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1918 Protective Sequestration: A Study of 7 Towns

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  • 1918 Protective Sequestration: A Study of 7 Towns

    http://www.med.umich.edu/medschool/c...enza/index.htm

    This is a 2005 study conducted by the University of Michigan Medical School on 7 towns that had experienced extremely low influenza rates. The report is lengthy and I've written a summary here: http://www.setbb.com/fluwiki2/viewto...forum=fluwiki2. We can bring any part of it over here for discussion if there is an interest.
    ------------------------------------------------------------------

    General Conclusions from the Historical Record with Policy Recommendations

    Pandemic Preparedness
    • Swift, agile, decisive, and coordinated action based on accurate information and advanced preparedness planning, before the appearance of influenza in the local area, is critical.
    • Standardized case definitions for suspected, probable, and confirmed diagnoses promote clarity and consistency in disease tracking and play a positive role in disease containment.

    Benefits and Liabilities of Protective Sequestration
    • Successful protective sequestration was the exception to the rule in the 1918-1920 pandemic. The escape of a community from the brunt of the pandemic was likely the result of multiple factors in the cases we studied, not least of which included good fortune, viral normalization patterns, and geographical separation. We should not be seduced into thinking we can easily translate these historical examples into contemporary situations.
    Protective sequestration (the shielding of a defined and still healthy group of people from the risk of infection from outsiders), if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved without draconian enforcement measures, and continued for the lengthy period of time during which the area is at risk, stands the best chance of protection against infection. When implemented
    successfully, protective sequestration also involves quarantine of any outsider who seeks entry, self-sufficiency in the supplies necessary for daily living, enforcement of regulations when necessary (including fining and jailing), and the ability of those sequestered to entertain themselves and maintain some semblance of a normal life. It also involves a brand of bold leadership which may not be common.
    • It is likely that once an outbreak of a highly virulent virus easily transmitted from person to person via aerosol or respiratory droplets occurs, larger communities will not be able to escape pandemic influenza completely. For this reason, plans for the protective sequestration of sub-communities within these areas should be considered. For example, personnel and facilities critical to the maintenance of national security and universities should consider formulating plans for the rapid protective sequestration of their populations at the first onset of cases in the wider region and before cases develop locally.
    • It is important to recall that the most successful protective sequestrations were maintained for a period of months to ensure that the pandemic was well on the wane. Measures to ensure the integrity of the protective sequestration (as well as concomitant NPI) while preventing alienation, depression, loneliness, stigmatization, resentment, and hostility among the confined population should be developed as a central part of a pandemic preparedness plan.
    • Protective sequestration employed during the second wave may have prevented influenza cases during this period and may have been a factor in these communities experiencing milder morbidity and mortality rates in successive waves once the measures were lifted. Conversely, these measures have the potential to create susceptible populations affected by subsequent waves of influenza. At the very least, in current pandemic planning, protective sequestration could shield selected populations from infection until vaccines and antiviral agents become available.

    Nonpharmaceutical Interventions (NPI) During a Pandemic
    • Available data from the second wave of the 1918 influenza pandemic fail to show that any other NPI (apart from protective sequestration) was, or was not, effective in helping to contain the spread of the virus. American communities engaged in virtually the same menu of measures, including: 1) the isolation of ill persons; 2) the quarantine of those suspected of having direct contact with the ill; 3) social distancing measures, such as the cancellation of schools and mass gatherings; 4) reducing an individual’s risk for infection, (e.g., face masks, hand washing, respiratory etiquette); and 5) public health information campaigns and risk communications to the public. Despite these measures, most communities sustained significant illness and death; whether these NPI lessened what might have been even higher rates had these measures not been in place is impossible to say on the basis of available historical data.
    • If other NPI stand a chance of working, the lines of political and legal authority must be transparent. The harmonious cooperation of trusted and competent local, state and federal health officials, backed by the letter of the law, is critical. Internecine rivalries or disagreements between local, state, and federal agencies have a strong potential to detract from pandemic influenza prevention and containment. More broadly, this is one of the strongest themes in the history of epidemics and disasters in the United States over the past two centuries.
    • At present there is great debate among public health experts on the efficacy of face masks. Learning a lesson from the past, we should not let masks engender a false sense of protection. Indeed, we could not locate any consistent, reliable data that would support the conclusion that face masks, as available and as worn during the 1918-1920 influenza pandemic, conferred any protection to the populations that wore them. Furthermore, recommendations and laws regarding face masks during this period often incited political and legislative controversies as well as outright resistance. In addition, when public health authorities relaxed these measures because they believed the pandemic had passed, only to confront new cases of influenza in their communities, they frequently found that the reinstitution of a face mask ordinance was met with a much lower degree of support and compliance when compared to its initial implementation. We also found numerous examples of people wearing face masks incorrectly during the 1918-1920 pandemic. Instructing people on the proper use of face masks (if they are to be worn at all in an upcoming pandemic), as well as their limitations, is important to public health education efforts.
    • Our study uncovered repeated examples of social concerns and anxieties associated with the mandated delay of funeral arrangements and/or the reduction of attendance at funerals in order to cut down on human contact during the crisis. An influenza pandemic has the potential to cause large numbers of deaths. The emotional strain of not being able to dispose of the dead promptly, and in accordance with cultural and religious customs, has the power to create social distress and unrest and needs to be considered in contemporary pandemic preparedness planning.
    The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

