Pandemics. A Challenge for Corporate Risk Management?

Table of contents

List of figures

1. Introduction

2. Pandemics
2.1 Definition of the term "pandemic"
2.2 Emergence of pandemics
2.3 Impact of previous pandemic cases Spanish influenza Asian flu and Hong Kong flu SARS
2.4 Scenarios of a future pandemic
2.5 Assessment of the current danger situation
2.6 Summary pandemicn

3. Economic effects of a pandemic
3.1 Impact of a pandemic on the economy
3.2 Economic sectors particularly affected by a pandemic
3.3 Summary: Economic impact of a pandemic

4. Impact of a pandemic on the individual company
4.1 Effects due to the illness of employees and their family members
4.2 Effects due to disruptions in the supply system
4.3 Effects due to the change in the economic environment
4.4 Summary of the impact of a pandemic on individual companies

5. Pandemic - a challenge for risk management?
5.1 Definition of “risk”
5.2 Definition of “risk management"
5.3 Risk management objectives
5.4 Costs and benefits of operational preparation for the pandemic
5.5 Implementation of pandemic planning as part of the Risk management in the company
5.6 Summary Risk management against the backdrop of a pandemic

6. Pandemic planning as part of risk management
6.1 Operational pandemic planning in the context of risk management
6.2 Approaches to the implementation of operational pandemic planning
6.2.1 Task of operational pandemic planning
6.2.2 Pandemic planning
6.3 Neuraminidase inhibitors as part of pandemic planning
6.4 Summary: Pandemic planning as part of risk managements

7. Conclusion

List of references

List of figures

Figure 1: Exchange of flu viruses

Figure 2: Possible effects of a flu pandemic in Germany

Figure 3: Impact of a pandemic on public life

Figure 4: WHO phase classification of an influenza pandemic

Figure 5: H5N1 cases in humans

Figure 6: Pandemic scenarios: Demand shortfall

Figure 7: Impact of the pandemic on industrial sectors in the Worst-case scenario

Figure 8: Estimation of the economic damage of a pandemic for one's own company

Figure 9: Pandemic consequences in one's own company (% of respondents)

Figure 10: Schematic course of a pandemic wave with effects on staff shortages

Figure 11: Systematics of the concept of risk

Figure 12: Risk analysis

Figure 13: Purpose of pandemic planning

1. Introduction

Entrepreneurial action means taking risks in order to take advantage of opportunities. Risks must not endanger the achievement of corporate goals. For this reason, successful corporate management also includes the recognition and analysis of risks as well as the achievement of an optimal opportunity-risk profile for the company. The focus of the risk assessment is on risks arising from an insufficient orientation of the company towards the business environment (strategic risks). Furthermore, risks are observed that can be the result of a negative development of the market and thus mean uncertainty of the future sales development (market risks). Risks affecting the financial stability and liquidity of a company (financial risks), risks arising from social or political changes and risks associated with the internal organisation and management are also taken into account in the management of a company.¹ In recent years, terrorist attacks, such as the attack on the World Trade Center or natural disasters, such as the floods on the Elbe in 2002, have shown that companies are not only exposed to risks that arise solely from their economic activities. On the one hand, such events are so drastic for the companies concerned that the entire business operation and thus the existence of the company is threatened by them. On the other hand, the occurrence of such an event is considered by most companies to be so unlikely that risk preparation does not seem necessary. For the examples of a terrorist attack or a natural disaster mentioned, this assessment may also be correct. However, with the outbreak of avian influenza in South-East Asia and the effects of the lung disease SARS in 2003, another threat came to the public's attention - the threat of a global infectious disease, a pandemic. The risk of a pandemic was commented on by the President of the Robert Koch Institute, Reinhard Kurth, as follows: "The question is not whether a pandemic is coming, but when it is coming."² The effects of a pandemic would not only be limited to a burden on health care, but economies would also be directly affected by the effects. This also raises the question for companies of how far-reaching the risk of a pandemic must be addressed in the context of risk management.

