures and suffered no cases for weeks. At the same time, Western Samoa lost 22% of its total population.1,2 Although Influenza reached most American communities by late September of 1918, the disease did not hit Alaska until late in the fall. This was due to the foresight of the territorial governor, Thomas Riggs Jr., who imposed a strict maritime quarantine. He stationed US Mar- shals at all ports to ensure the disease did not reach the territory’s widely dispersed towns and settlements. However, it would only take one mis- take to cause a catastrophe. That mistake occurred on October 20, when a small ship arrived in Nome. The doctor on duty placed the pas- sengers and its crew under a quarantine in the local hospital as per the new regulation. However, after five days, only one person had fallen ill. After an examination, the doctor dismissed this case as nothing more than a case of tonsillitis and he lifted the quarantine. Four days later, one of the hospital workers came down with a lethal case of the new Influenza. The virus was now loose in Nome.14 At the same time, a ship named the SS Victoria arrived and docked at the port so that its crew could unload bundles of mail. Although the bundles had been fumigated, some of the crew may have come into direct contact with the local mail carriers as they packed their dogsleds. These mail carriers may have picked up the viral infection at that time. Alternatively, the method used to decontaminate the mail before it was un- loaded has been lost to time and it is possible that live virus still contami- nated the letters in the bundles. Most viruses exhibit a prolonged sur- vival time outside the body if very cold, dehumidified air is present. What- ever the exact mechanism, as these carriers rode out of Nome on their

64 The Historical Threat of Pandemic Influenza dog sleds that day, they unwittingly delivered both the mail and the new deadly new strain of Influenza to the villages across western Alaska.14 Two-days later, the city of Nome was under quarantine and its in- habitants were ordered not to leave the city limits. It made no differ- ence. A major Influenza outbreak was already well underway in the nearby Eskimo village. Over the next few weeks, half of Nome’s white population fell ill. The nearby Eskimos suffered tremendously with ten to twenty of their number dying each day until more than half the pop- ulation of the village expired.14 In a desperate response to the pandemic, local leaders and doctors across Alaska now ordered the closure of churches, schools, and thea- tres. Traveling was prohibited between villages. Traditional Native as- semblies were banned. Armed guards took up positions outside some communities to establish a reverse quarantine. It made no difference. Within days, all contact with the villages across the Seward Peninsula was lost. Back in Nome, the local government now asked miners to take their dog sleds out to inspect the backcountry. As these teams traveled up the coast, they found that the Influenza epidemic had struck the villages at roughly the same time as it broke out in Nome.14 In the little settlement of Brevig Mission, the virus had struck quickly and brutally, killing 90 percent of the town’s population in five days, leaving scores of corpses frozen and unburied. These dead bodies would provide important clues to scientists 80-years later. The situation was even worse in a tiny town called Wales.2 Rescuers from Nome reached this settlement three weeks after the flu had struck the village. They found orphaned babies trying to suckle their dead mothers and a shivering girl keeping tins of milk warm against her body to feed her siblings. The rest of the survivors were sheltering in the local school- house, living on reindeer broth.14 In some cases, upon entering a Native igloo, children were found huddling together for warmth and living be- tween their dead parents. Because subsistence living was common throughout the area, influ- enza killed the native Alaskans both directly and indirectly. When a

THREE SECONDS UNTIL MIDNIGHT 65 family became ill with the virus, no one was left to tend the fires and many simply froze to death in their homes or found themselves unable to hunt large game or set and harvest their traps. They died of exposure from the lack of calories.14 Yet none of this compared to the truly apocalyptic effect that the new Influenza virus created on the other side of the world. Figure 8. Chart showing the Weekly Death Rate in Bombay, Madras, and Calcutta, 1918.15 On the Indian subcontinent the mortality of the 1918 influenza ep- idemic was higher than anywhere else on the planet and the descrip- tions that survive of this event are almost inconceivable today. Follow- ing the rail lines, the new Influenza virus swept across India in roughly three months. In the poor, high-density, low resource communities in Bombay, the Central Provinces and Berar, its impact was horrendous. There, the death demographics was the same as in Europe with the 20 to 29-year old age group affected the worst. The total number of fatal- ities in the Central and Berar regions reached 17.9% of the population within days. One estimate has suggested that India suffered some 18.5 to 22.5 million deaths.16,17 Other estimates have placed the total death rate at a lower 17.4 to 18.5 million, but even this number dead in a single country, is overwhelming.18 Whatever the precise figure, death was everywhere in India. Trains would arrive at their destination with passengers having died on board during their trip.1,2 In the Punjab, the hospitals were so overwhelmed that

