Andrew Milsten, MD, MS, FACEP
“I had a little bird
Its name was Enza
I opened up the window
and in flew enza.”
(children’s rhyme during 1918)
The 1918 influenza epidemic was a fast-moving horror that affected the entire world. In this article, I’ll review the epidemic’s US timeline and highlight some key and interesting points. The Influenza outbreak occurred during the last year of World War I. Medical science was growing, vaccines were being developed, but little was known about viruses. There was no equipment that could visualize a virus at this time, as electron microscopes wouldn’t come into existence until the 1930’s. The medical infrastructure didn’t exist to handle the large number of cases and many of the doctors/nurses needed for treatment were overseas in the war. Overall, the Influenza outbreak killed 50-100 million world-wide and claimed 600,000 lives in America at rapidly appalling pace (1-2% of the world died in less than a year). “It would be as if today, with our present population, more than 1,400,000 people were to die in a sudden outbreak for which there was no explanation and no known cure.”
The first peak is observed during October and November of 1918 and the second peak is seen between February and March of 1919. Half of all deaths in 1918 were of people between 20-40 years old and the virus was especially virulent with a case fatality rate of >2.5%, compared to <0.1% in other influenza pandemics. Many of the excessive deaths from the 1918 pandemic resulted from a disease process that began with a severe acute viral infection that spread down the respiratory tree, causing severe tissue damage that often was followed by secondary bacterial invasion. One proposed theory, has been a “cytokine storm, a deleterious overexuberant release of proinflammatory cytokines such as interleukin-6 and -8 and tissue necrosis factor—α, could have contributed to the high mortality and excessive number of deaths among the young and otherwise healthy during the 1918 pandemic”.
The 1918 influenza virus is indeed the “mother of all pandemics” in that “the impact of this pandemic was not limited to 1918-1919. All influenza A pandemics since that time, and indeed almost all cases of influenza A worldwide (excepting human infections from avian viruses such as H5N1 and H7N7), have been caused by descendants of the 1918 virus, including "drifted" H1N1 viruses and re-assorted H2N2 and H3N2 viruses.”
March 11, 1918
- An Army private at Fort Riley, Kansas reports to the camp hospital with influenza-like symptoms early in the morning. Before the day is over, over 100 soldiers have similar symptoms.
- 48 soldiers died of pneumonia that spring at Fort Riley
- Many Fort Riley soldiers were sent to Europe. There the flu spread. “American soldiers got sick. English soldiers. French. German. As it spread, the microbe mutated, day by day becoming more and more deadly.”
- When these soldiers returned to the US, they brought the virus with them.
- Public health officials in Philadelphia issue a warning about what they call the “Spanish influenza”. It was called the Spanish flu because it was first officially noticed in Spain in May 1918 (Spain was neutral in WWI and was one of the only countries with a reliable press at that time, so they reported the flu earlier than other countries).
- The virus was tracked along international shipping lanes, from Europe to North America, then to Asia, Africa, Brazil and eventually the South Pacific.
- Sailors stationed aboard the Receiving Ship at Commonwealth Pier in Boston begin reporting to the sick bay with cold symptoms.
- The Navy Radio School at Harvard University in Cambridge reports the first cases of influenza among the group of 5,000 young men studying radio communications.
- “Dr. Victor Vaughn, acting Surgeon General of the Army, receives urgent orders to proceed to Camp Devens near Boston. Once there, what Vaughn sees stuns him: “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. In the morning, the dead bodies are stacked about the morgue like cordwood.” That day, 63 men die of influenza.
- The culprit was identified as the flu, but “one of the factors that made this so particularly, frightening was that everybody had a preconception of what the flu was: it's a miserable cold and, after a few days, you're up and around, this was a flu that put people into bed as if they'd been hit with a 2 x 4. That turned into pneumonia, that turned people blue and black and killed them. It was a flu out of some sort of a horror story. They never had dreamed that influenza could ever do anything like this to people before.”
- Medical quackery and folk treatments popped up as people were desperate for medicine. One was wearing camphor balls (in a sack) around the neck. Supposedly the smell would keep germs away.
- Native Americans, who practiced different burial practices, became exposed at alarming rates. The chief clerk of the Navajo Indian reservation reports that influenza has taken the lives of more than 2,000 Navajos in Apache County, New Mexico.
- 12,000 people died of influenza in America during September.
Sept. 5, 1918
- The Massachusetts Department of Health informs local newspapers that they are dealing with an epidemic. A doctor with the Massachusetts State Health Department says, “unless precautions are taken the disease in all probability will spread to the civilian population of the city.”
Sept. 13, 1918
- US Surgeon General Rupert Blue of the United States Public Health Service dispatches advice to the press on how to recognize the influenza symptoms. Blue prescribed bed rest, good food, salts of quinine, and aspirin for the sick.
- Royal Copeland, Health Commissioner of New York City, announced, "The city is in no danger of an epidemic. No need for our people to worry."
Sept. 24, 1918
- Edward Wagner, newly transplanted from Chicago, falls ill with the flu. This flies in the face of San Francisco public health officials who had played down the threat of the flu to the public.
