Pandemics are not new. Have we learned anything from 1918-1919 Influenza?

The 2020 viral pandemic (COVID-19)[1], in spite of being due to a novel virus family, bears striking epidemiological and social resemblances to the Influenza pandemic of 1918[2]. Both seemed to have appeared from out of the blue and both caused severe disease around the globe[3].  Some have labeled the 1918 contagion as one of the worst in world history[4]. It was troubling in that no one knew what caused it. In the early 20th century, many physicians believed Influenza was caused by a bacterium (Pfeiffer’s Bacillus also called Hemophilus Influenza – see below). Viruses were a newly discovered series of pathogens[5] and were largely a theoretical construct, the understanding of which would have to wait until 1933[6]. The genetic makeup of the H1N1 Influenza A virus, which was responsible for the 1918/19 flu, would then not be defined until the last decade of the 20th century[7]. On the other hand, the causative organism for Covid-19 was discovered to be a virus of the Corona virus family very soon after the disease was first recognized.  An examination of the time course and of both the medical and social responses to the 1918-1919 Influenza epidemic might hold some insights and cautions as we look at the COVID -19 pandemic.

John Barry[8] and Susan Kent[9], among others, have written fairly comprehensive treatises on the 1918/19 epidemic.  They outline three distinct phases of the pandemic, which they believe first started in Haskell County in western Kansas.  It was initially considered simply a unique and somewhat harsher form of “seasonal influenza” that began just eight months after the US entered World War I. Young men were being introduced to basic training camps (cantonments) around the country. Several recruits from Haskell County ended up in Camp Funston in the Fort Riley, Kansas complex.  They probably brought the flu to Camp Funston, and then, as men from Camp Funston went to other cantonments around the country, they took more than just their kit and rifles. They took the new Influenza. In the spring of 1918, the virus infected mainly soldiers and made them quite ill, but this phase of the illness didn’t seem to carry a high mortality[10]. A second wave of this Influenza came in the fall of 1918.  This was incredibly severe and sudden with a high mortality mainly among young people, “in the prime of life”.

Both the 1918 Flu and the current 2020 Covid-19 illnesses are viral in origin. Viruses are, for many reasons, difficult to treat with only a few having specific drug therapies. Human Immunodeficiency Virus is one exception to this. HIV treatments, which are specific to this virus, have been successful in improving survival of people with or at risk of infection since the late 1980’s[11]. Another viral disease for which there are specific antiviral treatments is Hepatitis C[12].  Most viral diseases are best treated by prevention, and/or vaccination.

Viruses can cause illness by themselves, but these germs may also predispose the “victim” to developing superinfections with bacteria. Other than HIV and Hepatitis C drugs, there are to date (May 2020) no medications that do much more than shorten the duration of viral illnesses. If correctly identified, a bacterial complication can be treated with antibiotics which modifies the course of the illness.  On the other hand, both bacterial and viral pathogens can be attenuated by vaccination.  Today we have vaccines for “seasonal influenza” (either type A or B) and for the most common causes of bacterial pneumonia, as well as many other viral illnesses[13].  Development and testing of vaccines for viruses is difficult and time consuming[14]. In 1918, vaccines against pneumococcus were being developed and appeared to be useful in decreasing the mortality of those exposed to “the flu”.  The 1918 experience in Chicago suggested that people vaccinated against bacterial complications had a much more benign course than those not vaccinated[15]. In the 21st century it is essentially routine to vaccinate a large segment of the population with one of the Pneumococcal vaccines.

However, non-medical or Public Health interventions to decrease the community upshot of the virus, both then and now, have the most impact. Interfering with transmission of the virus from person to person seems to be the most effective with the least potential harm of the interventions available.  This was called “crowding control” in 1918 and “Social Distancing” in 2020.  Face coverings for the general population in the US and Western European countries have been controversial[16]. Recent data suggest that they may help decrease the infectiveness of viruses and they have a very low likelihood of harms. Facemasks were recommended in many, but not all, cities in 1918 and are again now. Keeping people with known disease away from others (quarantine) is an important component of breaking the transmission chain.  Optimally this requires identifying those carriers who are minimally symptomatic and isolating them (often using interventions in the rubric Test, Track and Trace).

