Louisiana Homeland Defense Education Team The Great Pandemic of 1918 - PowerPoint Presentation

Louisiana Homeland Defense Education Team

The Great Pandemic of 1918 Thomas C. Arnold, M.D., FAAEM, FACMT Professor and Chairman, Department of Emergency Medicine LSUHSC – Shreveport Medical Director, Section of Clinical Toxicology and the Louisiana Poison Center

Disclosure I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

Acknowledgements PBS Online Stanford University Virology Department National Museum of Health and Medicine US Navy Department Library The Great Influenza – John Barry FLU – Gina Kolata America’s Forgotten Pandemic – Alfred Crosby Influenza 1918 – Lynette Iezzoni

HISTORY "History is a vast early warning system" --Norman Cousins    "That men do not learn very much from the lessons of history is the most important of all the lessons that History has to teach." --Aldous Huxley    

INFLUENZA - Definition An acute contagious viral infection of humans or animals characterized by inflammation of the respiratory tract and by fever, chills, muscular pain, and prostration. Also called grippe . Italian, from Medieval Latin influentia, influence (so called apparently from the belief that epidemics were due to the influence of the stars) The term influenza has its origins in 15th-century Italy. Evolution in medical thought led to its modification to influenza di freddo , meaning "influence of the cold."

Types of influenza virus The influenza virus is an RNA virus . There are three types of influenza virus: Influenzavirus A, Influenzavirus B and Influenzavirus C The type A viruses are the most virulent human pathogens among the three influenza types and causes the most severe disease. Influenza B virus is almost exclusively a human pathogen, and is less common than influenza A. However, influenza B mutates enough that lasting immunity is not possible. The influenza C virus infects humans and pigs, and can cause severe illness and local epidemics.

Nomenclature Hemagglutinin (H) is an antigenic glycoprotein found on the surface of the influenza viruses It is responsible for binding the virus to the cell that is being infected. There are at least 16 different HA antigens. These subtypes are labeled H1 through H16. The first three hemagglutinins, H1, H2, and H3, are found in human influenza viruses. Neuraminidase (N) is a glycoside hydrolase enzyme It is frequently found as an antigenic glycoprotein and is best known as one of the enzymes found on the surface of the Influenza virus. Nine subtypes of influenza neuraminidase are known; Subtypes N1 and N2 have been positively linked to epidemics in man Flu strains are named after their types of hemagglutinin and neuraminidase surface proteins, so they will be called, for example, H3N2 for type-3 hemagglutinin and type-2 neuraminidase.

Antigenic Drift Antigenic drift is the accumulation of mutations in the genetic makeup of the influenza virus. These changes usually occur in the virus's surface proteins hemagglutinin and neuraminidase. As in all RNA viruses , mutations in influenza occur frequently because the virus has no way of checking its RNA for errors Antigenic drift has been responsible for heavier-than-normal flu seasons. All influenza viruses experience some form of antigenic drift, but it is most pronounced in the influenza A virus.

Antigenic Shift Antigenic shift is the process by which two different strains of influenza combine to form a new subtype having a mixture of the surface antigens of the two original strains. The term antigenic shift is specific to the influenza literature . When two different strains of influenza infect the same cell simultaneously, their protein lipid envelopes are removed, exposing their RNA, which is then transcribed to mRNA. The host cell then forms new viruses that combine antigens; for example, H3N2 and H5N1 can form H5N2 this way. Antigenic shifts have caused the Asian Flu pandemic of 1957, the Hong Kong Flu pandemic of 1968, and the Swine Flu scare of 1976.

