"21st Century Flu Pandemic Insights from 20th Century History." Presentation given 21 April 2009 for the NJ chapter of InfraGard. A look at "lessons learned" from history of pandemics.

1. 21st Century Flu Pandemic Insights
from 20th Century History
Presentation for NJ Chapter Infragard
Tuesday 21 April 2009
Jonathan D. Abolins, CHSP

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

3. Introduction
• Have forms and insurances cards ready.
(Just kidding.)
• Not speaking as a medical expert.
• Gleaning lessons from history to help
present planning for the future.

4. Flu by any other name…
• Influenza - from Italian “influenza di freddo” –
“influence of the cold.”
• Grippe - from Old French for “claw” or
“quarrel”
• Blitzkatarrh or Blitz Katarrh in German.
Lit. “Lightning catarrh” or “very fast mucus
discharge.”

5. Some technical terms
• Pathogen = a disease causing organism.
• Epidemic = local or regional outbreak of a contagious disease.
• Pandemic = global epidemic.
• Isolation = Controlling communicable disease spread by
separating persons known to be ill from those who aren’t.
• Quarantine = Like isolation, for people exposed to the disease
but who may or may not be ill yet.

6. Simplified flu virus nomenclature
(designation scheme)
Type of
Neuramindase
nuclear
material
Hemagglutinin
A/Fujian/411/2002 (H3N2)
Virus Geographic Strain Year of Virus
Type Origin Number Isolation Subtype

7. Typical flu symptoms
• Fever (usually high)
• Headache
• Tiredness (can be extreme)
• Cough
• Sore throat
• Runny or stuffy nose
• Body aches
• Diarrhea and vomiting
– More common among children than adults.
NOTE: Other diseases, such as the cold, may have these symptoms.

8. Why the fuss about the flu?
• Highly contagious.
• Flu can kill.
– The elderly and people with certain medical conditions at higher risk.
– Some flu strains can be far more lethal than the usual seasonal flu.
“I know how not to get AIDS.
I don’t know how not to get
the flu.”
- Alfred W. Crosby, Jr. quoted by Gina Kolata in “Flu”

9. Birds eye view of our timeline
• Pre – 20th Century
• 1918-1919 “Spanish Influenza” pandemic
• 1957-1958 “Asian Flu” pandemic
• 1968-1969 “Hong Kong Flu”
• 1976 “Swine Flu” potential pandemic
• 1997 & 1999 “Avian Flu” cases
• The present

10. Pre 20th Century
• 431 BCE plague hit Athens. Flu?
• 876 flu (?) epidemic slowed
Charlemagne’s conquest of Europe.
• 1580 flu followed new trade routes.
• 1889 – 1890: Severe pandemic.
– > 250,000 deaths in Europe
– 15-25 Million deaths worldwide.

11. 1918 “Spanish influenza” (H1N1)
• Deadliest known outbreak.
• 50-100 Million deaths worldwide. 675,000+ US.
– Influenza and complications killed 1.0% - 2.5% of the victims.
– Dropped 1918 US life expectancy by 12 yrs.
– Killed more people in 24 wks than AIDS had in 24 yrs.
– Compare with combat deaths:
• WW1 9.2 Million;
WW2 15.9 Million
Remember the human population
has grown since then:
World 1918 ≈ 1.8 Billion
2009 ≈ 6.7 Billion
US 1918 ≈ 103 Million
2009 ≈ 306 Million

12. Symptoms of the 1918 flu
• Normal flu symptoms.
• But many patients had other symptoms
that could include
– High fever
– Nasty, “rib cracking” cough
– Dark spots on cheeks
– cyanosis (turning blue), suffocation.
– Lungs filling with a frothy, bloody substance,
massive pulmonary hemorrhages
– Death.
• Sometimes, death came hours after the visible
onset of illness.

13. 1918 flu hits young adults hard
% Mortality for Ages
• Flu deaths usually among the very young
& the very old. Typical
• The 1918 flu tended to kill people 20 to
40 years old.
– “W mortality curve” <10 10s 20s 30s 40s 50s 60+
– People age <65 accounted for 99% of the
excess mortality of the time. 1918
• Possible reasons:
– Damage to the lungs as their healthier
immune systems fought the virus.
• Acute respiratory distress syndrome (ARDS) <10 10s 20s 30s 40s 50s 60+
– Another factor may be the impact of other
infections, including pneumonia or TB,
on top of the flu’s viral infection.

14. 3 Waves. 1st – Spring 1918
• Most likely first appeared in Kansas in March.
• Seemed mild at the time.
• The unusual age & mortality curve unnoticed.
– Influenza was not routinely tracked in those days.
– “It’s only the flu” view.
• By summer, subsided in the US. Went overseas.
• The flu went around the world in 4 months.
– This is before the era of air travel!