The aim of this work is to provide answers to the most important questions relating to the risks of a pandemic for companies. Furthermore, the aspects of the need for risk prevention against the dangers of a pandemic will be examined. In this way, it is intended to help companies rise to the challenge of proper pandemic planning.

In order to achieve this goal, the second chapter deals with the emergence of pandemics and their effects. On the basis of the experience gained with pandemic cases in the past, a risk assessment for the future is to be given. At the end of the chapter is an assessment of the current danger situation.

The third chapter elaborates on the economic impact of a pandemic. The consequences on the demand side as well as on the supply side are examined. The short-, medium- and long-term effects of a pandemic on the economy are another focus of this chapter. Since each industry will be affected differently by the outbreak of a pandemic, the effect of a pandemic on the different industries will be explained at the end of the section.

A pandemic will hit companies especially through the loss of employees. Furthermore, disruptions in the supply system and changes in the economic environment are to be expected, which will have an impact on the individual company. These effects will be examined in the fourth chapter.

The effects on the company described above can be addressed in the context of risk management. The fifth chapter will therefore discuss what is meant by the terms risk and risk management. The objectives and benefits of risk management should also be defined. At the end, the question is addressed as to why special planning is necessary for the risk of a pandemic.

The sixth chapter provides information on pandemic planning as part of risk management. The tasks and approaches for implementing pandemic planning will be examined. Since the use of drugs, such as "Tamiflu", to prevent the consequences of a worldwide infectious disease is currently being discussed in the public, this chapter will also address the use of neuraminidase inhibitors as part of risk management.

In addition to a summary of the contents of this work, a conclusion is to be drawn that illustrates to others the importance of a pandemic for the risk management of a company. It will also be necessary to answer the question of whether risk management, in addition to the necessary requirements, also represents an opportunity for the company.

2. Pandemics

Der schwarze Tod (Hermann von Lingg) Erzittre Welt, ich bin die Pest, ich komm' in alle Lande und richte mir ein großes Fest, mein Blick ist Fieber, feuerfest und schwarz ist mein Gewande.

Ich bin der große Völkertod, ich bin das große Sterben, Es geht vor mir die Wassernot, ich bringe mit das teure Brot, den Krieg tu' ich beerben.

Byzanz war eine schöne Stadt, und blühend lag Venedig; nun liegt das Volk wie welkes Blatt, und wer das Laub zu sammeln hat, wird auch der Mühe ledig.³

The poem by Hermann von Lingg, quoted here in excerpts, illustrates the devastating consequences of a pandemic on humanity using the example of the plague. It also illustrates the horror that the plague has left in humans. But recent events also show how great the fear of a worldwide infectious disease is. Thus, in 2006, the increasing number of birds infected with influenza terrified the public and brought the threat of a global pandemic into the public eye.⁴

2.1 Definition of the term "pandemic"

The term pandemic is derived from the Greek pan (= everything) and demos (= people). A pandemic is spoken of when a disease crosses national borders and spreads worldwide.⁵ The cause is a novel virus, which is highly contagious and therefore quickly spreads in the population. Due to the novelty of the virus, there is low immunity in the population.⁶ A recent example of a pandemic is the spread of HIV, which is the cause of AIDS. In 1982, the first cases of HIV infection were registered in the United States. In the aftermath, people all over the world became infected. However, since transmission cannot take place through the day-to-day treatment of infected people, this virus spreads relatively slowly.⁷ Despite everything, since the beginning of the eighties, more than 60 million people worldwide have been infected with hiv.⁸ A virus with a higher infection rate could have an even more devastating effect. At the moment, warnings are being given, in particular, about the outbreak of a flu pandemic. David Nabarro, the UN coordinator for bird flu, fears that the outbreak of a flu pandemic with several million deaths could occur at any time.⁹

2.2 Emergence of pandemics

The WHO currently estimates that the risk of a pandemic due to influenza viruses is the most likely.¹⁰ For this reason, the emergence of a pandemic will be explained here using the example of an infection with a flu virus. In order to understand how a flu virus can lead to a high number of patients and a high mortality rate worldwide, an overview of the medical mechanisms that can lead to a pandemic will be given below.