PANDEMIC - Definition An epidemic that is geographically widespread; occurring throughout a region or even throughout the world - (noun) epidemic - a widespread outbreak of an infectious disease; many people are infected at the same time Adj.- pandemic - epidemic over a wide geographical area; "a pandemic outbreak of influenza“ Late Latin pandemus, from Greek pandemos, of all the people

Six Stages of a Pandemic

WHO Phases and US Stages of a Pandemic WHO Phases US Stages Inter-Pandemic Period (New virus in animals, no human cases) Low risk of human cases 1 0 New domestic animal outbreak in at-risk country Higher risk of human cases 2 Pandemic Alert (New virus causes human cases) No or very limited human-human transmission 3 1 Suspected human-human outbreak overseas Evidence of increased human-human transmission 4 2 Confirmed human-human outbreak overseas Evidence of significant human-human transmission 5 Pandemic Period Efficient and sustained human-human transmission 6 3 Widespread human outbreaks in multiple locations overseas 4 First human case in North America 5 Spread throughout US 6 Recovery and preparation for subsequent waves

Remote Pandemic History The symptoms of human influenza were clearly described by Hippocrates roughly 2400 years ago . Since then, the virus has caused numerous pandemics. The first convincing record of an influenza pandemic was of an outbreak in 1580 , which began in Asia and spread to Europe via Africa. Pandemics continued sporadically throughout the 17th and 18th centuries , with the pandemic of 1830–1833 being particularly widespread

Timelines of Pandemics In Recent History 1889 Russian Flu (?H2N2) - 1 million 1918 Spanish Flu (H1N1) – 40 million 1957 Asian Flu (H2N2) – 1.5 million 1968 Hong Kong Flu (H3N2) – 1 million   Avian Influenza Virus (H5N1) – 262 (7/1/09) Novel (Swine) Flu (H1N1) – 816 (7/27/09)

Timelines of Pandemics In Recent History 1957 Asian Flu (H2N2) The Asian Flu pandemic occurred about 40 years after the Spanish Flu pandemic. Scientists were able to rapidly identify the H2N2 flu virus subtype. Science and technology advancements also enabled scientists to start developing an appropriate vaccine in May 1957, with a limited vaccine supply becoming available by August 1957. During this pandemic, attack rates (greater than 50%) were highest among school children (aged 5-19) , who spread the virus to their classmates. Those infected children carried the virus back to their families. Infection rates were also high among young adults and pregnant women . The elderly had the highest death rates .

Timelines of Pandemics In Recent History 1968 Hong Kong Flu (H3N2) This 1968 Hong Kong influenza pandemic of 1968 caused fewer deaths than the previous two pandemics. The virus subtype that caused this pandemic was somewhat analogous to the 1957 influenza virus because it had the same NA antigen, N2. Similar to the previous pandemic, schoolchildren suffered the highest attack rate. Many fewer people died during this pandemic than the other two pandemics for three reasons: (1) improved medical care that gave vital support to the very ill; (2) the availability of antibiotics that were more effective against secondary bacterial infections; and (3) the severity the illness probably was reduced among many people because they retained antibodies against N2 in their systems from the 1957 influenza pandemic.

Timelines of Pandemics In Recent History Avian Influenza Virus (H5N1) In May 1997 , the Government Virus Unit in Hong Kong isolated an influenza A virus from a three-year-old child who was admitted to the hospital with a fever and respiratory symptoms. This child later died of acute respiratory distress. Subsequently, the National Influenza Center in the Netherlands identified the virus as an influenza A H5N1 subtype. Six months after the virus's identification, 17 human H5N1 infections were documented in hospitalized patients in Hong Kong over a seven-week period. Six of the 18 patients died . During this time, the same virus was isolated from asymptomatic ducks and geese in local live-bird markets. Further studies revealed that humans became infected as a result of direct human-bird contacts and not person-to-person contact. This represented a novel outbreak.