  • #2
    Re: 1918 Protective Sequestration: A Study of 7 Towns

    Great summary mixin! Could you post it here please.

    Comment


    • #3
      Re: 1918 Protective Sequestration: A Study of 7 Towns

      There are also summary reports for each of the select communities on the U of M website.

      Two stand out: Fletcher, Vermont and Camp Crane, Allentown, PA. The latter wasn't in the original list, but was added for it's low morbidity and mortality, despite being a military training camp.

      Fletcher Vermont wasn't exactly a showcase for community public contact control. Despite it's proximity to Camp Devens and nearby towns struck hard by influenza, and despite considerable social activity during the height of the Fall wave, it managed to sqweek by with a very mild caseload.

      The reasons for this aberration are quite interesting; the population density ninety years later was only 1100 - it's not a thriving metropolis.

      Allentown PA was recovering nicely from the Long Depression (1870s-1890s), in the early Twentieth Century, and was on it's way to becoming one of the three largest textile centers in the US. It made steel, but not like nearby cities such as Bethlehem.

      It had beer. Lots of beer. Despite being just 60 miles north of one of the hardest hit cities of the 1918 pandemic, Allentown didn't fare too badly. Camp Crane, situated in the heart of the industrial sector of Allentown, instituted sensible sanitary controls, including generous bed spacing, boiling all public use vessels and utensils, use of bed canopies to control exhaled contagion, and early isolation of early fever symptom cases. They also installed temporary shelving/walls between beds to break up air flow - that was probably a big factor in controlling secondary infection, in lieu of antibiotics that were yet to be discovered.

      Officers lived in public housing off-camp; they were encouraged to follow camp sanitary controls - so camp controls weren't 'air tight'. The relatively low troop density present during the Fall outbreak was an important factor for the low morbidity - despite it's location in the middle of a smaller city; it was the unusual degree of antiseptic controls played a significant role in infection containment.

      The military command also employed camp sanitary modifications unknown at other installations, including sequential site drainage projects, installation of large centralized hot water boilers for showering/cleaning within most buildings and secondary boilers for the mess hall (cooking/ food prep quarters also paid close attention to state-of-art knowledge of sanitation). The camp was built on the County Fairgrounds - so buildings were hastily modified for initial use, then refurbished and the site improved during 1917 and early 1918.

      See Camp Crane History pdf, at the UMMS website.

      What is missing in the synopsis page and its references on Camp Crane at the UMMS website, is this:

      In 1917, when the decision was made by the President with agreement of Congress to enter into WWI, the US First Expeditionary Force was formed.

      "As soon as practical, Camp Crane was established at Allentown, Pa. primarily as a mobilization and training camp for the Ambulance Service, though later it was utilized as a general mobilization camp for Medical Department units."