Flu viruses are divided into three groups, which are called type A, B and C. The type B virus can only reproduce in humans, type C in humans and pigs, and the type A influenza virus can multiply not only in humans and pigs, but also in horses, birds and other animals living in the water.¹¹ Influenza viruses of type A are the origin of pandemics due to this property and their ability to form ever new variants. How a pandemic virus can form is shown by the following scenario: Should a person become infected with an avian influenza virus and a human flu virus at the same time, there is a possibility of a new virus strain developing. This virus strain takes over gene components from both virus types. The resulting virus can have a high risk potential for humans due to the proportion of bird flu and at the same time be highly contagious due to the gene content of the human virus. The formation of new virus strains by mixing gene components can take place especially by pigs, because pigs can be carriers of both human and bird viruses.¹²

Figure 1: Exchange of flu viruses

Abbildung in dieser Leseprobe nicht enthalten

Roche Deutschland, Grenzach-Wyhlen¹³

The pathogen resulting from the gene exchange of avian influenza and a human influenza virus currently poses the greatest risk of being the possible starting point for a pandemic. Now that this virus has acquired the ability to transmit from person to person, the disease is expected to spread worldwide.¹⁴ Also, the following three reasons contribute to the spread of the flu disease:

1. Between infection with the virus and the onset of the disease, up to four days pass in the case of influenza. During this time, infection is already possible without the carrier of the disease itself knowing that it is already a virus carrier.
2. Influenza viruses spread through the so-called "droplet infection". For example, they are transmitted from a short distance when speaking, but especially by sneezing, to the mucous membranes of other people.¹⁵
3. The high mobility of people enables a rapid worldwide spread of infectious diseases.¹⁶

Due to the novelty of the virus, the human immune system has not yet been confronted with this pathogen, so that no defense mechanisms could be developed and a high disease rate can be expected. For this reason, it is also to be feared that the course of the disease will be severe and a high mortality rate is to be expected.¹⁷ It will not be possible to protect it by vaccination in the foreseeable future, because the development of a flu vaccine can only take place once the new influenza virus has been identified. It should be noted that from the decoding of the virus to the approval of a vaccine, a period of up to eight months can pass. In this respect, it must be assumed that in the first year after the outbreak of a flu pandemic, a very limited quota of vaccination doses is available.¹⁸ Due to the lack of vaccination protection in the population, the possibilities of preventing the spread of the virus are severely limited.

2.3 Impact of previous pandemic cases

While pandemics are a rare occurrence, they have occurred time and again in history. In order to be able to estimate the impact of a future pandemic, it is worth taking a closer look at the course and impact of past pandemic cases. The comparison of previous pandemics provides an opportunity to derive common factors that allow a better assessment of the consequences of a future pandemic.

Since 1700, up to 13 flu pandemics have been counted worldwide. The last three occurred in the past 20th century: in 1917/1918 the "Spanish flu", in 1957 the "Asian flu" and in 1968 the "Hong Kong flu".¹⁹ The "Spanish flu" is with forty to fifty million deaths²⁰ an example of a worldwide infectious disease with a severe course. In contrast, the "Asian flu" with one million deaths worldwide and the "Hong Kong flu" with about 700,000 deaths²¹, for pandemics with a moderate course. The effects of aggressive infectious diseases in today's world can be demonstrated by the consequences of the lung disease SARS. In 2003, more than 3,000 people worldwide contracted SARS. Of these, more than 1,000 people died.²² Although SARS did not reach the status of a pandemic, the consequences of this disease were felt worldwide and thus allow conclusions to be drawn about the effects of a wave of diseases in today's world.