66 The Historical Threat of Pandemic Influenza the dead could not be removed quick enough and both the streets and alleys became littered with corpses. Bodies were simply collected and placed into pits for large-scale cremation and the ashes put into the river. When the firewood ran out, the bodies themselves were dumped into the river.2 By 1918, medical science had recognized that Influenza was a specific infectious disease, but most scientists were of the conviction that it was caused by a still unknown type of bacteria. Yet scientists could not consist- ently isolate bacteria from the lungs in many of the cases. As the 1918 pandemic began its exponential rise to its full lethality, the Medical Research Council (MRC) in England felt that some attention should be turned to the possible role of a ‘filterable agent’ causing the disease. At the time, small teams of physicians and pathologists did most of the wartime medical research in England. Consequently, in November of 1918, two teams of MRC scientists were sent to France. Both teams discovered that a ‘filterable agent’ did indeed seem to be present in sol- diers suffering from the classical signs and symptoms of Influenza.19 Using filters to remove the bacteria from the bronchial secretions of an influenza patient, they injected this cleared filtrate into the eyes and noses of experimental animals that in turn, developed a fever. This same filtrate was later administered to a brave volunteer by subcutaneous in- jection who went on to developed some of the signs of Influenza.20 However, the team’s findings remained controversial. The so-called ‘filterable agent’ could not be seen with the microscopes of the time, and it could not be cultured, so its presence was inferred. In addition, with the First World War still raging, medical science was already over- stressed by the treatment challenges posed by thousands of poison gas injuries, traumatic brain injuries (“shell shock”), trench foot, facial re- construction surgery, epidemic typhus in the trenches, and overwhelm- ingly staggering numbers of infected wounds and gangrene. The 1918 Influenza outbreak simply joined the long list of the suffering and

THREE SECONDS UNTIL MIDNIGHT 67 horrors inherent in the First World War. Perhaps a more important factor was that scientists had already be- come fixated on the false clues that were attributing bacteria to be the cause of Influenza. The scientists involved had failed to keep an open inquiring mind. Work towards developing a specific vaccine as had been done previously for other ‘filterable agents’ never occurred. In- deed, it took until 1933 for scientists to conclusively prove the existence of the human Influenza virus by using ferrets as an animal model of the disease. The actual direct visual observation of the Influenza virus did not occur until years later, and this had to wait until several diverse technologies had matured and combined. The first breakthrough in visualizing the virus came in 1931, when scientists managed to grow influenza and several other viruses inside fertilized chickens’ eggs. This allowed the first pure cultures of the filter- able “Influenza agent” to be made. By 1939, these pure cultures could be analyzed by ultracentrifugation using special centrifuges with high- speed steel rotors capable of concentrating the virus by spinning at 65,000 rpm. This made it possible to study the invisible “filterable agent” in solu- tion and it gave scientists a rough estimate for the general size of a virus. All during this time, the electron microscope was being developed into a practical instrument for research. Invented in 1931, this type of microscope used a beam of accelerated electrons for illumination in- stead of visible light. In 1937, the physicist Ernst Ruska built one that exceeded the res- olution of the normal optical (light) microscope and in 1939, a ‘filtera- ble agent’ called the Tobacco Mosaic Virus was first imaged. By 1943, these three technologies came together, allowing scientists for the first time to make a visual observation of the Influenza virus.21 More recently, the actual genetic blueprints for the deadly 1918 strain of Influenza have been recovered from preserved tissue sections archived from soldiers that had died from Influenza during World War I. In con- junction with other frozen tissue samples taken from Eskimo bodies buried in the Arctic permafrost at the time, the complete instructions

68 The Historical Threat of Pandemic Influenza for making the 1918 pandemic virus was determined (Figure 9). Consequently in 2005, an influenza virus bearing all 8 gene seg- ments of the pandemic virus was artificially constructed in the labora- tory using reverse genetics. The first studies on this recreated 1918 In- fluenza virus showed that it was an H1N1 strain and that it retained the “blueprints” of Influenza viruses that are primarily found in birds. Figure 9. This negative-stained transmission electron micrograph shows the recreated 1918 Influenza virus replicating in infected Madin-Darby Canine Kidney (MDCK) cells cultured for 18-hours after infection. In contrast to the human influenza H1N1 viruses found today, the 1918 strain has the ability to cause death in mice and it shows an ex- tremely high replication rate when cultured in the type of cells that line the human airways. Alarmingly, further research suggests that it may take fewer genetic adaptations than it was once thought for a bird Influenza virus to jump into man and efficiently spread from person to person. This has serious and ominous implications for the future.