      Yuppers. It was a trained US Army Medical Emergency Response Unit.

      http://history.amedd.army.mil/booksd...s/chapter6.htm

      Comment


      • #4
        Re: 1918 Protective Sequestration: A Study of 7 Towns

        The towns studied were:
        Yerba Buena Island (San Francisco Training Station)
        Gunnison, Colorado
        Princeton, New Jersey (Princeton University)
        Pittsburgh, Pennsylvania (Western PA Institution for the Blind)
        Saranac Lake, New York (Trudeau Tuberculosis Sanatoruim)
        Bryn Mawr, Pennsylvania (Bryn Mawr College)
        Fletcher, Vermont.
        Camp Crane @ Allentown PA was also included because of its strong NPI selection.

        The report concludes:
        (1) Protective sequestration (the shielding of a defined and still healthy group of people from the risk of infection from outsiders), if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved without draconian enforcement measures, and continued for the lengthy period of time at which the area is at risk, stands the best chance of protection against infection.

        When implemented successfully, protective sequestration also involves quarantine of any outsider who seeks entry, self-sufficiency in the supplies necessary for daily living, enforcement of regulations when necessary (including fining and jailing), and the ability of those sequestered to entertain themselves and maintain some semblance of a normal life.

        (2) Available data from the second wave of the 1918-1920 influenza pandemic fail to show that any other NPI (apart from protective sequestration) was, or was not, effective in helping to contain the spread of the virus.

        American communities engaged in virtually the same menu of measures:
        1) the isolation of ill persons
        2) the quarantine of those suspected of having direct contact with the ill
        3) social distancing measures, such as the cancellation of schools and mass gatherings
        4) reducing an individual’s risk for infection, (e.g., face masks, hand washing, respiratory etiquette)
        5) public health information campaigns and risk communications to the public.

        Despite these measures, most communities sustained significant illness and death; whether these NPI lessened what might have been even higher rates had these measures not been in place is impossible to say on the basis of available historical data. Moreover, we could not locate any consistent, reliable data that would support the conclusion that face masks, as available and as worn during the 1918-1920 influenza pandemic, conferred any protection to the populations that wore them.
        The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

        Comment


        • #5
          Yerba Buena

          All interactions with others living in the Bay Area were halted.
          Crews of supply tugs were prevented from coming any closer than 20 feet from sailors on the dock.
          Recruits coming from the mainland were required to have their nasopharynxes sprayed with a 10 per cent argyrol solution (a topical anti-infective solution prepared by the reaction of silver oxide with gelatin or albumin) and were required to wear gauze masks before they were allowed to board the ferry bound for Yerba Buena Island.
          Upon arrival at the island they were placed in a quarantine camp for several days.
          During this period they were required to wear masks, had their throats sprayed with argyrol solution three times a day, and maintain a distance of 20 feet from one another.

          Other NPI:
          Quarantine,
          daily inspection of personnel and the taking of temperatures,
          early isolation of the sick,
          the wearing of face masks and gowns and rigid aseptic technique by attendants upon the sick
          the early transfer of patients to a base hospital
          the retention and isolation of patients in dispensaries where they could be segregated in small groups instead of being brought into immediate or indirect contact with large numbers of other patients
          strict attention to ventilation
          relief of overcrowding
          use of muslin screens between bunks or hammocks in barracks prevention of gatherings indoors as much as possible
          restrictions on travel, particularly by common carriers
          the application of nose and throat sprays to those not yet attacked
          the use of prophylactic vaccines
          the very general and intensive use of educational measures
          the very rigid enforcement of sanitary rules and regulations
          the spigots of all drinking fountains were heated twice daily with the flame of a gas torch
          all telephone transmitters were disinfected

          (Interesting bit about the 3rd wave and the neighboring island)
          While the number of cases among military personnel experienced only a slight increase in January, civilian personnel at the navy yard were “seriously affected” by the resurgence of the disease. Some observers thought that the third wave primarily affected civilians who might have already contracted some type of upper respiratory infection but who had not contracted influenza during the earlier wave.
          The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

          Comment


          • #6
            Gunnison, Colorado

            The news headline read: "The Flu is After Us" and part of the story was "“We should take every precaution and while nothing in the world can prevent our having it, the measures taken will doubtless distribute it over a longer time so that everybody will not be sick at once, with not one left to care for the dangerously ill.”

            Unlike most other western Colorado towns, Gunnison took a very early and active interest in the spread of influenza across the United States in 1918.
            Barracades were erected on the main highways
            Lanterns and signs warned anyone stopping would be quarantined
            Travel points within the county were temporarily prohibited
            Closings, etc were also enacted.

