Critical Lessons of the Spanish Influenza Pandemic of 1918

For the past 90 years, infectious disease experts have looked to the 1918 Spanish Influenza pandemic to provide the clues they need to combat the next worldwide contagion. The influenza outbreak of 2009 is showing signs of being that long awaited infection.

Influenza pandemics are not a new phenomenon. Medical researchers such as Dr. Michael T. Osterholm, University of Minnesota, believe that the first flu pandemic to be documented occurred in 1580. Its rapid spread from Asia to Europe devastated a number of Spanish cities and an estimated 10% of Rome's population in six weeks. Since then there have been periodic incidences of a virus gone global, including the Russian Flu outbreak in the spring of 1889.

Influenza Patterns of Infection

The 1889-1890 pandemic came in three waves beginning with a mild form that appeared in the spring followed by an aggressive, deadly version in the late summer and fall, and finally a third, milder adaptation appearing in the winter. Approximately 1 million people died.

The three-phase pattern established in previous pandemics remained true for the Spanish Influenza Pandemic of 1918-1919. The first known case of the flu was on an army base in Kansas in March 1918. The spring outbreak was a mild form of the virus, which disappeared by early summer.

Deadly Second Wave: Fall 1918

When the second phase of the disease struck in the fall, the virus had mutated into the H1N1 subtype, a new aggressive and deadly strain of the disease. The majority of the deaths in both North America and Europe took place between September and early November 1918, although cases would continue into the middle of 1919. In a single week in October 1918, 21,000 Americans died of the flu or the resulting pneumonia. By the time the infectious storm had passed, 22 million people in the country became ill. The resulting mortality rate of 2.5% was 250 times the average flu American season.

The importance of proper communication cannot be illustrated any better than the actual events that took place in Philadelphia, PA at the end of September 1918 as shown in the Robert Kenner film "Influenza 1918" produced for the PBS series The American Experience. Although numerous influenza cases had been reported to pubic health officials eleven days earlier, city leaders downplayed the disease and did not inform the public of the danger large groups presented. On September 28, some 200,000 people attended a parade in support of the war. By 4 October, there were 638 cases of infection and 139 deaths reported. By the time the virus had run its course, Philadelphia had lost 13,000 citizens.

The decisions public officials made during the 1918 epidemic directly contributed to the number of people who became ill and consequently to the number of deaths.

Tips to Reduce Influenza Infection

Pandemics may not be avoidable but spread of the disease and the ensuing mortality rates can be reduced. To help check the spread of the disease, the Centers for Disease Control and Prevention (CDC) in Atlanta in the section of their website dedicated to the H1N1 flu suggests the following guidelines.

• Use a tissue when coughing or sneezing; dispose of the tissue immediately.
• Frequently wash hands with warm water and soap or an alcohol-based hand cleanser. Soap and water is best. Keep nails short and pay good attention to cleaning cuticles.
• Try not to touch your eyes, nose or mouth unless your hands are freshly washed.
• Wipe down hard surfaces with disinfecting cleaner or use a spray. Common areas of transmission are kitchen and bathroom countertops, home and office phones, keyboards, doorknobs, shopping cart handles, and steering wheels of company or rental vehicles.
• If exhibiting symptoms, stay home. The influenza virus is capable of being passed from the day prior to symptoms being noticed to seven days after becoming ill. Committing to voluntary isolation when ill is an effective way to help reduce the spread of the disease.
• If coworkers or family members become ill, consult your doctor about the possibility of taking a prescription anti-viral medication such as Tamiflu or Relenza. This is especially important if you take care of children or the elderly.

The CDC has an excellent short presentation regarding the appropriate response to take as it equates to the level of severity the WHO releases. The media presentation can be found here.

The Legacy of the Great Pandemic

The mistakes and successes of those who fought the 1918 Spanish Influenza Pandemic play a significant role in the manner that epidemic disease is managed today. The lessons learned by studying events of that time are the foundation of the current policies regarding timely, accurate public communication, closing schools and otherwise discouraging crowds, proper hygiene, and other basic steps used to restrict the spread of infectious disease.

The World Health Organization and the CDC in Atlanta, GA are actively preparing for what they suspect will be the second, stronger wave of the flu later this year. Taking the simple, yet effective precautions that have been recommended can make their jobs and your health go much smoother should the pandemic keep to its classic pattern.

Sources:

http://virus.stanford.edu/uda/, http://www.cdc.gov/flu/whatyoushouldknow.htm, http://www.pbs.org/wgbh/amex/influenza/index.html, http://www.nytimes.com/2009/06/09/health/09docs.html