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The 1918 flu pandemic (commonly referred to as the Spanish flu) was an influenza pandemic that was first found in the United States, appeared in Sierra Leone and France, and then spread to nearly every part of the world. It was caused by an unusually severe and deadly Influenza A virus strain of subtype H1N1. Many of its victims were healthy young adults, in contrast to most influenza outbreaks which predominantly affect juvenile, elderly, or otherwise weakened patients. The Spanish flu lasted from March 1918 to June 1920,[1] spreading even to the Arctic and remote Pacific islands. It is estimated that anywhere from 20 to 100 million people were killed worldwide, or the approximate equivalent of one third of the population of Europe,[2][3][4] more than double the number killed in World War I.[5] This extraordinary toll resulted from the extremely high illness rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms.

The disease was first observed at Fort Riley, Kansas, United States, on March 4, 1918,[6] and Queens, New York, on March 11, 1918. In August 1918, a more virulent strain appeared simultaneously in Brest, France, in Freetown, Sierra Leone, and in the U.S. at Boston, Massachusetts. The Allies of World War I came to call it the Spanish flu, primarily because the pandemic received greater press attention after it moved from France to Spain in November 1918. Spain was not involved in the war and had not imposed wartime censorship.[7]

Scientists have used tissue samples from frozen victims to reproduce the virus for study. Given the strain's extreme virulence there has been controversy regarding the wisdom of such research. Among the conclusions of this research is that the virus kills via a cytokine storm, which explains its unusually severe nature and the unusual age profile of its victims (the virus caused an overreaction of the body's immune system—the strong immune systems of young adults ravaged the body, while the weaker immune systems of children and middle-aged adults caused less morbidity and mortality). File:1918 Flu pandemic-en.svg

Mortality

The difference between the influenza mortality age-distributions of the 1918 epidemic and normal epidemics. Deaths per 100,000 persons in each age group, United States, for the interpandemic years 1911–1917 (dashed line) and the pandemic year 1918 (solid line).[8]
Chart of deaths in major cities

The global mortality rate from the 1918/1919 pandemic is not known, but is estimated at 2.5 to 5% of the human population, with 20% or more of the world population suffering from the disease to some extent. Influenza may have killed as many as 25 million in its first 25 weeks (in contrast, AIDS killed 25 million in its first 25 years). Older estimates say it killed 40–50 million people[9] while current estimates say 50 million to 100 million people worldwide were killed.[10] This pandemic has been described as "the greatest medical holocaust in history" and may have killed more people than the Black Death.[11]

An estimated 7 million died in India, about 2.78% of India's population at the time. In the Indian Army, almost 22% of troops who caught the disease died of it. In the U.S., about 28% of the population suffered, and 500,000 to 675,000 died. In Britain as many as 250,000 died; in France more than 400,000. In Canada approximately 50,000 died. Entire villages perished in Alaska and southern Africa. Ras Tafari (the future Haile Selassie) was one of the first Ethiopians who contracted influenza but survived,[12] although many of his subjects did not; estimates for the fatalities in the capital city, Addis Ababa, range from 5,000 to 10,000, with some experts opining that the number was even higher,[13] while in British Somaliland one official on the ground estimated that 7% of the native population died from influenza.[14] In Australia an estimated 12,000 people died and in the Fiji Islands, 14% of the population died during only two weeks, and in Western Samoa 22%.

This huge death toll was caused by an extremely high infection rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms.[9] Indeed, symptoms in 1918 were so unusual that initially influenza was misdiagnosed as dengue, cholera, or typhoid. One observer wrote, "One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred."[10] The majority of deaths were from bacterial pneumonia, a secondary infection caused by influenza, but the virus also killed people directly, causing massive hemorrhages and edema in the lung.[8]

The unusually severe disease killed between 2 and 20% of those infected, as opposed to the more usual flu epidemic mortality rate of 0.1%.[8][10] Another unusual feature of this pandemic was that it mostly killed young adults, with 99% of pandemic influenza deaths occurring in people under 65, and more than half in young adults 20 to 40 years old.[15] This is unusual since influenza is normally most deadly to the very young (under age 2) and the very old (over age 70), and may have been due to partial protection caused by exposure to a previous Russian flu pandemic of 1889.[16]

History

While World War I did not cause the flu, the close troop quarters and massive troop movements hastened the pandemic. Researchers speculate that the soldiers' immune systems were weakened by the stresses of combat and chemical attacks, increasing their susceptibility to the disease.

