Cette étude a pour objectif d’évaluer la stratégie d’utilisation de critères de base, d’un point de vue éthique, dans l’allocation d’une quantité limitée d’antiviraux pour une utilisation préventive, lors d’une pandémie. Il est entendu qu’une réserve publique pour la prévention n’est pas présentement en vue. Ainsi un des objectifs de cette recherche est de servir de guide aux personnes ressources en positions décisionnelles, à savoir si l’acquisition d’une telle réserve est justifiée, et dans l’affirmatif, à qui elle serait destinée. La perspective spécifique de deux groupes de professionnels de la santé œuvrant en première ligne est considérée. Le premier groupe est constitué de professionnels provenant des hôpitaux de la région de Toronto qui ont vécu l’expérience du SRAS en 2003. Le second groupe est composé de travailleurs en santé de la région de Montréal qui n’auront pas vécu cette crise sanitaire. Les deux groupes sont analysés ensemble sur leur discours verbal et sur leurs réponses à un questionnaire bâti afin d’évaluer quel poids les participants donnent aux critères proposés. / The goal of this study is to assess the use of criteria as a means of deciding who might be priority recipients of an antiviral stockpile, aimed specifically at prevention, during an influenza pandemic. It is understood that a public antiviral stockpile for prevention is not available at this time. Thus one of the objectives of this research is to provide guidance to decision-makers in terms of feedback from healthcare workers on the issue of whether it is necessary to acquire such a stockpile and, if so, for whom. The specific perspectives of two groups of front-line healthcare workers are considered. One group consists of healthcare workers from Toronto hospitals who have experienced the 2003 SARS outbreak. The other group consists of healthcare workers from hospitals in Montreal who did not experience the SARS outbreak. The two groups analyses are based on verbal comments and their responses to a questionnaire designed to evaluate how participants with different background experiences will view and rank the proposed criteria.

Delivering health care services in an efficient and effective way has become a great challenge for many countries due to the aging population worldwide, rising health expenses, and increasingly complex healthcare delivery systems. It is widely recognized that models and analytical tools can aid decision-making at various levels of the healthcare delivery process, especially when decisions have to be made under uncertainty. This thesis employs stochastic models to improve decision-making under uncertainty in two specific healthcare settings: inpatient flow management and infectious disease modeling. In Part I of this thesis, we study patient flow from the emergency department (ED) to hospital inpatient wards. This line of research aims to develop insights into effective inpatient flow management to reduce the waiting time for admission to inpatient wards from the ED. Delayed admission to inpatient wards, also known as ED boarding, has been identified as a key contributor to ED overcrowding and is a big challenge for many hospitals. Part I consists of three main chapters. In Chapter 2 we present an extensive empirical study of the inpatient department at our collaborating hospital. Motivated by this empirical study, in Chapter 3 we develop a high fidelity stochastic processing network model to capture inpatient flow with a focus on the transfer process from the ED to the wards. In Chapter 4 we devise a new analytical framework, two-time-scale analysis, to predict time-dependent performance measures for some simplified versions of our proposed model. We explore both exact Markov chain analysis and diffusion approximations. Part I of the thesis makes contributions in three dimensions. First, we identify several novel features that need to be built into our proposed stochastic network model. With these features, our model is able to capture inpatient flow dynamics at hourly resolution and reproduce the empirical time-dependent performance measures, whereas traditional time-varying queueing models fail to do so. These features include unconventional non-i.i.d. (independently and identically distributed) service times, an overflow mechanism, and allocation delays. Second, our two-time-scale framework overcomes a number of challenges faced by existing analytical methods in analyzing models with these novel features. These challenges include time-varying arrivals and extremely long service times. Third, analyzing the developed stochastic network model generates a set of useful managerial insights, which allow hospital managers to (i) identify strategies to reduce the waiting time and (ii) evaluate the trade-off between the benefit of reducing ED congestion and the cost from implementing certain policies. In particular, we identify early discharge policies that can eliminate the excessively long waiting times for patients requesting beds in the morning. In Part II of the thesis, we model the spread of influenza pandemics with a focus on identifying factors that may lead to multiple waves of outbreak. This line of research aims to provide insights and guidelines to public health officials in pandemic preparedness and response. In Chapter 6 we evaluate the impact of seasonality and viral mutation on the course of an influenza pandemic. In Chapter 7 we evaluate the impact of changes in social mixing patterns, particularly mass gatherings and holiday traveling, on the disease spread. In Chapters 6 and 7 we develop agent-based simulation models to capture disease spread across both time and space, where each agent represents an individual with certain socio-demographic characteristics and mixing patterns. The important contribution of our models is that the viral transmission characteristics and social contact patterns, which determine the scale and velocity of the disease spread, are no longer static. Simulating the developed models, we study the effect of the starting season of a pandemic, timing and degree of viral mutation, and duration and scale of mass gatherings and holiday traveling on the disease spread. We identify possible scenarios under which multiple outbreaks can occur during an influenza pandemic. Our study can help public health officials and other decision-makers predict the entire course of an influenza pandemic based on emerging viral characteristics at the initial stage, determine what data to collect, foresee potential multiple waves of attack, and better prepare response plans and intervention strategies, such as postponing or cancelling public gathering events.