15. 2nd Wave – Late August 1918
• The flu changed into new strain or strains.
• First hit 3 ports
– Boston; Brest France; Freeport, Sierra Leone
• Really bad! Got people’s attention.
• Now, we’ll look at the conditions & responses…
Boston
 Brest, France

Freeport, Sierra Leone


17. Wartime conditions
• Collision of public heath & the war effort.
• This was a WORLD war.
– High mobility.
– Push to get “doughboys” to Europe ASAP.
– Military demand for doctors & more nurses. Shortages.
• Highly crowded conditions.
• Liberty Loan drives and other patriotic gatherings.
• Some people suspected German germ warfare.
• Wartime censorship.
– Why “Spanish” Flu?

19. Social & economic impacts
• Many people panicked by the
symptoms.
• While some helped the ill, others
fled.
– Some of the sick died from
starvation, etc.
– Sometimes, it was hard to recruit
volunteers.
• The pandemic may have cost the
US >$600 Billion (est. in present
day dollars)
– Including decreased
business & closings.

20. Medical services overwhelmed
• Example: San Francisco Hospital
– By end of Oct 1918, had 1,100 pneumonia patients,
overflowing capacity.
– Admitted 3,509 respiratory cases during the
pandemic. Of these, 26% died
– 78% of nurses fell ill.
– Others may have been
ill but soldiered on.
Emergency hospital set up in
an auditorium in Oakland.

21. Measures varied across the US
Among measures used:
– Prohibited or restricted public
gatherings.
– Quarantine & isolation.
– Education campaigns.
– Deploying public health doctors & nurses.
– Vaccinations (ineffectual)
– Mask laws and laws against spitting, etc.
• Stiff fines for “mask slackers,” spitters, etc.
A “mask slacker” barred from
getting onto a streetcar.

22. Philadelphia & the 1918 flu
• 26% of doctors & even more nurses in
military.
• 75% hospital staff overseas.
• Sep18th: Flu first appeared at the naval
base.
• Campaign against coughing, sneezing,
and spitting. Days after Philadelphia’s
Liberty Loan parade in
• Oct 3rd: public gathering ban issued. September 1918, which was
attended by 200,000 people,
• Firemen, garbage collectors & other hundreds of cases of
influenza were reported.
city employees fall sick. [Credit: Naval Historical
Center]
• City morgue overflowing. Convicts dig
graves. City opens 5 more morgues.
• Oct 27th: public gathering ban lifted.

23. What to tell the public?
• Officials sought to keep up morale.
– Full information was not given.
– Emphasized a “do not fear” message.
– “Fear Kills More Than the Disease.”
– Said that one’s safe if following
recommended precautions.
• But the public was seeing a
drastically different reality.
– That may have increased fear.
• Challenge of communications
to gain compliance, keep up
morale, etc. without “cognitive
dissonance” or disillusionment.

24. Racing for a vaccine - 1918
• Viral cause unknown until 1930s.
– Flu though to be caused by bacteria.
“Pfeiffer’s Bacillus” (Haemophilus influenzae)
• Vaccine research was on the wrong track.
– Viral cause of flu discovered later.
• Dr. Joseph Goldberger’s
experiment to get 39
volunteers infected.
– Pfeiffer’s Bacillus doses, contact with
flu patients, etc. It fails! Non caught
the flu. (Murphy’s Law at work.)

25. 3rd Wave – Spring 1919
• Not as bad as the 2nd wave.
• Much of the world exposed.
• Still, many people got ill.
– Many communities had lifted measures.
– In many places, public balked at renewed
restrictions.
• Afterwards
– Some people had some debilitation.
– Possible impact upon Versailles Treaty negotiations.
– Scientific progress in understanding flu.

26. Vaccines after 1918
• 1930s-1940s – Techniques for making flu
vaccines start to be developed.
– Viruses can be grown in embryonated chicken eggs.
– US military develops & tests vaccines in the 1940s.
• Time factors:
– At least 6 months to develop, test, and produce
vaccines for commercial distribution.
– ≈3 weeks after injection to have immunity.
• Obstacles
– Early vaccines had common side effects. Fever and
sore arms.
– Economic issues (liability, profitability)

27. 1957-1958 Asian Flu (H2N2)
• Unlike 1918 flu, this one’s quickly identified.
• Despite advance in medicine, still killed.
– Worldwide ≈ 2 Million deaths.
– US ≈ 70,000 deaths, mostly among the elderly.
• Vaccine available but too little too late.
– Asian Flu detected in February.
– Vaccine approved in July. Production begins.
– Not ready until winter.
– By mid October, ≈7 Million people vaccinated.
– Many unused doses left after flu had passed.

28. 1968-1969 Hong Kong Flu (H3N2)
• Detected in July.
• All out vaccine production effort.
– But 1st lot not available until mid-Nov, 3
weeks after 1st US outbreak in California.
– At peak of outbreak, only 10M doses
distributed and ≈6M people protected.
• Again, vaccine was too little too late.
• Milder than previous pandemics.
• Still, ≈ 34,000 deaths in the US.