A large factor of worldwide flu prevalence was increased travel. The modern transportation systems made it easier for soldiers, sailors, and travelers to spread the disease quickly and to communities worldwide.

American Red Cross nurses tend to flu patients in temporary wards set up inside Oakland Municipal Auditorium, 1918

Two poems, dedicated to the Spanish flu, were popular in those days:

I had a little bird,
Its name was Enza,
I opened the window,
And in-flew-enza.
-American Skipping Rhyme circa 1918

Obey the laws
And wear the gauze.
Protect your jaws
From septic paws.

Patterns of fatality

The influenza strain was unusual in that this pandemic killed many young adults and otherwise healthy victims – typical influenzas kill mostly infants (aged 0-2 years), the elderly, and the immunocompromised. Another oddity was that this influenza outbreak was widespread in summer and fall (in the Northern Hemisphere). Typically, influenza is worse in the winter months.

People without symptoms could be stricken suddenly and within hours be too weak to walk; many died the next day. Symptoms included a blue tint to the face and coughing up blood caused by severe obstruction of the lungs. In some cases, the virus caused an uncontrollable hemorrhaging that filled the lungs, and patients drowned in their body fluids (pneumonia). In others, the flu caused frequent loss of bowel control and the victim would die from losing critical intestinal lining and blood loss.

In fast-progressing cases, mortality was primarily from pneumonia, by virus-induced consolidation. Slower-progressing cases featured secondary bacterial pneumonias, and there may have been neural involvement that led to mental disorders in a minority of cases. Some deaths resulted from malnourishment and even animal attacks in overwhelmed communities.

Devastated communities

Street car conductor in Seattle not allowing passengers aboard without a mask in 1918.

While in most places less than one-third of the population was infected, only a small percentage of whom died, in a number of towns in several countries entire populations were wiped out.

Even in areas where mortality was low, those incapacitated by the illness were often so numerous as to bring much of everyday life to a stop. Some communities closed all stores or required customers not to enter the store but place their orders outside the store for filling. There were many reports of places with no health care workers to tend the sick because of their own ill health and no able-bodied grave diggers to bury the dead. Mass graves were dug by steam shovel and bodies buried without coffins in many places.

Unaffected locales

In Japan, 257,363 deaths were attributed to influenza by July 1919, giving an estimated 0.425% mortality rate, much lower than nearly all other Asian countries for which data are available. The Japanese government severely restricted maritime travel to and from the home islands when the pandemic struck. The only sizeable inhabited place with no documented outbreak of the flu in 1918–1919 was the island of Marajó at the mouth of the Amazon River in Brazil. In the Pacific, American Samoa[17] and the French colony of New Caledonia [18] also succeeded in preventing even a single death from influenza through effective quarantines. In Australia, only 12,000 perished compared to higher rates in other countries.

Government Response

The Great Influenza was the source of much fear in citizens around the world. Further inflaming that fear was the fact that governments and health officials were downplaying the influenza. While the panic from WWI was dwindling, governments attempted to keep morale up by spreading lies and dismissing the influenza. On Sept. 11, 1918, Washington officials reported that the Spanish Influenza had arrived in the city. The following day, roughly thirteen million men across the country lined up to register for the war draft, providing the influenza with an efficient way to spread. However, the influenza had little impact upon institutions and organizations. While medical scientists did rapidly attempt to discover a cure or vaccine, there were virtually no changes in the government or corporations. Additionally, the political and military events were fairly unaffected due to the impartiality of the disease, affecting either side likewise. [19]