When there is a way of identifying carriers, this sequence is fairly easy to do. If the infecting organism is not known, as it wasn’t in 1918, then retrospectively identifying contacts and isolating them is much harder. It is easier to find asymptomatic carriers of the virus if we can by simply test and perform a culture. In 1918 most industrial plants, offices and schools were kept open, but entertainment venues including theaters, dance halls, and sporting events were prohibited by Public Health Commissioners[17].  Another means of transmission of infecting organisms is from “fomite-to-finger-to-mucosa” transmission.  This suggests that wiping surfaces and frequent hand washing should also be an important means of mitigating contagions. In addition, fumigating buildings and rooms with disinfecting sprays or fumigation should help interfere with viral transmission. Whether using ultraviolet or infrared lights will have an impact on sanitization has not yet been shown.

Public health initiatives are thought to work best when directed by a central source. In 1918, as in 2020, developing public initiatives that were known to be effective were delayed. In 1918, as today, the initial official response to the illness has been to the effect that “it won’t be so bad”[18].  However, in many cases, as our understanding of the mechanism and intensity of the spread of the virus becomes more complete, public health experts have modified and or walked back from more optimistic assessments of the potential seriousness of the problem. In part, the hesitancy of public health officials to sound an alarm is at least twofold. First, scientists want to be fairly sure of the data that might suggest one stance or another. Secondly, officials are hesitant to raise alarm and increase society’s anxiety inappropriately. They don’t want to be caught in the bind of being the “boy who cried wolf too often”. These two considerations are potentially in conflict with educating the public on potential consequences of an impending plague.  In retrospect majority of public health authorities, point out that education of the public is of paramount importance. Striking the balance between generating public anxiety and fully informing the populace is very delicate.

The autumnal outbreak of the 1918 illness ran a course of approximately 3.5 to 4 months across the country from early September in Boston to mid-December in Los Angeles. There was a third unanticipated wave, of the disease from January to April 1919[19]

The 1918-1919 flu killed between 40 million and 50 million people worldwide including approximately 675,000 Americans[20].  It was reported to have affected/infected about ¼ of the world’s population. Counting those with minimally symptomatic or asymptomatic infection may have resulted in a higher estimate of the extent of the disease but lower estimates of the mortality rate. The rates for the current Covid-19 illness are yet to be determined. Rates in different communities appear to vary. There have been suggestions that social vulnerability has been associated with worse outcomes from pandemics both currently and in 1918. In 1918, looking at the death rates in the British Military in India showed that the British troops had a 10% mortality while the Indian troops had an almost 20% mortality[21].  Similar variations in Covid-19 mortality rates exist between socially vulnerable and the more well-to-do populations in the US[22]. In Chicago in 1918, on the other hand, the Black Communities were said to do better than the general population[23]. That discrepancy is hard to reconcile, and MAY have been related to poorer record keeping in that community.

In 1918 there was no national response to epidemics or pandemics. Medicine was just beginning to take on a scientific bent and federalism certainly superseded central government planning and control. In the early 21st century, on the other hand, there has been an increased understanding and reliance on forward thinking responses to problems based on planning.  There have been many potentially lethal situations that have been mitigated by having a pre-thought-out response in advance[24].  In the summer of 2019, there was a federally sponsored multi state planning exercise, called the “Crimson Contagion” exercise to test the community’s ability to respond to a respiratory virus threat.  There were recommendations to improve central planning and the ability to provide needed equipment to areas of need. The report was evidently not acted upon[25]

The 1918/9 H1N1 Influenza epidemic and the 2020 Covid-19 Coronavirus epidemics in the United States have many similarities. The differences in the sophistication of the medical responses then and now have perhaps blunted the severity of the Covid-19 illness. However, the main responses inducing various isolation techniques are similar. As of the middle of May 2020, the illness has essentially shut the country down, to a greater extent than 1918. The autumnal peak of 1918 illness lasted slightly longer than three months[26]. The shut down in the US in 2020 began in late March (two months ago as of 5/19/20). There WAS, however, a second lower volume but also severe wave that began in beginning of 1919.  That wave almost took President Wilson’s life while he was in the negotiations to wrap up WW I.