Spanish influenza

The "Spanish flu" began in the spring of 1918 as a flu wave in Europe and Asia. Since the flu first appeared in San Sebastián, a Spanish holiday village, it was given the name "Spanish flu".²³ The trigger for this flu pandemic was an avian flu virus, which jumped directly into humans.²⁴ Through pure mutation of the bird flu virus, this pathogen acquired the ability to infect humans. Since this novel virus lacked gene segments of a human virus, it was completely unknown in terms of human infection and thus acquired the ability to induce a high rate of victim.²⁵ By the summer of 1918, the first flu wave had subsided again. This first wave of the disease was mainly characterized by a high rate of disease, but the mortality rate was relatively low.²⁶ At the end of August 1918, however, the Spanish flu virus caused a second wave of illness. The symptoms were initially similar to those of a grippal infection. However, after a few days, the disease turned into severe pneumonia. This is how a military doctor described the "Spanish flu" by saying: "The sick spat blood and often died a cruel death by suffocation."²⁷ In total, up to fifty percent of the world's population at that time was infected with the virus.²⁸ For the population, the excessive demands on the health system were particularly threatening. In Nuremberg alone, for example, more than 3,000 people fell ill with the "Spanish flu" in the period from 12 to 18 October. With the result of overcrowded hospitals, the standstill of public life and widespread anxiety among the population.²⁹

The special feature of this disease was the 25 times higher mortality rate compared to an ordinary flu.³⁰ Also striking was the distribution of flu victims within the population. Normally, it is mainly children and the elderly who die. The mortality rate in an ordinary flu can thus be mapped U-shaped. In the case of the "Spanish flu", however, the mortality curve reflects a W, because there was also a peak in young adults.³¹ With the third wave, the symptoms of which were much weaker, this pandemic ended in 1920.³²

In summary, the following findings can be derived from the flu pandemic of 1918/1920. The "Spanish flu" was triggered by a virus that passed directly from birds to humans. This virus did not need the intermediate step over another host, e.g. the route of infection via pigs in order to infect humans. The "Spanish flu" also occurred in several waves, which meant that the world was confronted with the disease in several spurts. Each of these relapses had different effects. With the consequences of this pandemic, the health care system was correspondingly overwhelmed. The helplessness of the health system led to panic-like reactions in the population. The high morbidity and mortality rate of the "Spanish flu" also demonstrates how significant a pandemic can be in its effects. Equally unusual is mortality among young adults, which shows that a pandemic can also be rampant outside the usual risk groups, such as children and the elderly.

Asian flu and Hong Kong flu

The "Asian flu" that broke out in 1957 originated in China. Refugees brought the virus to Hong Kong, from where travelers also made it to the American continent and Europe. In 1968, the "Hong Kong flu" followed as the cause of which a mutation of the pathogen of the "Asian flu" was identified.³³ As with the "Spanish flu," the "Asian" and "Hong Kong flu" were in waves, with the second wave having the more disastrous effects in these cases of pandemics.³⁴ About one million people died of the "Asian flu" worldwide, 30,000 of them in the Federal Republic of Germany. Worldwide, 700,000 people succumbed to the "Hong Kong flu". Here, too, the Federal Republic recorded about 30,000 deaths.³⁵

The "Asian" as well as the "Hong Kong flu" make it clear that a pandemic does not always have to be as disastrous as the "Spanish flu". Here, too, it is shown that pandemics occur in several waves and the disease can spread all over the world. It was also noted that global transmission has been particularly encouraged by human mobility.