THREE SECONDS UNTIL MIDNIGHT 69 NOTES FOR CHAPTER 4 1 The Great Influenza: The Story of the Deadliest Pandemic in History, John M. Barry Paperback, Revised Edition, 560 pages. Published October 4th, 2005 by Penguin Books (first published 2004) ISBN 0143036491 (ISBN13: 9780143036494). 2 America’s Forgotten Pandemic: The Influenza of 1918, Alfred W. Crosby Paperback, Second Edition, 2003 by Cambridge University Press. (ISBN0-521-54175-1). 3 Gerard Kian-Meng Goh, Vladimir N. Uversky et.al. Protein intrinsic disorder and influenza virulence: the 1918 H1N1 and H5N1 viruses. Virology Journal 2009 6:69 DOI: 10.1186/1743-422X-6-69. 4 Vaughan, Victor C., Influenza and pneumonia in Brest, France. Journal of Laboratory and Clinical Medicine, vol. 4, (Jan 1919, p223). 5 Dudley, Sheldon F., The biology of epidemic Influenza, illustrated by Naval experience, Proc. Royal Soc of Medicine, vol14, War Section (9 May1921) pp.44-45 6 Weiner, Tim (2012). “Anarchy”. Enemies a history of the FBI (1 ed.). New York: Random House. ISBN 978-0-679-64389-0 7 Department of the Navy (US) Annual Report, 1919. Washington: U.S. Government Printing Office; 1920 (p. 2473–4) 8 Monthly Bulletin of the Health Department of the City of Boston, Vol. 7 (September 1918) 42 9 The epidemic of Influenza at Camp Devens, Massachusetts, Journal of Laboratory and Clinical Medicine vol.4 March 1919; Wooley PC. Box 84, Entry 31, RG 112. College Park, MD: National Archives and Records Administration; 1918. Sep 16, to Surgeon General. 10 War Department (US) Office of the Surgeon General, Medical Department of the United States Army in the World War, vol. 4, activities concerning mobilization camps and ports of embarkation. Washington: U.S. Government Printing Office; 1926. pp. 49–50. 11 Wolbach, S., Comments on the Pathology and Bacteriology of Fatal Influenza Cases, as observed at Comp Devens Massachusetts Johns Hopkins Bulletin, vol. 30 (April 1919) 12 Symmers, Douglas, Pathological Similarities Between Pneumonia of Bubonic Plague and of Pandemic Influenza, Journal of the American Medical Association, Vol. 71 (2 November 1918 13 K.F. Cheng, P.C. Leung, What Happened to China During the 1918 Pandemic? International Journal of Infectious Diseases (2007) 11, 360-364. doi: 10.1016/j.ijid.2006.07.009

70 The Historical Threat of Pandemic Influenza 14 Alaska and the 1918 “Spanish Flu”, Colleen Pustola, http://alaskaweb.org (with permission). 15 Siddharth Chandra and Eva Kassens-Noor; The evolution of pandemic influenza: evidence from India, 1918–19 BMC Infectious Diseases: 510, 19 September 2014. https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-510 16 Phipson, E. S., The Pandemic of Influenza in India in the Year 1918 (With Special Reference to the City of Bombay). Indian Medical Gazette 1923 Vol.58 No.11 pp.509-524 ref.13 17 Davis K., The Population of India and Pakistan. 1951, Princeton: Princeton University Press. 18 Mills, I. D., Influenza in India during 1918-19. Chapter 8 in T. Dyson (ed.) India’s Historical Demography: Studies in Famine, Disease and Society. 1989, London: Curzon Press. 19 Nicolle and Le Bailly, BMJ, 11/2/1918. 20 JAMA. 1918; 71(26):2154-2155. doi:10.1001/jama.1918.02600520040012 21 A. R. Taylor, D. G. Sharp, Dorothy Beard, J. W. Beard, John H. Dingle and A. E. Feller Isolation and Characterization of Influenza A Virus (PR8 Strain) J. Immunol. September 1, 1943, 47 (3) 261-282.