            After some opposing opinions, Gunnison officials agreed to keep all NPI in place until mid January. On Feb 5, all measures were lifted for the town and county.

            The 3rd wave hit in mid March and a total of 140 flu cases were reported but all were mild. The fact that the county had very few cases during the period of protective sequestration and then reported at least 140 influenza cases after the policy was lifted suggests that the NPI played a role in keeping Gunnison County relatively safe in the autumn and early winter of 1918-19.

            When county officials did contemplate partially lifting the quarantine measures in December, they had the examples of other towns that had done just that and had courted renewed disaster.

            If protective sequestration is determined to be effective in dealing with an influenza pandemic, the issue still remains of how to keep up morale and cooperation at a time of heightened stress.
            The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

            Comment


            • #7
              Re: 1918 Protective Sequestration: A Study of 7 Towns

              Interesting notes about 2 of the sequestered facilities:

              The Institution for the Blind: After lifting sequestration late in November and allowing students to go home for Thanksgiving, 12 cases were diagnosed upon their return in December. While the flu raged in Pittsburgh, the school reported no deaths, despite the fact that it was located in the heart of a residential neighborhood.

              Trudeau Tuberculosis Sanatorium: Even though isolation was practiced before and after the flu outbreak, there were 27 flu cases in Feb 1919, during the 3rd wave. No patient deaths were reported; however 1 orderly died.

              Interestingly, most of these patients were vaxed with Pfeiffer's bacillus.
              -----------------------------------------------------------------------------

              I read in another article that it was suspected the reason for such a high fatality rate among young people was because many of them also had Tuberculosis. That is contradictory to the findings here.
              The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

              Comment


              • #8
                Face Masks

                Typically, mask orders were first issued for health workers
                As the epidemic worsened, mask wearing was often recommended for the general population
                Finally, as the pandemic further intensified, mask ordinances were passed by city, county, and state authorities and the violation of such ordinances made punishable by fines ranging from $5 to $10 and jail sentences ranging from several days to weeks.

                Conclusion:
                • Initially, many people wore face masks willingly and voluntarily, in deference to both the importance of public health and patriotism during World War I.
                • As time went on, however, especially in areas where mandatory face mask laws were enacted, political and legislative debate and grassroots resistance often developed.
                • From the epidemiological evidence related to the 1918 pandemic, it is not possible to prove or infer that the wearing of face masks affected the infectivity rate in either a positive or negative way in the communities where ordered.
                • Communities were much less likely to support disruptive NPI when ordered a second time.
                When community-wide social distancing measures were lifted and then reinstated and then followed by further restrictions or ratcheting-up, the historical record suggests that non-compliance and resistance were likely to follow.

                Effectiveness:
                Dr. Kellogg (CA state health commissioner) demonstrated that infection and death rates were similar in Boston and Buffalo, neither of which passed a mask ordinance
                Los Angeles had lower rates without a mask law
                Stockton suffered even higher rates than San Francisco despite a more consistent and stringent mask policy.
                Crosby corroborates this conclusion, noting that the number of deaths in San Francisco was similar to deaths in non-masked cities – in the end, about 50,000 cases and about 3,700 deaths in a city with a population of approximately 500,000

                Tucson residents did not comply as willingly with the mask ordinance as their San Francisco and Seattle counterparts. The Tucson Citizen estimated that 90% of the city’s residents were non-compliant.

                In some places, handkerchiefs were accepted as substitutes
                Many women chose to wear chic masks made of chiffon lest they appear unfashionable.

                The historical record suggests that the institution of a mandatory face mask ordinance has the potential to produce social conflict.
                The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

                Comment


                • #9
                  Re: 1918 Protective Sequestration: A Study of 7 Towns

                  Barry reports the celebration in San Francisco after the
                  2nd wave was gone, how they beated the flu with masks.

                  Barry:
                  > they thought, _they_ did it (with masks). But it was just that
                  > the flu lost its
                  > virulence after time. And then the 3rd wave did hit SF hard,
                  > worse than other cities in the west.