SARS

In 2003, the spread of the SARS virus showed that there is still a risk of a global disease.³⁶ Looking at the consequences of SARS illustrates the consequences of a threatening infectious disease in today's world. Sars was first described in Hanoi in February 2003. SARS is caused by a subspecies of coronaviruses. Coronaviruses were previously known as carriers of harmless colds in medicine.³⁷ Symptoms of SARS are comparable to those of pneumonia and include fever, difficulty breathing, cough, sore throat, head and muscle pain, as well as nausea, vomiting and diarrhea. The time span between infection and the onset of the disease can vary from two to ten days. Sars, like flu viruses, is also transmitted by droplet infection.³⁸ The high death rate among SARS patients was threatening. Ten percent of all patients died and in the age group from the age of sixty, about fifty percent of the patients died as a result of SARS.³⁹

These facts prompted the WHO to declare a global alert on 12 March 2003. It recommended postponing non-urgent travel to areas affected by SARS.⁴⁰ Between November 2002 and July 2003, a total of around 8,000 people contracted SARS, of whom 774 people died. The disease affected around thirty countries on six continents.⁴¹ The spread of SARS has proven that, in a globalised world, the spread of a disease is possible in the shortest possible time. Computer models developed from the spread of SARS show that London, New York and Frankfurt airports are primarily responsible for the spread of an epidemic. The reason for this is the high global network of these airports.⁴² Furthermore, the following findings from the SARS epidemic could be gained. The close global economic relations have exacerbated the economic consequences of this crisis. Due to the influence of the media on the population, fears have been heightened to the stage of panic.⁴³ These effects should be given particular attention because there were no objective reasons for panic reactions. The economic consequences of the SARS crisis, which were medically within the framework of normal disease events, were enormous. For example, the economic damage in the Asian region amounted to about twenty billion US dollars⁴⁴ and around sixty billion US dollars worldwide.⁴⁵ But also positive aspects could be observed. Due to global cooperation, it was possible to establish an international network to research and combat the disease in a short time, which succeeded in successfully reducing the SARS virus in a short time.⁴⁶

2.4 Scenarios of a future pandemic

In order to be able to assess the consequences of a future pandemic, it makes sense to develop appropriate scenarios. It should be noted that important questions for predicting the hazard potential cannot be answered. It is not possible to make statements about the starting point of the pandemic, the speed of its spread and the danger of the virus.⁴⁷ Nevertheless, experience gained in the context of pandemic cases in the past can be the starting point for a forecast for the future.

In order to be able to estimate the effects of a pandemic, one should first consider the worst possible case (worst case) For this, the key data of the "Spanish flu" can be used as a basis. For the Federal Republic of Germany, this could mean that about 20 to 25 million people would fall ill with the flu. Of these, about 1.2 million people would suffer from pneumonia. As a result, approximately 200,000 additional hospital admissions are expected, which would lead to 1.6 million additional hospital days with an average length of stay of 8.2 days. The consequences of influenza would kill around 120,000 people in Germany alone. If one adds the fatalities associated with influenza, the number would rise to a foreseeable 175,000 people.⁴⁸

However, it should be noted that these figures are unlikely to give a realistic picture of the impact of a future pandemic. Compared to the situation of 1918, more drugs and a more efficient health system are available today.⁴⁹ For this reason, the National Pandemic Plan⁵⁰ based on more moderate figures. These plans assume a disease rate of 30 - 35 percent of the population. This would lead to about 12 million additional doctor visits and 360,000 additional hospital admissions in The Federal Republic. The consequences would foreseeably result in the death of 96,000 people. However, in order to be able to carry out realistic risk planning and to be able to check the effectiveness of intended measures, an all too moderate assessment of a future pandemic is not recommended. Therefore, a scenario with a disease rate of 15 percent or less is not helpful.⁵¹

Figure 2: Possible effects of a flu pandemic in Germany

Abbildung in dieser Leseprobe nicht enthalten

Robert Koch Institute⁵²

The economic impact of a global infectious disease was considered by the Lowy Institute in 2006. According to conservative estimates, a pandemic can be expected to cost a loss of 0.8 percent of gross domestic product worldwide. This corresponds to a loss of approximately 330 billion US dollars. Based on the worst-case scenario, the loss rises to 12.6 percent of gross domestic product, or $4.4 trillion.⁵³

Other effects of a pandemic would be panic reactions and public infrastructure failures. Depending on the rate of illness, medical care can be strained until it collapses. These consequences for public life can be summarized in the following presentation:

Figure 3: Impact of a pandemic on public life

Abbildung in dieser Leseprobe nicht enthalten

Institute for Biological Safety Research GmbH, Halle - all data and data⁵⁴

2.5 Assessment of the current danger situation

The current risk assessment for the outbreak of a pandemic plays a decisive role in the company's assessment of whether the risk of a pandemic should be addressed in the context of risk management.