5 THE CITY OF PHILADELPHIA ALL COMMUNITIES WILL EXPERIENCE a global Influenza pandemic as their own individual local epidemic. If they can successfully manage the medical effects of the outbreak in their area, then the community is free to work on the other problems that may be associated with the event. These could involve the loss of family incomes, a reduced food supply to the locality, the loss of mass transit services, maintaining the community’s electricity and water supply, its garbage collection ser- vices, and helping families already dealing with non-epidemic related medical issues. An important factor that must always be considered, is the dignified disposal of the dead. This requires knowledgeable and intelligent community leaders along with some degree of pre-planning and preparation. Such planning does not require a great expense, but it does require time and careful

72 The Historical Threat of Pandemic Influenza thought. It also requires an application of the science of Public Health. Public Health refers to the practice of medicine on an entire popu- lation rather on just individuals. It is one of the major factors that allow millions of people to continue to safely live and work under our modern unnaturally high population densities. When examining the possible effects that a 1918-type event might exert today in the United States, it is useful to examine what a worst-case sce- nario looked like in the past. In this respect it is recognized that in 1918, the city of Philadelphia, Pennsylvania, was the most seriously affected major urban center in the United States. It is therefore reasonable to exam- ine if there were any factors that made this city different from the other U.S. cities affected by Influenza at the time, and to look at how Philadel- phia managed its event. There are important lessons to be learned for today. One factor that immediately stands out was Philadelphia’s rapid and uncontrolled increase in its population. Federal estimates in 1918 give the official civilian population of Philadelphia as 1,700,000. However, as the U.S. prepared for the First World War, the city experienced an unprecedented surge in population as new transient workers (many poor immigrants) flocked to the rapidly expanding war-time industries of steel production, shipbuilding, and munitions manufacturing). In 1918, the Philadelphia Department of Public Health and Charities had estimated that these transient workers and their families added an ad- ditional 300,000 people to the official city population.1,2 Consequently, most homes in the non-affluent areas had lodgers and the rapid influx of workers and families created its own public health crisis. This was in the form of inadequate, unsanitary, and over- crowded urban housing areas. Multiple large high-density immigrant slums and tenement districts quickly developed. Many had public out- houses that served dozens of families and multiple families crowded into small two-room or three-room apartments. “Rooming Houses” of- ten shared beds among different single men sleeping in shifts.1,2 The most difficult conditions were found in South Philadelphia in the southern part of the Seventh Ward running along Lombard and South

THREE SECONDS UNTIL MIDNIGHT 73 Streets, together with the whole Thirtieth Ward. This was Philadel- phia’s first slum and it was one of the largest in the northern U.S.3 These slum and tenement areas provided an ideal setting for the spread of any infectious disease and it would be these communities that would soon suf- fer the worst.4 We will discuss this Public Health aspect further on in this book when we look at the problem of the high-density economically- disadvantaged urban areas of the 120 largest cities in the United States. Compounding the problems created by these 1918 high-density population areas, was a chronic shortage of health care workers. During the previous 12-months, over 26% of Philadelphia’s doctors and even more nurses, had left to become part of the war effort. The Pennsylva- nia General Hospital in Philadelphia itself had three-quarters of its staff called overseas to France.2,5 While these are all major factors, the biggest reason for the soon-to- occur catastrophe lay in the utter lack of leadership provided by a corrupt Philadelphia city government and its combination with an incompetent City Public Health Department. As we have noted previously, human be- havior plays a major role in every epidemic and in the case of Philadel- phia this was in the form of the original Sins of “Greed and Power.” In 1918, the City government was run by the dominating and cor- rupt Senator Edwin Vare who had amassed a huge wealth, apparently generated by contractor kickbacks. The Mayor of Philadelphia acted as Vare’s deputy and the Mayor himself would be eventually indicted for conspiracy to murder but was never charged.1,2 The Director of Public Health and Charities at the time was a phy- sician and while basically a good man, he had little understanding of Public Health and he was serving under the Mayor’s discretion. This, plus the rest of the list of hack political appointees to the city govern- ment, assured that Philadelphia would be incapable of responding to any serious large public health emergency. The city had dodged its first bullet back on June 30, 1918, when the Influenza riddled British cargo ship the “City of Exeter” had arrived at the Philadelphia docks with its dying sailors onboard. However,