It would appear that central coordination and decisive action, based on the best available data – both scientific and social – would serve the country well. Reviewing contemporary reports with an unbiased eye considering both benefits and harms of either action or inaction would be critical to optimizing a response.  Armed with data such as that provided in the Crimson Contagion report, other planning documents, as well as the after-action reports from prior catastrophes, both potential and aborted, our responses to the current and future threats should be able to be mitigated.

End Notes:
[1] The Acronym stands for Coronavirus Disease from 2019. It would almost be neater to write as CoViD-19
[2] There have been many other pandemics that have affected a large part of the world as it was known at the time. (https://listverse.com/2009/01/18/top-10-worst-plagues-in-history/  ; https://www.washingtonpost.com/graphics/2020/local/retropolis/coronavirus-deadliest-pandemics/  )
[3] Kent, S.K: The Influenza Pandemic of 1918-1919: A Brief History with Documents: 2013; Bedford/St. Martin’s, Boston MA (ISBN: 978-1-319-24162-9 (ePub)
[4] The numbers quoted for some of the “worst” plagues are at best a little fluid. Some data suggest that the “Spanish Flu” was about the 3rd worst: Bubonic Plague (1347-1351) worst with 750,000 to 1 MM killed worldwide: and Smallpox in the “New World” in 1520 killed 56MM First Nations People.  However, if we use 100MM as the worldwide death toll of the “Spanish Flu” then it is up there.  https://www.washingtonpost.com/graphics/2020/local/retropolis/coronavirus-deadliest-pandemics/
[5] The tobacco mosaic virus was suspected in 1892 as a “filterable” agent. The influenza virus was not characterized until 1933, after the electron microscope was perfected.
[6] Barry, J.M.; The Great Influenza: The Story of the Deadliest Pandemic in History.  Penguin Books 2018 and Kent op cit
[7] Taubenberger, J.K; Reid, A. H.; Krafft, A.E, Bijwaard, K. E., Fanning, T. G.: Initial Genetic Characterization of the 1918 “Spanish” Influenza Virus; 1997; Science, 275, 1793-6: https://www.jstor.org/stable/2892709
[8] Barry, J.M.; op cit.
[9] Kent, S.K: op cit.
[10] http://ocp.hul.harvard.edu//contagion/influenza.html
[11] https://ccr.cancer.gov/news/landmarks/article/first-aids-drugs
[12] https://www.hepatitisc.uw.edu/page/treatment/drugs accessed 5/19/2020
https://www.healthline.com/health/hepatitis-c/evolution-of-treatments#late-zeros
[13] Pneumovax as prophylaxis against most dangerous superinfection is almost universal (Prevnar 13 or 23) now a days as are vaccines to counter smallpox, measles, mumps, rabies, and many other viral and bacterial pathogens
[14] Up to the middle of 2020 the world record for development of a vaccine against a viral illness was approximately four years (https://www.nytimes.com/2013/05/07/health/maurice-hilleman-mmr-vaccines-forgotten-hero.html)
[15] Robertson, JD:  A Report on An Epidemic of Influenza in the City of Chicago in the Fall of 1918  Department of Health City of Chicago, 1918:  https://archive.org/details/reportonepidemic00robe/page/n5/mode/2up  P 90
[16] There was significant controversy as to the effectiveness of non N-95 face masks as a preventive for influenza Until new data from the 20teens and 2020.
a. MacIntyre, C.R;  Chughtai, A.A.: A rapid Systemic Review of the Efficacy of Face Masks and Respirators Against Coronaviruses and other Respiratory Transmissible Viruses for the Community, Healthcare Workers and Sick Patients: Int J Nurs Stud 2020 Apr 30-P 103629.  doi: 10.1016/j.ijnurstu.2020.103629  accessed 5/14/20
b. Offeddu, V.; Yung, CF;l Low, MSF; Tom, CC: Effectiveness of Masks and Respoirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis:  2017 Clinical Infectious Disease: 65; 1934-1942?  https://doi-org.ezproxy.galter.northwestern.edu/10.1093/cid/cix681   accessed 5/14/20