Timelines of Pandemics In Recent History Novel (Swine) Influenza Virus (H1N1) 18 March 2009 : Federal District of Mexico begins to pick up cases of swine flu. 21 April 2009 : CDC laboratories confirm two cases in California. 27 April 2009: The WHO raises pandemic alert level to 4 29 April 2009 : The WHO raises pandemic level alert to phase 5. First swine-flu death outside Mexico reported as a baby dies in Texas. 2 May 2009: China, Costa Rica, Denmark, France, and the Republic of Korea join the list. Total cases reported to the WHO are now at 658 in 16 countries. 12 May 2009 : The CDC notes that it is seeing some severe complications in cases of H1N1 in pregnant women, including one death in the US. 11 June 2009: Phase 6 has been declared. The world is in a full-blown influenza pandemic for the first time in 41 years.

1918 Spanish Flu Modest Beginnings The First Wave Fort Riley, Kansas , - Camp Funston 26,000 men 20,000 acres bone-chilling winters and sweltering summers. blinding dust storms. On Saturday, March 9, 1918 , a threatening black sky forecast the coming of a significant dust storm. The sun was said to have gone dead black in Kansas that day.

The First Wave Shortly before breakfast on Monday, March 11 , the first domino would fall signaling the commencement of the first wave of the 1918 influenza. Company cook Albert Gitchell reported to the camp infirmary with complaints of a "bad cold." Right behind him came Corporal Lee W. Drake voicing similar complaints. By noon, camp surgeon Edward R. Schreiner had over 100 sick men on his hands

The First Wave In April and May over 500 prisoners at San Quentin in California came down with the same condition that had struck soldiers at camp Riley, as well as camps Hancock, Lewis, Sherman, Fremont, and several others. Influenza spreading amongst men living in close quarters did not particularly alarm the public health officials of the day. Little data existed at the time to indicate a sizable spread among the civilian population. Besides, the nation had bigger matters on its mind. There was a war to win.

The First Wave In March 84,000 American "dough-boys" set out for Europe; they were followed by another 118,000 the next month. While sailing across the Atlantic, the 15th U.S. Cavalry incurred 36 cases of influenza, resulting in six deaths .

The First Wave Great Britain reported 31,000 influenza cases in June alone. Military attacks that had been painstakingly planned had to be postponed due to a shortage of healthy men . Numerous cases of influenza were reported in Russia, North Africa , and India . The Pacific Ocean provided no protection as influenza spread to parts of China, Japan, the Philippines , and down to New Zealand .

The First Wave By July , the influenza of 1918 had left its mark globally. Tens of thousands had fallen ill and died. Public health officials in Philadelphia issue a bulletin about the so-called Spanish influenza. This first wave was a mere prelude….

PRE WWI EUROPE

The Name “Spanish Flu” At the height of WWI French, German and British newspapers were forbidden from printing anything negative that could impact troop morale But, Spain was neutral during the war and therefore did not censor the press Spanish newspapers were filled with reports of the disease, most notably King Alphonse XIII who fell seriously ill Hence, it was believed this flu originated in Spain and became known as “The Spanish Flu”

The Second Wave Victor Vaughan In September, Vaughan, a former president of the American Medical Association, received urgent orders to proceed directly to Camp Devens outside of Boston. "The saddest part of my life was when I witnessed the hundreds of deaths of the soldiers in the Army camps and did not know what to do. At that moment I decided never again to prate about the great achievements of medical science and to humbly admit our dense ignorance in this case." "I saw hundreds of young stalwart men in uniform coming into the wards of the hospital. Every bed was full, yet others crowded in. The faces wore a bluish cast; a cough brought up the blood-stained sputum."

The Second Wave On the day Vaughan arrived at Camp Devens, 63 men succumbed to influenza. Vaughan uncovered the unnerving fact that while most influenza viruses prey on the old or the very young, this strain took aim at those in the prime of life . "This infection, like war, kills the young, vigorous, robust adults....The husky male either made a speedy and rather abrupt recovery or was likely to die."

The Second Wave September • The Navy Radio School at Harvard University in Cambridge reports the first cases of influenza among the group of 5000 young men studying radio communications. • On September 5, the Massachusetts Department of Health alerts area newspapers that an epidemic is underway. Dr. John S. Hitchcock of the state health department warned that "unless precautions are taken the disease in all probability will spread to the civilian population of the city."