A presente pesquisa investiga as epidemias de febre amarela - em 1897 e 1900 - e de gripe espanhola - em 1918 - ocorridas em Sorocaba e a atuação do médico Álvaro César da Cunha Soares no seu combate, a fim de revelar as condições sanitárias de uma cidade que passava por grandes transformações, como o crescimento urbano e a industrialização, em um contexto de consolidação da medicina oficial e de acirrados debates em torno das questões relacionadas à saúde pública. Para tanto, traça-se um panorama das condições sanitárias e de saúde pública de Sorocaba entre o final do século XIX e o início do século XX, apontando o agravamento dos problemas sociais e o aumento do número de casos de determinadas enfermidades. Desse modo, pretende-se demonstrar como a condição de vida da população pobre sorocabana foi se deteriorando cada vez mais enquanto a cidade apresentava um relativo crescimento urbano e industrial. As epidemias de febre amarela são reconstituídas, abordando-se questões políticas, sociais e científicas que se desenrolaram no decorrer dos surtos epidêmicos, em um contexto de disputa entre o poder estadual, representado pelo Serviço Sanitário do Estado de São Paulo, e os poderes locais, representados por médicos e autoridades públicas municipais, na condução das medidas de combate às epidemias. A epidemia de gripe espanhola na cidade representou um desafio às autoridades públicas locais e uma ameaça à estabilidade econômica local - em um momento em que o crescimento industrial da cidade era colocado em evidência. Desse modo, estudando as epidemias que assolaram Sorocaba na virada do século XIX para o XX e acompanhando a atuação de Álvaro Soares nesse contexto, pretende-se compreender melhor a relação entre a consolidação da medicina oficial no Estado de São Paulo e suas implicações nas práticas em saúde pública / This research investigates epidemics of yellow fever - in 1897 and 1900 - and the Spanish flu - in 1918 - occurred in Sorocaba and the performance of the medical Álvaro César Soares da Cunha in combating them, in order to reveal the sanitary conditions of a city passing through major transformations, such as urban growth and industrialization, in a context of consolidation of official medicine and heated debates on issues related to public health. To this end, draws up an overview of public health and sanitary conditions of Sorocaba in the late nineteenth and the early twentieth century, pointing to the worsening of social problems and the increasing number of cases of certain diseases. Thus, it is intended to demonstrate how the living conditions of the poor in Sorocaba was deteriorating more and more as the city had a relative urban and industrial growth. The yellow fever epidemics are reconstituted, addressing political, social and scientific issues that unfolded over the outbreaks, in a dispute context between state power, represented by the State Sanitation Service of São Paulo, and local authorities, represented by physicians and municipal authorities, in the conduct of measures to combat epidemics. The Spanish flu epidemic in the city was a challenge to local public authorities and a threat to local economic stability - at a time when the industrial growth of the city was placed in evidence. Thus, studying the epidemics that ravaged Sorocaba in the late nineteenth century to the twentieth and monitoring the performance of Alvaro Soares in this context, it is intended to better understand the relationship between the consolidation of official medicine in the State of São Paulo and its implications for practice in public health

About 3850 men of the First Australian Imperial Force were captured on the Western Front in France and Belgium between April 1916 and November 1918. They were mentioned only briefly in the volumes of the Official Histories, and have been overlooked in many subsequent works on Australia and the First World War. Material in the Australian War Memorial has been used to address aspects of the experiences of these neglected men, in particular the Statements that some of them completed after their release This thesis will investigate how their experiences ran counter to the narratives of CEW Bean and others, and seeks to give them their place in Australia???s Twentieth Century experience of war.

About 3850 men of the First Australian Imperial Force were captured on the Western Front in France and Belgium between April 1916 and November 1918. They were mentioned only briefly in the volumes of the Official Histories, and have been overlooked in many subsequent works on Australia and the First World War. Material in the Australian War Memorial has been used to address aspects of the experiences of these neglected men, in particular the Statements that some of them completed after their release This thesis will investigate how their experiences ran counter to the narratives of CEW Bean and others, and seeks to give them their place in Australia???s Twentieth Century experience of war.

