Louisiana Homeland Defense Education Team

1. Louisiana Homeland Defense Education Team

2. 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

3. 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.

4. 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

6. 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  

7. 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."

8. 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.

9. 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.

10. 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.

11. 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.

13. 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

14. Six Stages of a Pandemic

15. WHO Phases and US Stagesof a Pandemic

16. Remote Pandemic History • The symptoms of human influenza were clearly described by Hippocrates roughly 2400 yearsago. • 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 18thcenturies, with the pandemic of 1830–1833 being particularly widespread

17. 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)

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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

25. 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.

27. 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.

29. 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.

32. 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….

35. PRE WWI EUROPE

36. 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”

38. 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."

40. 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."

44. 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."

46. 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 StatesPublic 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.

48. 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,"

50. 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."