The Second Wave Rupert Blue A large part of the burden of informing and protecting the public fell to 50-year-old Rupert Blue, Surgeon General of the United States Public Health Service. Blue was in sole command of 180 health officers and 44 quarantine stations throughout the country. Blue's 1918 advisory to the nation regarding how to recognize influenza stated: "In most cases a person taken sick with influenza feels sick rather suddenly. He feels weak, has pains in the eyes, ears, head or back, abdomen, etc., and may be sore all over. Many patients feel dizzy... Ordinarily the fever lasts from three to four days and the patient recovers. But while the proportion of deaths is usually low, in some places the outbreak is severe and deaths are numerous...“ Blue prescribed bed rest, good food, salts of quinine, and aspirin for the sick.

The Second Wave He issued urgent bulletins to camps on the dangers of making incorrect diagnoses. "It is important that influenza be kept out of the camps as far as practicable. To this end it must be recognized as a disease which is distinct and separate from the so-called 'cold, bronchitis, laryngitis, coryza, or rhinitis and fever type' which are continually with us and from time to time become prevalent,"

The Second Wave Later in September Edward Wagner , a Chicagoan newly settled in San Francisco, falls ill with influenza on September 24. San Francisco public health officials downplayed the potential dangers posed by the flu. The Chief of San Francisco's Board of Health had gone so far as to predict that the flu would not even reach the city . Royal Copeland , the Health Commissioner of New York City, announces, "The city is in no danger of an epidemic. No need for our people to worry."

The Second Wave October Boston registers 202 deaths from influenza on October 2. Shortly thereafter, the city canceled its Liberty Bond parades and sporting events. Churches were closed and the stock market was put on half-days. Congress approves a special $1 million fund to enable the U.S. Public Health Service to recruit physicians and nurses to deal with the growing epidemic.

The Second Wave Blue summoned scores of doctors out of retirement, including those debilitated by old age, disfigurement, and in some cases, near-blindness. Somehow Rupert Blue was able to enlist 250 additional doctors to aid the Public Health Service. He went on record as being in favor of closing "all gathering places if the community is threatened with the epidemic."

The Second Wave Later in October 851 New Yorkers die of influenza in a single day . In Philadelphia, the city's death rate for one single week is 700 times higher than normal. The crime rate in Chicago drops by 43 percent. Authorities attributed the drop to the toll that influenza was taking on the city's potential lawbreakers. October 1918 turns out to be the deadliest month in the nation's history as 195,000 Americans fall victim to influenza.

The Aftermath Victor Vaughan In the late autumn of 1918, as the flu cut a deadly path through entire towns and villages "If the epidemic continues its mathematical rate of acceleration, civilization could easily disappear from the face of the earth." In its aftermath, Vaughan knew that Americans and all citizens of the world were lucky the "Spanish Lady" hadn't claimed even more victims. Vaughan pointed out that doctors of the day "knew no more about the flu than 14th century Florentines had known about Black Death.”

The Aftermath Blue warned: "The Health Service urges the public to remember that there is as yet no specific cure for influenza and that many of the alleged cures and remedies now being recommended by neighbors, nostrum vendors and others do more harm than good." He proposed a " centralized national department of health with powers far greater than the U.S.P.H.S. had ever had before..."

The Aftermath November Celebrating the end of World War I, 30,000 San Franciscans take to the streets to celebrate. There was much dancing and singing. Everybody wore a face mask . Sirens wail on November 21, signaling to San Franciscans that it is safe--and legal--to remove their protective face masks. At that point, 2,122 were dead due to influenza. December 5,000 new cases of influenza are reported in San Francisco.