74 The Historical Threat of Pandemic Influenza Philadelphia’s luck only lasted for another month. As previously de- scribed, in August 27, 1918, a new lethal mutated Influenza virus arrived in the United States when a group of American soldiers returned to Boston Harbor. In mid-September with the Boston epidemic already underway, some 300 Navy personnel were transported out of the city and shipped by train to the Navy Yard in Philadelphia.1,2 This quickly led to an out- break of the new Influenza strain in the Philadelphia Navy Yard, and within a few days, the first civilian infections in Philadelphia itself were underway. The public health authorities had missed their chance and they com- pounded this by issuing only a pathetically weak public warning and health campaign that advised against coughing, spitting, and sneezing in public. It made no serious public health preparations and it was only at the end of September when Philadelphia decided to make Influenza a notifiable disease in the city.6 The Director of Public Health stated there was little chance of the Influenza outbreak spreading.1 Just as to- day, the National Press demonstrated their usual ignorance of medical matters. Philadelphia’s major newspapers falsely reported that the cause of Influenza was a recently discovered bacterium (Hemophilus influen- zae) and that doctors now had a causative organism on which to base their campaign against the disease.2 Incredibly, on September 28th, the Philadelphia city government allowed a massive Liberty Loan Drive to take place in the downtown area. Some 200,000 residents crowded the city streets to watch the marchers and listen to the bands on parade (Figure 10).1,2 At the same time, primitive military biplanes flew overhead. When the parade halted, people would gather close together to hear patriotic speeches. In another part of town, a large audience packed into the Willow Grove Park to hear the martial music performed by John Philip Sousa and his Naval Reserve Band. Within three-days of this event, the appearance of 635 new civilian cases of serious Influenza signaled the beginning of a catastrophic explosion of the Influenza epidemic in the city. It first became noticeable in the Hog Island Shipyard in Philadel- phia. This was the largest shipyard in the world with some 35,000

THREE SECONDS UNTIL MIDNIGHT 75 workers. Three days after the Liberty Drive, some 2800 workers at the Yard came down with Influenza.2 By October 3, the outbreak was out of control. Doctors in the city became so overworked with patients that the mandatory case reporting was not done. At the same time, Influ- enza was spreading through the other cities of the state. Figure 10. Rally down Broad Street on Sept. 28, 1918 helped spread Influenza among the general population of Philadelphia. On October 3, the Acting State Commissioner of Health issued an emergency order for all bars and places of ‘public amusement’ through- out the state be closed.1,2,7 The next day, Philadelphia closed all bars, schools, theaters, churches, and other public mixing places. At the same time the ineffective Surgeon General of the United States, sent out tel- egrams to all the states recommending the same actions. However, the narrow window had already closed for any mandated social distancing measures to have any effect in Philadelphia. This win- dow for Non-Pharmaceutical Interventions to be effective was missed in other large U.S. cities as well.

76 The Historical Threat of Pandemic Influenza INFRASTRUCTURE DISRUPTION IN THE CITY By the end of the first week of October, the Philadelphia General Hos- pital was at its full capacity of 2,000 patients and it struggled to find room for 1,400 more seriously ill cases. By the end of the following week, 52 of the hospital’s nurses had contracted Influenza and an ad- ditional 2,600 deaths had been registered in the city. At the same time, doctors were falling ill and some were dying. Over the following week, an additional 4,500 people deaths from Influenza were recorded. The epidemic by now become a plague and it was impossible to manage this number of dead. At the same time, the number of people with incapac- itating Influenza infections began to rise into the hundreds of thou- sands. These cases continued to overflow the area hospitals filling the empty beds left by the dead. At the small Lebanon Hospital, there would soon be only 3 nurses to care for 125 seriously ill patients.8 At the same time, doctors were falling ill and some were dying. Over the following week, an additional 4,500 people deaths from Influenza were recorded. The epidemic by now become a true plague and it was impossible to manage this number of dead. At the same time, the num- ber of people with incapacitating Influenza infections began to rise into the hundreds of thousands. These cases continued to flood the area hospitals filling the empty beds left by the dead. The infrastructure of the city began to falter when some 850 em- ployees of the city telephone company failed to report for work and the telephones had to be restricted to essential calls only.9 Over the next two weeks, thousands more city workers fell ill, with some dying. Rec- ords show that 487 police officers became too ill to work. Although not clearly documented in the records of the time, the absentee rate for other essential city personnel such as firefighters, clerks, transport driv- ers, bank staff, grocery store workers, and garbage collectors, must have been equally as high.2 The organization that today would be known as Child Services, quickly became overloaded with hundreds of children whose parents were ei- ther too ill to care for them or had tragically died. This is a factor that