The WHO divided a pandemic into three periods with six different phases. These describe the course of a pandemic from the first occurrence of a new influenza subtype in the animal kingdom to the worldwide spread of the disease in humans. If a new phase is reached, this will be announced by the WHO.

Figure 4: WHO phase classification of an influenza pandemic

Abbildung in dieser Leseprobe nicht enthalten

Credit reform Rating AG/CCS, Robert Koch Institute⁵⁵

According to the WHO, the most likely trigger for a pandemic at the moment is the bird flu virus H5N1.⁵⁶ The current situation is assigned by the WHO to phase 3.⁵⁷ In order to ultimately trigger a pandemic, the virus currently lacks the ability to spread from person to person. All persons who have been ill so far have had close contact with infected poultry. With each infection, however, the risk increases that a simultaneous infection of avian influenza viruses and human influenza viruses will lead to gene exchange between these two viruses. The newly formed pathogen may under certain circumstances have the ability to pass from person to person.⁵⁸ So far, the numbers of infected people are extremely low. Until 2006, cases of infected and deceased persons increased continuously. There was a slight decline in 2007.

Figure 5: H5N1 cases in humans

Abbildung in dieser Leseprobe nicht enthalten

World Health Organization (WHO)⁵⁹

If the bird flu virus succeeds in adapting to spread from person to person, a pathogen completely unknown to the human immune system can develop, which has a pandemic potential.⁶⁰ For these reasons, both the WHO and the Robert Koch Institute assume that the risk of a pandemic is currently greater than it has been for decades.⁶¹

2.6 Summary pandemicn

In the history of mankind, illnesses have repeatedly occurred that have crossed national borders and have affected large parts of the population. If a disease reaches the status of a worldwide spread, it is also called a pandemic. With regard to the consequences of pandemics in the past, it should be noted that pandemics are often associated with a high number of patients and have a high mortality rate. As a result, pandemics have an impact on public life and the global economy. At present, special warnings are being given about the dangers of a pandemic caused by influenza viruses. The cause could be the bird flu virus H5N1. So far, this virus has only been able to infect people who have had close contact with poultry. An effective transition of the virus from person to person has not yet occurred. If successful, H5N1 could be considered as a trigger for a pandemic. Due to the high mobility in our time, a virus would have the opportunity to spread worldwide in the shortest possible time. With an assumed disease rate of 30 percent in the population, society would face immense challenges in coping with the consequences and effects of such a global wave of diseases. However, the crucial question of when the next pandemic will break out must remain unanswered for the time being.

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¹ cf. Gleißner, Werner / Lienhard, Herbert / Stroeder, Dirk H. (2004), p. 39.

² Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 7.

³ Lingg, Hermann v. (1906).

⁴ cf. Muth, Clemens / Zweimüller, Manuela (2007), p. 6.

⁵ cf. Pickel, Michael (2005), p. 10.

⁶ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 10.

⁷ cf. Robert Koch Institute, Federal Statistical Office (ed.) (2006b), p. 10.

⁸ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 13.

⁹ cf. Hotz, Manuela / Müller-Gauss, Uwe (2006), p. 70.

¹⁰ cf. World Health Organization WHO (2005), p. 4.

¹¹ cf. Allwinn, Regina / Doerr, Hans Wilhelm (2005), p. 710.

¹² cf. Schmitt, Heinz.-J. (2005).

¹³ Roche Deutschland (2008).

¹⁴ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 17.

¹⁵ cf. Hotz, Manuela / Müller-Gauss, Uwe (2007a), p. 19.