The Philadelphia Story Wilmer Krusen , Philadelphia Public Health Director After meeting with officials on a national level he agreed reluctantly to a mass publicity campaign against coughing, spitting and sneezing. Because of the huge war effort the political power players in Philadelphia planned a city-wide parade to support the “Liberty Loan” campaign…

The Philadelphia Story The day before the September 28 th parade date local hospitals admitted nearly 200 patients suffering influenza Bowing to pressure Krusen allowed the “Liberty Loan” parade and associated rallies to proceed Krusen had assured them they were in no danger…

The Philadelphia Death Toll On October 1 , three days after the parade the epidemic killed 117 people in a single day On October 3 rd , Krusen banned all public meetings in the city On October 5 th , 254 people died. “The Peak of the Influenza epidemic has been reached” Krusen Announced : “These deaths mark the high water mark in the fatalities, and it is fair to assume that from this time until the epidemic is crushed the death rate will constantly be lowered”

The Philadelphia Story The city was paralyzed… Undertaker and and gravediggers were in short supply as were coffins Bodies stacked up on porches and in homes and hospitals * Reminiscent of the Black Plague , horse-drawn wagons moved through the streets collecting bodies for burial ** Requests for nurses received, 2955 ; requests not filled , 2758

The Philadelphia Story On the single day of October 10 th the epidemic alone killed 759 people in Philadelphia † The week of October 16 th 4597 Philadelphians died as a result of Influenza (Worst week of the epidemic)

The Aftermath Placing Blame By the early 1900's, many Americans had lulled themselves into thinking that the wonders of medical science could vanquish any foe, no matter how microscopic. Researchers had developed vaccines for diseases ranging from anthrax to smallpox . Great advances in microbiology had eliminated the mystery from once fatal diseases. That America was engaged in a World War provided a convenient target upon which to heap suspicion: the reviled Kaiser and his German countrymen. On September 17, 1918, Lt. Col. Philip Doane , head of the Health and Sanitation Section of the Emergency Fleet Corporation, forcefully voiced his opinion that the epidemic might have been started by Germans put ashore from U-Boats. "It would be quite easy for one of these German agents to turn loose influenza germs in a theater or some other place where large numbers of persons are assembled. The Germans have started epidemics in Europe, and there is no reason why they should be particularly gentle with America."

The Aftermath Placing Blame Other notions of this strain of influenza's origin contained less-politically charged, but equally specious logic. According to one theory, poison gases used in the war, air charged with carbon dioxide from the trenches , and gases formed from decomposing bodies and exploding munitions had all fused to form a highly toxic vapor that flu victims had inhaled Among the other causes advanced were: air stagnation, coal dust, fleas, the distemper of cats and dogs, and dirty dishwater .

Searching for Cures The United States Public Health Service (U.S.P.H.S.) faced the challenge of educating the public about an illness that was largely a mystery. Surgeon General Rupert Blue , the nation's Chief Public Health Officer, ordered the printing and distribution of pamphlets with titles like, "Spanish Influenza," "Three-Day-Fever," and "The Flu." The Colgate company pitched in by placing ads detailing twelve steps to prevent influenza. Among the recommendations: chew food carefully and avoid tight clothes and shoes. Alfred Crosby , in "Epidemic and Peace, 1918," his definitive history of Spanish influenza, observed that if influenza could have been smothered by paper, many lives would have been spared.

Searching for Cures The Committee of the American Public Health Association (A.P.H.A.), believing the disease extremely communicable, strongly advocated legislation that would prevent the use of common cups and utensils and would ban public coughing and sneezing. The A.P.H.A. implored the public to develop the habit of washing their hands before every meal and paying special attention to general hygiene. They cautioned that nervous and physical exhaustion should be avoided and encouraged exposure to fresh air. A more controversial method of flu prevention, disputed by the A.P.H.A., involved gargling with a variety of dubious elixirs . Various physicians advised rinsing with everything from chlorinated soda to a mixture of sodium bicarbonate and boric acid .