Cultural Impact

In the United States, despite the relatively high morbidity and mortality rates that resulted from the epidemic in 1918-1919, the Spanish flu remained a relatively obscure event until the rise in public awareness of bird flu and other pandemics in the 1990s and 2000s. This has led some historians to label the Spanish flu a “forgotten pandemic.” [20] Indeed, one of the only major works of American literature written after 1918 that deals directly with the Spanish flu is Katherine Anne Porter’s Pale Horse, Pale Rider. More recently (2006), author Thomas Mullen wrote a novel called The Last Town on Earth, about the impact of the Spanish flu on a fictional mill town in Washington and author Myra Goldberg wrote a novel called Wickett's Remedy that is set in Boston during the pandemic.

Several theories have been offered as to why the Spanish flu may have been “forgotten” by historians and the public over so many years, including the rapid pace of the pandemic (it killed most of its victims in the United States in a period of less than nine months), Americans' familiarity with pandemic disease in the late 19th and early 20th centuries, and the distraction of the First World War.[21] Another explanation is shown when observing the age group affected by the disease. The majority of fatalities, in both World War One and by the Spanish Flu, were young adults. The deaths caused by the flu were overlooked due to the deaths from the war. When people would read the obituaries they would see the deaths from war and the deaths from the influenza side by side. Seeing the figures right next to each other lessened the impact the influenza had on individual people. [22] The fact that the disease would usually only affect a certain area for a month before leaving, left little time for the disease to have a significant impact on the economy. During this time period pandemic out breaks were not uncommon, the terror of typhoid, yellow fever, diphtheria, and cholera all occurred near the same time period. These outbreaks lessened the impact the Influenza pandemic had on Americans. [23]

Spanish flu research

One theory is that the virus strain originated at Fort Riley, Kansas, by two genetic mechanisms – genetic drift and antigenic shift – in viruses in poultry and swine which the fort bred for local consumption, but evidence from a recent reconstruction of the virus suggests that it jumped directly from birds to humans, without traveling through swine.[24]

An effort to recreate the 1918 flu strain (a subtype of avian strain H1N1) was a collaboration among the Armed Forces Institute of Pathology, Southeast Poultry Research Laboratory and Mount Sinai School of Medicine in New York; the effort resulted in the announcement (on October 5, 2005) that the group had successfully determined the virus's genetic sequence, using historic tissue samples recovered from a female flu victim buried in the Alaskan permafrost and samples preserved from American soldiers.[25]

On January 18, 2007, Kobasa et al. reported that monkeys (Macaca fascicularis) infected with the recreated strain exhibited classic symptoms of the 1918 pandemic and died from a cytokine storm[26] – an overreaction of the immune system. This may explain why the 1918 flu had its surprising effect on younger, healthier people, as a person with a stronger immune system would potentially have a stronger overreaction.[27]

Victims

Albertan farmers wearing masks to protect themselves from the flu.

Famous

Fictional

  • Hazel Forrest Bellamy, a fictional character in the television series "Upstairs, Downstairs" (played by Meg Wynn Owen) († 1918)
  • William Krichinsky, a fictional character in the film "Avalon", directed by Barry Levinson
  • Fanny and Jemma Macgregor in If I Die Before I Wake by Jean Little
  • Elizabeth Masen and Edward Anthony Masen Sr., fictional characters in the Twilight series by Stephenie Meyer. († 1918) Main character Edward Cullen was saved from a similar influenza death by being bitten by a vampire.