29. 1976 Swine Flu (H1N1)
• January: Pvt. David Lewis at Ft. Dix dies.
– Soon, 300 other soldiers ill.
• Indications that the flu might be related to the
1918 pandemic.
– Similar strain had been found in pigs since 1920s.
– Legionnaires' disease thought to be the flu.
• This time, the push was to have enough
vaccines in time.
• The National Influenza Immunization
Program

30. Swine Flu vaccination snarls
• Challenges of public perceptions of risks vs. benefits,
unrealistic expectations, and bad press coverage.
• 3 elderly people died soon after the flu shot.
• Cases of Guillain-Barré syndrome (GBS) among some flu
shot recipients.
– Many possible factors for GBS.
– But some people blamed the flu shot for GBS
• Dec 16th, US suspends the program.
– 40 Million people vaccinated for flu that didn’t come.
• Fallout from the “Swine Flu Fiasco”
– Cynicism about govt. health programs.
– For decades afterwards, pandemic flu was a topic best to avoid.

31. But it couldn’t be avoided forever

32. 1997 & 1999 Avian Flu cases
• 1997: H5N1. Hong Kong.
– Several hundred people ill. 18 hospitalized, of which 6 died.
– The more severe illness in young adults resembled the 1918 flu.
– All chickens in Hong Kong killed to prevent virus spread.
– No further human infections found.
• 1999: H9N2. Hong Kong.
– Caused illness in couple of Hong Kong children.
• Direct Bird to Human transmission in both cases.
– No pig intermediary.
– No Human to Human transmission.
• Concerns:
– The viruses presence in birds. Several other cases since 2000.
– Flu viruses ability to change & become transmissible among
humans.
– Avian flu is being monitored.
• That brings us to today.

33. Time factors are critical
• Time to detect & isolate virus.
• Time to decide to make vaccine.
• Time to enact the decision (legal, PR, liability hurdles)
• Time to develop, test, and manufacture vaccine (6 mos)
• Time to vaccinate people.
• Time to develop immunity after vaccination.
• Time for the pandemic to reach your part of the world.
• Might not have vaccine until after the flu passed.
Hypothetical present day: 180 days
1968: 342 days

34. Other lessons
• Time is critical. Yet difficult to commit.
– Value of medical surveillance & early detection.
• Value of volunteers & public cooperation.
• Murphy’s Law can (will) apply.
– Other things can compete for attention.
– Medical people & responders getting sick.
– People may act in unexpected ways.
• Challenge of communications
– Maintaining morale without losing trust.
• We’ve been through this before & survived.

35. Thank you.
Jonathan D. Abolins
Jon.Abolins@gmail.com
jonathan.d.abolins@infragard.org
Blog: http://jabolins.livejournal.com
Certified Homeland Security Professionals
[CHSP] Certification & Learning Portal:
http://www.sighls.org/learning/

36. Bibliography
• “1918 Influenza A (H1N1) Fact Sheet.” Federation of American Scientists.
<http://www.fas.org/programs/ssp/bio/factsheets/H1N1factsheet.html>
• “Author Brings quot;The Great Influenzaquot; to the School.” Johns Hopkins Bloomberg School of Public Health.
<http://www.jhsph.edu/publichealthnews/articles/2005/great_influenza.html>
• Barry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Penguin Books, 2004.
ISBN 0670-8947347.
• The Great Pandemic: The United States in 1918-1919. Office of the Public Health Service Historian.
<http://1918.pandemicflu.gov/>
• Homeland Security – Consequence Management: Pandemic Flu. GlobalSecurity.org.
<http://www.globalsecurity.org/security/ops/hsc-scen-3.htm>
• Iezzoni, Lynette. Influenza 1918: The worst epidemic in American history. New York: TV Books, L.L.C., 1999. ISBN
157500108X
• Kolata, Gina. 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, 1999. ISBN 0374157065.
• Osborn. June, ed. History, Science, and Politics: Influenza in America 1918-1976. New York: PORDIST, 1977. ISBN
0882021761.
• PandemicFlu.gov. US Department of Health & Human Services. <http://www.pandemicflu.gov/>
• “Philadelphia, Nurses, and the Spanish Influenza Pandemic of 1918.” US Navy Historical Center.
<http://www.history.navy.mil/library/online/influenza%20phil%201918.htm>
• Tracking the Next Killer Flu. National Geographic. October 2005. Print edition and Online edition.
<http://ngm.nationalgeographic.com/ngm/0510/feature1/index.html>
• With Every Epidemic, Tough Choices, by Lawrence K. Altman, MD. New York Times; March 28, 2006.
<http://www.nytimes.com/2006/03/28/health/28docs.html>