The Great Goose Chase Richard Pfeiffer , Scientific Director of the Institute for Infectious Disease in Berlin Isolated a tiny slender, rod-shaped bacteria from a large number of Influenza cases He named the bacteria Bacillus influenzae (today known as Hemophilus influenzae ) Scientists quickly began calling it Pfeiffer’s Bacillus and few doubted the validity of his discovery

The Great Goose Chase The World’s scientific community put so much faith behind Pfeiffer’s work that no one would challenge his assertion In fact, the quality of a scientists work became judged by his/her ability to isolate this organism from their patients All efforts began to focus on isolating this organism , growing it in culture then creating a vaccine

The Great Goose Chase Because of this diversion , it would take 13 years for the causative agent to be identified A swine virus was ultimately identified that had descended directly from the 1918 virus In 1931 Richard Shope published three papers in the Journal of Experimental Medicine revealing a virus as the offending agent

The Silver Lining Oswald Avery found that adding blood heated to 200 °F to the media was highly successful. He promptly published the recipe for this preparation in JAMA . “Chocolate agar” today continues to be a staple in microbiology labs worldwide

The Silver Lining In 1928 Alexander Fleming left a petri dish uncovered with staphylococcus overgrowth in it…

The Silver Lining – Alexander Fleming Two days later he discovered a mold that inhibited the growth He extracted the inhibiting substance from the mold and named it… penicillin Fleming found that penicillin killed staph, strep, pneumococcus, gonococcus, diphtheria and other bacteria but did no harm to the influenza bacillus Fleming did not try to develop penicillin into a medicine….

The Silver Lining A decade later Howard Florey and Ernst Chain developed Fleming’s discovery into the first “wonder drug”

The Silver Lining In 1945 , Florey, Chain and Fleming shared the Nobel Prize for their work

The Silver Lining Oswald T. Avery’s life work was pursuing the cause and a cure for Influenza He never discovered the responsible etiologic agent “Disappointment is my daily bread. I Thrive on it.”

The Silver Lining – Oswald T. Avery But, in February 1944 he published in the Journal of Experimental Medicine a paper titled “Studies on the Chemical Nature of the Substance Inducing Transformation of Pneumococcal Types. Induction of Transformation by a Desoxyribonucleic Acid Fraction Isolated from Pneumoccus Type III” He demonstrated that DNA carried genetic information Years later as Watson and Crick received the Nobel Prize for their discovery of the structure of DNA, they acknowledged Oswald Avery for opening the field of molecular biology …all from his efforts against influenza

The Final Toll At final count world-wide estimates of death ranged from 40 to 100 million The pandemic of 1918 killed more people in 24 weeks than AIDS has killed in 24 years It killed more in one year than the Black Death killed in a century It is without question the deadliest pandemic in world history

Nonpharmaceutical Interventions (NPI) Historical Assessment of Nonpharmaceutical Disease Containment by the Defense Threat Reduction Agency in 2006 made the following conclusions: “Protective Sequestration”, if enacted early enough in the pandemic,… stands the best chance of protection against infection. Available data from the second wave of the 1918 pandemic fail to show that any other NPI was or was not effective in containing the spread of the virus Moreover, no reliable data supported the conclusion that face masks , as worn during the 1918 pandemic, conferred any protection to the population that wore them.

What Could Louisiana Expect from a Pandemic? FluAid 2.0 from CDC – “Most Likely” estimates based on various attack rates Outpatient visits – 350 K to 816K “Possible” Ranges from 270K to 1.2 million Hospitalizations – 7.5K to 17K “Possible” Ranges from 2.6K to 22K Deaths – 1.7K to 3.9K “Possible” Ranges from 0.9K to 6.6K

H1N1 in the US 2009-2010 CDC estimates that about 61 million people were infected with H1N1. CDC estimates that there were about 274,000 H1N1-related hospitalizations . CDC estimates that there were about 12,470 H1N1-related deaths .

One Final Note… “Those who cannot remember the past are condemned to repeat it." --George Santayana