¹⁶ cf. Schröder-Bäck, Peter / Sass, Hans-Martin / Brand, Helmut et al. (2008), p. 195.

¹⁷ cf. Bundesamt für Bevölkerungsschutz und Katastrophenhilfe, Regierungspräsidium Stuttgart, Landesgesundheitsamt (2007), Anhang 2 H1, p. 4.

¹⁸ cf. Fock, Rüdiger (2001), p. 972.

¹⁹ cf. IBM Global Tchnology Services (2006), p. 3.

²⁰ cf. Witte, Wilfried, (2006), p. 5.

²¹ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 12.

²² cf. Haas, Walter H. (2005), p. 1020.

²³ cf. Jütte, Robert (2006), p. A32.

²⁴ cf. Meyer, Rüdiger (2004), p. A609.

²⁵ cf. Paukstadt, Waltraud (2005), p. 5.

²⁶ cf. Witte, Wilfried (2006), p. 5.

²⁷ Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 12.

²⁸ cf. Hotz, Manuela / Müller-Gauss, Uwe (2006), p. 70.

²⁹ cf. Jütte, Robert (2006), p. A33.

³⁰ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 12.

³¹ cf. Stracke, Andrea / Heinen, Winfried (2006), p. 6.

³² cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 12.

³³ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 12.

³⁴ cf. Reiter, Sabine / Haas, Walter (2005), p. 36.

³⁵ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 12.

³⁶ SARS: severe acute respiratory syndrome (German translation)

³⁷ cf. Rossboth, Dieter / Kraus, Günther / Allerberger, Franz (2006), p. 92.

³⁸ cf. Gaber, Walter / Hofmann, Rainer (2003), p. 3.

³⁹ cf. Marschall, Manfred / Fleckenstein, Bernhard (2007), p. 8.

⁴⁰ cf. Glasmacher, Susanne / Kurth, Reinhard (2006), p. 12.

⁴¹ cf. Glasmacher, Susanne / Kurth, Reinhard (2006), p. 15.

⁴² cf. Geisel, Theo (2004), p. 3.

⁴³ cf. Bundesamt für Gesundheit, Abteilung Epidemiologie und Infektionskrankheiten (2003), p. 544.

⁴⁴ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 40.

⁴⁵ cf. Hewitt, Jonathan (2006), p. 14.

⁴⁶ cf. Bundesamt für Gesundheit (2003), p. 544.

⁴⁷ cf. Bundesamt f. Bevölkerungsschutz u. Katastrophenhilfe, Regierungspräsidium Stuttgart (2007), Anhang 2, H1, p. 1.

⁴⁸ cf. Fock, Rüdiger (2001), p. 971.

⁴⁹ cf. Allianz, Rheinisch-Westfälisches Institut f. Wirtschaftsforschung (2006), p. 18.

⁵⁰ National Pandemic Plan: On the recommendation of the WHO, the Robert Koch Institute developed an emergency plan in the event of a flu pandemic. This pandemic plan was published in the Bundesgesetzblatt and is part of the National Katastrophenvorsorgeplanung.

⁵¹ cf. Haas, Walter (2005), p. 1023.

⁵² Reiter, Sabine / Haas, Walter (2005), p. 35.

⁵³ cf. Hewitt, Jonathan (2006), p. 16.

⁵⁴ Kekulé, Alexander (2008), p. 18.

⁵⁵ Thiel, Dirk (2007), p. 6.

⁵⁶ cf. World Health Organization (2005), p. 5.

⁵⁷ cf. Bundesamt für Gesundheit (2005), p. 725.

⁵⁸ cf. Auswärtiges Amt, Gesundheitsdienst (ed.) (2005), p. 3.

⁵⁹ cf. WHO (2008).

⁶⁰ cf. Bundesärztekammer, Kassenärztliche Bundesvereinigung (2006), p. 17.

⁶¹ cf. Robert Koch Institute (2007).