THREE SECONDS UNTIL MIDNIGHT 77 must be remembered when creating future local authority and state pandemic plans. Yet, there is another even more critical factor that must be pre-planned for when considering a future 1918-type pandemic. Before the Philadelphia outbreak, only a handful of doctors, nurses, and social workers had a responsibility to work in the slum areas of the city. It would be there, like in all the other cities of the world, that the highest infection and death rates from Influenza would occur. For Phil- adelphia, the statistics would show that its poor communities suffered some 1,500 more total deaths than any other area of the city. Nurses entering the slum areas witnessed almost the same scenes as described 500-years earlier during the outbreak of the “Black Death” in the Eu- rope.1,2 Throughout the slums and tenements, dead bodies began to putrefy in the streets or in the cramped housing areas still occupied by living family members too ill and weak to do anything about the situa- tion.1,2 Un-embalmed bodies piled up outside Philadelphia’s only morgue at Thirteenth and Wood Streets.2,10 With the hospitals inundated, the corrupt city government turned to the local Public Health Boards to set up soup kitchens and turn churches, schools, and armories into makeshift emergency care facili- ties. However, most of these Health Boards were understaffed with poor leadership and little coordination. In addition, there was still a severe shortage of health care workers. The lack of effective city leadership was evident as the bodies con- tinued to pile up and more essential services began to break down. While some extremely courageous volunteers could still be found in the religious and civic associations, most of the public were afraid of con- tracting the disease and bringing it home to their families. The popu- lation became demoralized and afraid. Neighbors refused to help or even talk to each other for fear of infection. As witnessed during the previous historical times of plague, the native- born residents of the city quickly turned their blame towards the immigrant sector of the population. Looking for a scapegoat, Public Health officials blamed the hygiene habits of the immigrants as the cause of the outbreak.

78 The Historical Threat of Pandemic Influenza During the European Bubonic Plague pandemic some 500-years earlier, the immigrant population of Paris had been accused of poison- ing the city and they were dragged into the streets and burnt alive. In 1918, the overall social behavior was milder and in Philadelphia, the authorities only issued city fines for spitting on the sidewalks which added to the corrupt city coffers.2 The city government did little else to provide effective leadership against the expanding epidemic. Never at any time did any branch of the Federal government, make an attempt to help Philadelphia. The one exception was when the U.S. military sent 10 Army morticians to the city to assist with the dead.2 The death toll from Influenza now continued to mount as Philadel- phia moved closer to a complete infrastructure collapse. Only one thing saved the city, and this was the result of an unintended consequence of the war. This needs to be described because there are lessons to be learned here that are applicable for metropolitan pandemic management today. In 1916, anticipating the eventual involvement of the United States in World War One, President Wilson’s representatives met with the most prominent leaders in labor and industry throughout the United States. The purpose was to form a Council for National Defense to pre- pare the U.S. economy for war should it be necessary. At the time, the US Government could not simply print more money when it needed it, so the money for any war had to be raised from its citizens. As part of this national plan, smaller versions of the Council were set up as committees in America’s largest cities. These daughter organizations were composed of the most prominent, edu- cated, leading citizens of each city and their job was to politicize the population and lead Liberty Loan Drives to raise money for the war effort. These Liberty Loan Drives not only raised money, but they helped to create a feeling of national unity among the donors who felt that they were now part of the war effort as well. Fortunately, the local chapter in Philadelphia was composed of some very strong personalities, some of them women which was highly unu- sual for the time. Dissatisfied with the pandemic response by