                  I remember one request from the major in another town to
                  report experience from using masks. That document is somewhere online
                  I'm interested in expert panflu damage estimates
                  my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

                  Comment


                  • #10
                    Re: 1918 Protective Sequestration: A Study of 7 Towns

                    After reading this, I wonder about the *waves*.
                    Maybe they were more successful in containing the flu than they thought?
                    They would enact NPI and the flu would recede; as soon as they lifted NPI, the flu returned.

                    What places, either here or other parts of the world, did not use any forms of NPI? Did they have waves also, or did it devastate and leave?
                    The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

                    Comment


                    • #11
                      Re: 1918 Protective Sequestration: A Study of 7 Towns

                      Lose of virulence and the quarantine of Australia
                      other lessons we are learning from the re-examinations of the 1918 pandemic. The illness struck in three distinct waves, each spaced by a few months, like an earthquake and its aftershocks -- something we will have to prepare for with bird flu.

                      The value of staying isolated from the early stages of the disease has also become apparent. H1N1 hit Samoa early in its lifecycle, arriving on the island in October 1918, and killed 22% of those infected. It arrived in New Zealand just a month later and mortality was down to 2%. Australia's quarantine kept the disease out until January 1919 and the subsequent death rate was less than 1%.

                      Spanish flu ran down the lethality curve remarkably quickly. Jennings says this is why with pandemic planning now, every week the disease can be delayed is critical. Even travel between country towns will be restricted if it comes down to it.
                      http://www.flutrackers.com/forum/showthread.php?t=66854

                      Comment


                      • #12
                        Re: 1918 Protective Sequestration: A Study of 7 Towns

                        "Australia's quarantine kept the disease out until January 1919 and the subsequent death rate was less than 1%."

                        When people traveled a month by ships to go there ...

                        That's why all air travel must be grounded very early instead of the "temperature sensoring policy". Allowing eventualy only cargo plains with staff/goods decontamination procedures.

                        Alternatively every airport must have quarantined apartmans facilities incorporated (min. 2 weeks stay) for all passengers - that seems dificult.

                        Comment


                        • #13
                          Re: 1918 Protective Sequestration: A Study of 7 Towns

                          the high CFR in Samoa had probably other reasons.

                          Do we have a statistics for cities:
                          date of peak in fall 1918, CFR ?


                          -------edit---------
                          page 10 here: [large file !]
                          http://statelibrary.dcr.state.nc.us/...R34JuneDec.pdf

                          --------edit------------

                          http://www.flutrackers.com/forum/showthread.php?t=27075


                          [could be large files, not for slow connection]
                          http://statelibrary.dcr.state.nc.us/...19.pdf#Table10
                          page 2 , cities - table --###done
                          page 3f, together with 28f : deaths per state rural vs. cities, influenza and all deaths , 4 numbers per state
                          page 12-13 , total deaths 1919 by month and city


                          same for 1918 :
                          http://statelibrary.dcr.state.nc.us/...18.pdf#Table10
                          presumably other years are in the library too

                          http://statelibrary.dcr.state.nc.us/...USPHR47All.pdf
                          page 6
                          6 cities, autumn 1918, weekly


                          http://statelibrary.dcr.state.nc.us/...USPHR35All.pdf
                          page 4f , cases 1920 by city, weekly
                          page7f , excess influenza by cities, 1918, 12weeks

                          more deaths in later waves in cities who did well
                          in the 2nd wave. The relationship is D(3)+D(4)~-0.15*D(2)+22.
                          where D(i) is the deathrate per 1000 in wave i .

                          So 15% of spared deaths (compared with e.g. Philadelphia)
                          come back as real deaths (in average)
                          in later waves.


                          age and sex and races data not yet considered. Could be useful to determine whether the
                          virus has changed, how much pre-1918 was similar to 1918 or nowadays H3N2


                          http://statelibrary.dcr.state.nc.us/...R34JuneDec.pdf
                          page5 , weekly 1918, 13 British cities
                          page6 , weekly 1918 , 14 European and Indian cities
                          page13 , weekly 1917,1918 , London,Paris,Dublin



                          lots of intersting graphs and figures about 1918 here:
                          http://www.cdc.gov/ncidod/dq/pdf/flu_figures.pdf
                          I'm interested in expert panflu damage estimates
                          my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

                          Comment

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