c. Javid, B; Weekes, MP; Mateson, NJ: Covid-10 should the public wear face masks? Population benefits are plausible and harms unlikely:  2020 BMJ; 369:m1442   doi: 10.1136/bmj.m1442
[17] Robertson, JD, op cit p. 46
[18] Dr. John Dill Robertson, the Commissioner of Health for Chicago is reported to have downplayed the potential hazard of the reported risks of influenza: he is reported to have said on September 24 “There is no cause for alarm whatever.” Chicago Sun Times on October 16, 2005:  https://chicago.suntimes.com/coronavirus/2020/3/20/21186633/coronavirus-chicago-spanish-flu-influenza-pandemic-1918
Public health experts today initially did not push for vigorous interventions. https://www.snopes.com/fact-check/fauci-nothing-to-worry-about/
Many times this desire not to worry people has “political” motives. In 1918, President Wilson’s government forbad discussions that would hinder “the War Effort”.  Officials also don’t want to get a reputation for unnecessarily painting a “doom and gloom” scenario.  Their credibility is at least partly at stake
[19] There is a website housed at the University of Michigan which has a well-documented event timeline http://www.influenzaarchive.org
[20] https://virus.stanford.edu/uda/
[21] From Barry in: Institute of Medicine (US) Forum on Microbial Threats; Knobler SL, Mack A, Mahmoud A, et al., editors. The Threat of Pandemic Influenza: Are We Ready? Workshop Summary. Washington (DC): National Academies Press (US); 2005. 1, The Story of Influenza. Available from: https://www.ncbi.nlm.nih.gov/books/NBK22148/
[22] Villarosa, L: ‘A Terrible Price’: The Deadly Racial Disparities of Covid-19 in America.  New York Times, April 29, 2020:  https://www.nytimes.com/2020/04/29/magazine/racial-disparities-covid-19.html
[23] Robertson, J.D.: Op  Cit  p 99
[24] The fact that the recent outbreaks of Ebola has not become more of an international problem probably relates to the fact that the regions in West Africa are reasonably isolated from the rest of the world. Thomas E. Duncan who evidently brought the virus to the US. He was diagnosed and treated in isolation.  Two nurses who cared for him contracted the illness and were treated with isolation. They survived.
[25] Crimson Contagion 2019 Functional Exercise:  https://int.nyt.com/data/documenthelper/6824-2019-10-key-findings-and-after/05bd797500ea55be0724/optimized/full.pdf
The report concluded:
“Existing statutory authorities tasking HHS to lead the federal government’s response to an influenza pandemic are insufficient and often in conflict with one another
Currently, there are insufficient funding sources designated for the federal government to use in response …
It was unclear if and how states could repurpose HHS and the CED grants as well as other federal dollars to support the response to the influenza pandemic”
[26] From early September in Boston until mid to late December in St. Louis

About Ted

Edward B. J. (Ted) Winslow received an MD from the Faculty of Medicine of the University of British Columbia in Vancouver and an MBA by the Kellogg School of Northwestern University. Before getting his MBA, Ted practiced Cardiology and Internal Medicine at several Chicago institutions (University of Illinois, Veterans West Side, Illinois Masonic, Northwestern Memorial and Evanston Northwestern Healthcare – each one at a time). As a practicing physician, Ted has had experience in managing a medical practice, and implementing the adoption of electronic medical record systems
This entry was posted in General Interest, Health Information, Leadership, Public Health and tagged , , . Bookmark the permalink.

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.