References

  1. Institut Pasteur. La Grippe Espagnole de 1918 (Powerpoint presentation in French)
  2. America: A Narrative History by Tindall, George Brown & Shi, David Emory 7th ed. copyright 2007 by W.W Norton & Company, Inc.
  3. The 1918 Influenza Pandemic
  4. www.ncbi.nlm.nih.gov. NCBI. PubMed. Johnson NP, Mueller J. Updating the accounts: global mortality of the 1918-1920 "Spanish" influenza pandemic. (2002)
  5. Hakim, Joy (1995). War, Peace, and all that Jazz. New York: Oxford University Press. pp. 21–24. 
  6. Avian Bird Flu. 1918 Flu (Spanish flu epidemic)
  7. See: Talk:Spanish flu#Origin of the name "spanish flu"
  8. 8.0 8.1 8.2 Taubenberger, J (2006). "1918 Influenza: the mother of all pandemics". Emerg Infect Dis. 12 (1): 15–22. PMID 16494711.  Unknown parameter |coauthors= ignored (help)
  9. 9.0 9.1 Patterson, KD (1991). "The geography and mortality of the 1918 influenza pandemic". Bull Hist Med. 65 (1): 4–21. PMID 2021692.  Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)
  10. 10.0 10.1 10.2 Knobler S, Mack A, Mahmoud A, Lemon S (ed.). "1: The Story of Influenza". The Threat of Pandemic Influenza: Are We Ready? Workshop Summary (2005). Washington, D.C.: The National Academies Press. pp. 60–61. 
  11. Potter, CW (2006). "A History of Influenza". J Appl Microbiol. 91 (4): 572–579. PMID 11576290. doi:10.1046/j.1365-2672.2001.01492.x.  Unknown parameter |month= ignored (help)
  12. Harold Marcus, Haile Sellassie I: The formative years, 1892-1936 (Trenton: Red Sea Press, 1996), pp. 36f; Richard Pankhurst, An Introduction to the Medical History of Ethiopia (Trenton: Red Sea Press, 1990), pp. 48f
  13. Pankhurst, Medical History, p. 63
  14. Pankhurst, Medical History, pp. 51f
  15. Simonsen, L (1998). "Pandemic versus epidemic influenza mortality: a pattern of changing age distribution". J Infect Dis. 178 (1): 53–60. PMID 9652423.  Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)
  16. O Hansen, 1923, Undersøkelser om influenzaens opptræden specielt i Bergen 1918 - 1922 Skrifter utgit ved Klaus Hanssens Fond. Bergen: Medicinsk avdeling, Haukeland Sykehus, 1923: 3.
  17. Influenza of 1918 (Spanish Flu) and the US Navy
  18. World Health Organization Writing Group (2006). "Nonpharmaceutical interventions for pandemic influenza, international measures". Centers for Disease Control and Prevention (CDC) Emerging Infectious Diseases (EID) Journal. 12 (1): 189. 
  19. Graham, Rod. "Author Brings "The Great Influenza" to the School.." John Hopkins Bloomberg School of Public Health. 4 Mar 2005. John Hopkins Bloomberg School of Public Health. 6 Jun 2008 http://www.jhsph.edu/publichealthnews/articles/2005/great_influenza.html
  20. Crosby, Alfred. America's Forgotten Pandemic. New York: Cambridge University Press, 2003.
  21. Crosby, America's Forgotten Pandemic, pp. 320–322.
  22. Simonsen, L; Clarke M, Schonberger L, Arden N, Cox N, Fukuda K (Jul 1998). "Pandemic versus epidemic influenza mortality: a pattern of changing age distribution."
  23. Morrisey, Carla R. "The Influenza Epidemic of 1918." Navy Medicine 77, no. 3 (May-June 1986): 11-17.
  24. Sometimes a virus contains both avian adapted genes and human adapted genes. Both the H2N2 and H3N2 pandemic strains contained avian flu virus RNA segments. "While the pandemic human influenza viruses of 1957 (H2N2) and 1968 (H3N2) clearly arose through reassortment between human and avian viruses, the influenza virus causing the 'Spanish flu' in 1918 appears to be entirely derived from an avian source (Belshe 2005)." (from Chapter Two : Avian Influenza by Timm C. Harder and Ortrud Werner, an excellent free on-line Book called Influenza Report 2006 which is a medical textbook that provides a comprehensive overview of epidemic and pandemic influenza.)
  25. Center for Disease Control: Researchers Reconstruct 1918 Pandemic Influenza Virus; Effort Designed to Advance Preparedness Retrieved on 2008-08-14
  26. Kobasa, Darwyn (2007). "Aberrant innate immune response in lethal infection of macaques with the 1918 influenza virus". Nature. 445: 319–323. doi:10.1038/nature05495.  Unknown parameter |coauthors= ignored (help)
  27. USA Today: Research on monkeys finds resurrected 1918 flu killed by turning the body against itself Retrieved on 2008-08-14
  28. Duncan, Kirsty (2003). Hunting the 1918 Flu: One Scientist's Search for a Killer Virus. University of Toronto Press. p. 304. ISBN 0802087485. 
  29. Duncan, Kirsty (2003). Hunting the 1918 Flu: One Scientist's Search for a Killer Virus. University of Toronto Press. p. 304. ISBN 0802087485. 
  30. PBS. Influenza 1918. Victims
  31. PBS. Influenza 1918. Victims
  32. PBS. Influenza 1918. Victims