The purpose of this thesis is to find out how a hundred and its public healthcare system managed the 1918 flu pandemic, with Näs hundred as a case study. Relevant information is found using archived copies of the provincial physician's sent letters, editions of the local newspaper, and death-and-funeral books. Such information includes mortality statistics, which measures were taken, which role the private sector had, and if there was any change within the public healthcare system. The study finds that the Spanish flu stood out from other illnesses and the general state of health. At its culmination in October, hundreds were sick and private workplaces were short of staff. The mortality rate seems to have been around 0.49% of the population, which is a reasonable rate in comparison to other case studies. When the epidemic was at its height, the authorities closed schools and prohibited events that attracted larger masses of people. This was announced through the local newspaper, alongside urges for the people to avoid crowding. Within the public healthcare system, there were no extensive changes, except an increase in workdays, a higher salary and a decrease in the number of nurses. There was a discussion on who should be allowed to be cared for in the epidemic hospital, as this hospital, according to routine, did not care for people with influenza or people from outside the central locality. There is no evidence on how this turned out, but some information seems to suggest that the hospital, or at least the epidemic nurse, did get to care for people with influenza. Nonetheless, it is clear that the public healthcare system could not manage the epidemic, and that the majority of people had to be treated in their homes by a relative or an ambulating nurse. When it comes to actions taken by the private sector, charity funding for the victims is the sole provable action. In contrast to other case studies, there is no evidence of private healthcare or charity organizations that would have cooperated with the public healthcare system. This charity, as well as those measures taken by the authorities, can be seen as consequences of a so-called institutional weakening, which itself would be a consequence of the epidemic outbreak. The outbreak showed that the public healthcare system could not handle an epidemic of this size, which in turn made established routines obsolete, showed that there were holes in the system and legitimized interventions made by the authorities. As a consequence, the aforementioned measures were taken to inhibit the spread of the epidemic and to care for the sick. / Syftet med denna uppsats är att undersöka hur ett härad och dess sjukvårdsorganisation klarade av 1918 års influensapandemi, med Näs härad som fallstudie. Relevant information hittades genom att granska provinsialläkarens konceptböcker, nummer av Säffle-Tidningen och död- och begravningsböcker från tiden. Sådan information inkluderar hur sjukan utmärkte sig som bidragande faktor till det allmänna hälsoläget, vilka åtgärder som vidtogs som reaktion av epidemin och ifall någon förändring i sjukvårdens organisation skedde till följd av spanska sjukan. Uppsatsen kommer fram till att spanska sjukan stod ut från övriga sjukdomar och det allmänna hälsoläget. Vid kulmen i oktober var hundratals insjuknade och arbetsplatser hade brist på personal. Dödstalet låg på runt 0,49% av befolkningen, vilket är ett rimligt tal i jämförelse med tidigare forskning. När epidemin var som mest utbredd stängde myndigheterna skolor, biografer och liknande tillställningar som drog till sig större folkmassor. Detta utannonserades i Säffle-Tidningen, samtidigt som de uppmanade folk att hålla distans till sjuka och undvika trängsel. Inom sjukvården kom inga större förändringar, utan främst utökade arbetstider, höjd lön och en minskning i antal sköterskor. En diskussion fanns dock kring vilka som skulle få vårdas i epidemisjukhuset, som enligt rutin inte tog emot folk sjuka av influensa eller folk utanför den centrala köpingen. Det går inte att belägga hur detta kom att se ut, men en del tyder på att epidemisjukhuset, eller åtminstone epidemisjuksköterskan, trotts allt kom att vårda folk sjuka i influensa. Oavsett är det klart att sjukvården inte hade beredskap nog att hantera sjukan, och att majoriteten av de sjuka fick vårdas i hemmet av anhörig eller kringvandrande sjuksköterska. Av vad man kan belägga med det givna källmaterialet är en välgörenhetsfond åt de utsatta det närmsta man kommer vad gäller reaktioner från privat sektor. Till skillnad från fallstudier i tidigare forskning finns inget bevis på att privat vård eller välgörenhetsorganisationer kom att samarbeta med sjukvården. Oavsett kan detta, samt de åtgärder och förändringar som vidtogs av myndigheterna, ses som ha kommit till följd av en institutionell försvagning, som i sig var en följd av det epidemiska utbrottet. Epidemin påvisade nämligen att sjukvården och samhället inte kunde hantera en så stor mängd sjuka, vilket gjorde att rutiner blev obsoleta, att hål i systemet uppenbarades, och interventioner kunde legitimeras av myndigheterna. Som följd vidtogs ovannämnda åtgärder för att försöka hämma epidemins spridning och vårda de sjuka.