Sept. 28, 1918
- “There were two enormously important things going on at once and they were at right angles to each other. One, of course, was the influenza epidemic, which dictated that you should sort of shut everything down and the war which demanded that everything should speed up, that certainly the factories should continue operating, you should continue to have bond drives, soldiers should be put on boats and sent off to France.... It's as if we could, as a society, only contain one big idea at a time and the big idea was the war.”
- 200,000 gather for a 4th Liberty Loan Drive in Philadelphia. Days after the parade, 635 new cases of influenza were reported. Within days, the city will be forced to admit that epidemic conditions exist. Churches, schools, and theaters are ordered closed, along with all other places of “public amusement.”
- Congress approves $1 million to study the Flu and work on a vaccine.
Oct. 2, 1918
- By this point, the death toll in Boston is 202. The Liberty Bond parades are cancelled as well as all sporting events. The stock market goes on half-days.
Oct. 3, 1918
- The epidemic reaches Seattle, Washington, with 700 cases and one death at the University of Washington Naval Training Station.
Oct. 6, 1918
- Philadelphia records 289 influenza-related deaths in a single day.
Oct. 7, 1918
- New Mexico, which had remained largely untouched by the influenza, reports its first case.
Oct. 11, 1918
- Santa Fe, New Mexico reports its first flu-related death.
- In a single day, 851 New Yorkers die. The death rate in Philly for the period of a single week is 700 times the average. The Chicago crime rate drops 43 percent.
Oct. 19, 1918
- In Philadelphia, Dr. C.Y. White announces he has developed a preventative vaccine. More than 10,000 complete series of inoculations are sent to the Philadelphia Board of Health. Researchers worked on vaccines, under the auspices of the US Public Health Services, but they were focused on bacterium and missed the mark. Thousands of people were inoculated, with no effect.
Oct. 29, 1918
- Six-ply gauze masks become mandatory in Seattle.
- “They were thin and porous -- no serious restraint to tiny microbes. It was like trying to keep out dust with chicken wire.”
Oct. 30, 1918
- Six-ply gauze masks become mandatory in the entire state of Washington.
Oct. 31, 1918
- Because of the Influenza Pandemic that grips the nation, most Halloween celebrations are cancelled due to quarantines.
End of October
- 195,000 people died of influenza in America during October
- Funeral homes had to hire armed guards to stop people from stealing coffins.
- Violence erupted in some areas, with people being shot for not wearing their masks, along with homicides and suicides. “An epidemic erodes social cohesiveness because the source of your danger is your fellow human beings, the source of your danger is your wife, children, parents and so on. So, if an epidemic goes on long enough, and the bodies start to pile up and nobody can dig graves fast enough to put the people into them, then morality does start to break down.”
Nov. 3, 1918
- The News of the World prints some suggested flu precautions: “Wash inside nose with soap and water each night and morning; force yourself to sneeze night and morning, then breathe deeply; do not wear a muffler; take sharp walks regularly and walk home from work; eat plenty of porridge.”
Nov. 11, 1918
- Armistice is announced and World War I came to an end. Though much of the joy is weighed down by the epidemic, people around the world venture out into the streets for the first time in order to celebrate. Many go out without their masks for the first time, leading to a surge in influenza cases in many cities for weeks after the Armistice.
Nov. 18, 1918
- By this date, 5,000 have died in New Mexico.
- Celebrating the end of World War I, 30,000 San Franciscans take to the streets to celebrate. There is much dancing and singing. Everybody wears a face mask.
Nov. 21, 1918
- Sirens sound in San Francisco announcing that it is safe for everyone to remove their face masks.
- 5,000 new cases of influenza are reported in San Francisco.
- Schools reopen in Seattle.
- This is the first month that no influenza deaths are reported in Seattle.
Where did the 1918 Influenza virus originate? The American Experience document noted 3 different discoveries:
- Using lung tissue taken 79 years earlier during the autopsy of a U.S. Army private who died of the 1918 flu, scientists at the Armed Forces Institute of Pathology analyze the 1918 virus and conclude that it is a unique virus but is related to the “swine flu.” According to one researcher: “The hemagglutinin gene matches closest to swine influenza viruses, showing that this virus came into humans from pigs.” (Science, March 21, 1997)
- Feb. 6, 2004. Researchers working separately at the Scripps Institute in La Jolla, California and at Britain’s Medical Research Council discover that the 1918 virus may have jumped directly from birds to humans rather than going from birds to pigs and then infecting humans. They say it explains why the 1918 strain was so deadly, since human immune systems aren’t prepared for viruses coming directly from birds.
- Oct. 2005. Using a technique called reverse genetics, scientists at the Armed Forces Institute of Pathology recreate the 1918 virus. They recovered the genome information from a flu victim who had been buried in Alaskan permafrost since 1918.
- “The Impact of Pandemic Influenza on Public Health” Rashid A. Chotani, MD, MPH. Director, Global Infectious Disease Surveillance & Alert System. Johns Hopkins Bloomberg School of Public Health (ppt lecture)
- Jeffery K. Taubenberger and David M. Morens. Rev Biomed 2006; 17:69-79. 1918 Influenza: The mother of all pandemics. Armed Forces Institute of Pathology, Rockville, Maryland, USA.
- David M. Moren and Anthony S. Fauci. The 1918 Influenza Pandemic: Insights for the 21st Century. The Journal of Infectious Diseases, Volume 195, Issue 7, 1 April 2007, Pages 1018–1028.
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