Further reading

  • Beiner, Guy (2006). "Out in the Cold and Back: New-Found Interest in the Great Flu". Cultural and Social History. 3 (4): 496–505. 
  • Collier, Richard (1974). The Plague of the Spanish Lady - The Influenza Pandemic of 1918-19. USA: Atheneum. ISBN 0-8371-8376-6. 
  • Crosby, Alfred W. (1990). America's Forgotten Pandemic: The Influenza of 1918. Cambridge: Cambridge University Press. ISBN 0689105924. . A popular history.
  • Crosby, Alfred W. (1976). Epidemic and Peace, 1918. Westport, Ct: Greenwood Press. ISBN 0-8371-8376-6. 
  • Johnson, Niall (2006). Britain and the 1918-19 Influenza Pandemic: A Dark Epilogue. London and New York: Routledge. ISBN 0-415-36560-0. 
  • Johnson, Niall (2003). "Measuring a pandemic: Mortality, demography and geography". Popolazione e Storia: 31–52. 
  • Johnson, Niall (2003). "Scottish ’flu – The Scottish mortality experience of the “Spanish flu". Scottish Historical Review. 83 (2): 216–226. 
  • Johnson, Niall (2002). "Updating the accounts: global mortality of the 1918–1920 ‘Spanish’ influenza pandemic". Bulletin of the History of Medicine. 76: 105–15. doi:10.1353/bhm.2002.0022.  Unknown parameter |coauthors= ignored (help)
  • Kolata, Gina (1999). Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It. New York: Farrar, Straus and Giroux. ISBN 0-374-15706-5. 
  • Noymer, Andrew (2000). "The 1918 Influenza Epidemic's Effects on Sex Differentials in Mortality in the United States". Population and Development Review. 26 (3): 565–581. ISSN 0098-7921. doi:10.1111/j.1728-4457.2000.00565.x.  Unknown parameter |coauthors= ignored (help)
  • Oxford JS, Sefton A, Jackson R, Innes W, Daniels RS, Johnson NP (2002). "World War I may have allowed the emergence of "Spanish" influenza". The Lancet infectious diseases. 2 (2): 111–4. PMID 11901642. doi:10.1016/S1473-3099(02)00185-8. 
  • Oxford JS, Sefton A, Jackson R, Johnson NP, Daniels RS (1999). "Who's that lady?". Nat. Med. 5 (12): 1351–2. PMID 10581070. doi:10.1038/70913. 
  • Phillips, Howard (2003). The Spanish Flu Pandemic of 1918: New Perspectives. London and New York: Routledge.  Unknown parameter |coauthors= ignored (help)
  • Rice, Geoffrey W. (1993). "Pandemic Influenza in Japan, 1918-1919: Mortality Patterns and Official Responses". Journal of Japanese Studies. 19 (2): 389–420. ISSN 0095-6848. doi:10.2307/132645.  Unknown parameter |coauthors= ignored (help)
  • Rice, Geoffrey W. (2005). Black November: the 1918 Influenza Pandemic in New Zealand. Canterbury University Press. ISBN 1-877257-35-4. 
  • Hakim, Joy (1995). War, Peace, and all that Jazz. New York: Oxford University Press. pp. 21–24. 
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