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AFD - 1918 Pandemic Histories

sharon sanders

Editor-in-Chief & President
Remembering 1918 - An Oral History




# 2114

http://afludiary.blogspot.com/2008_06_01_archive.html




The Spanish Flu of 1918-1919 may be the least mentioned major event of the last century in popular culture. That is in songs, movies, television shows, and novels.

As a bit of a movie buff, particularly very old movies, I constantly look for references to the great pandemic, but almost never find them.

There are a great many movies about the events of that era - World War I, the wildness of the roaring twenties - even the sinking of the Titanic . . . but the influenza that ravaged the world and killed tens of millions gets practically no mention at all.

It is as if the survivors collectively wiped it out of their minds, fearing that even mentioning it would bring bad luck - or perhaps a return of the pandemic.
I can personally think of no other reason that the events of 1918-1919 have been so thoroughly wiped from our collective consciousness. It was simply too horrific to remember.

A notable exception was the short novel Pale Horse, Pale Rider by Katherine Anne Porter published in 1939. It doesn't appear to have ever been made into a movie, although in the 1960's a television play with the same name was produced. I've been unable to obtain a copy, so I am unsure if it is about the same subject.

As a young paramedic in the 1970's, I was lucky enough to have met, and to have talked to many survivors of the Spanish Flu. A great many of my patients were teenagers or young adults in 1918, and on routine calls (nursing home transfers, mostly) they would often talk about `the old days'.

Occasionally, the subject of 1918 would come up. It was obviously a major trauma for most of them, even nearly sixty years after the fact. When they did talk about that time, it was in hushed tones.



Just about all of those of that generation are gone now. My father, now 83, was born six years after the Spanish Flu, and can remember very little talk about it growing up. It just wasn't mentioned. Anyone old enough in 1918 to have much remembrance would have to be at least 95 years old by now.


And so we forgot. As a nation, and as a world.


We spoke not of it in books or movies, nor in television or song. We banished its remembrance and silently prayed it would never return.


Perhaps that is why it is so hard for most people today to accept the possibility that it could happen again.

We don't remember the last time.

Luckily, there are a few serious historical references to 1918.


John Berry's Book, The Great Influenza is of course well known today. The HHS has put together a good website chronicling the events of 1918 as well.



This morning I ran across a video which utilizes photos from the Library of Congress (and other sources) along with audio from Charles Hardy's excellent Talking History segment on the impact of the Spanish Flu on Philadelphia. Recorded in the early 1980's, there were still many survivors of the flu left to interview.



This video, entitled The Killer Within, is hosted on both Youtube, and You Remember That (among others I suppose). It runs about 9 minutes, and while disturbing, is well worth the time to view.



A longer (and arguably better) retrospective comes from the Charles Hardy Talking History show I remember When, which runs about 34 minutes. In it you will hear much about how the influenza was treated in 1918 and the impacts on society.



"I Remember When: What Became of the Influenza Pandemic of 1918." (1983)
Real Media. MP3. Time: 34:51.
"What Became of the Influenza Pandemic of 1918" was also part of Hardy's I Remember When series. Initially aired on January 18, 1983, it focused on the worst pandemic of the Twentieth Century and its impact on Philadelphia, the hardest hit of American cities.

Both of these presentations are extremely well done and well worth your time.

posted by FLA_MEDIC @ 7:59 AM
 
Re: AFD - 1918 Pandemic Histories

Study: Deaths From Bacterial Pneumonia During 1918-1919 Influenza Pandemic




# 2155






Suggested citation for this article: Brundage JF, Shanks GD. Deaths from bacterial pneumonia during 1918?19 influenza pandemic. Emerg Infect Dis. 2008 Aug; [Epub ahead of print]








For nearly 90 years, the debate over why the Spanish Flu of 1918-1919 was so deadly has raged. Estimates put the number of deaths well in excess of 20 million worldwide, with some studies suggesting twice or three times that number.



Survival rates varied immensely from one region to another, and even among disparate ethic groups in the same area.



In New Zealand, as this study points out, death rates were ≈7? higher for indigenous (Maori) populations (influenza deaths 2,160, mortality rate 42.3/1,000) than for other residents (influenza-related mortality rate 4.5/1,000).



In the United States, the overall case fatality ratio (CFR) was roughly 2%, but that wasn't the whole story. Among indigenous peoples, that number was many times higher.



Here is how the authors of this study. appearing in the August edition of the Journal of Emerging Infectious Diseases, describe their hypothesis. (Reparagraphed for readability)





Deaths from Bacterial Pneumonia during 1918?19 Influenza Pandemic

John F. Brundage* and G. Dennis Shanks?
*Armed Forces Health Surveillance Center, Silver Spring, Maryland, USA; and ?Australian Army Malaria Institute, Enoggera, Queensland, Australia



Deaths during the 1918?19 influenza pandemic have been attributed to a hypervirulent influenza strain. Hence, preparations for the next pandemic focus almost exclusively on vaccine prevention and antiviral treatment for infections with a novel influenza strain.



However, we hypothesize that infections with the pandemic strain generally caused self-limited (rarely fatal) illnesses that enabled colonizing strains of bacteria to produce highly lethal pneumonias.



This sequential-infection hypothesis is consistent with characteristics of the 1918?19 pandemic, contemporaneous expert opinion, and current knowledge regarding the pathophysiologic effects of influenza viruses and their interactions with respiratory bacteria.


This hypothesis suggests opportunities for prevention and treatment during the next pandemic (e.g., with bacterial vaccines and antimicrobial drugs), particularly if a pandemic strain?specific vaccine is unavailable or inaccessible to isolated, crowded, or medically underserved populations.





In other words, the authors believe the high death rates encountered in the 1918 pandemic were caused primarily by secondary bacterial pneumonias, not by the inherent pathogenicity of the pandemic virus.





Much of this study is based on contemporaneous reports from doctors treating patients in 1918-1919. Bacterial pneumonia was often cited as the cause of death in pandemic victims.



The authors postulate that those who initially developed bacterial pneumonia became `superspreaders' - via paroxysms of coughing in enclosed areas - of common colonizing strains of bacteria, such as pneumococci, hemolytic streptococci, H. influenzae, and S. aureus.




Quoting from the study:




Finally, for brief periods and to varying degrees, affected hosts became ?cloud adults? who increased the aerosolization of colonizing strains of bacteria, particularly pneumococci, hemolytic streptococci, H. influenzae, and S. aureus (39).



For several days during local epidemics?particularly in crowded settings such as hospital wards, military camps, troop ships, and mines?some persons were immunologically susceptible to, infected with, or recovering from infections with influenza virus. Persons with active infections were aerosolizing the bacteria that colonized their noses and throats, while others?often, in the same ?breathing spaces??were profoundly susceptible to invasion of and rapid spread through their lungs by their own or others? colonizing bacteria.





The authors present a good deal of data in support of their theory, including the two following charts.

























Here we see the attack rate, by age, of the Influenza virus. Notice that the most commonly affected age group are children aged 5 to 9.



























This second chart tracks the incidence of pneumonia by age, along with the overall excess deaths by age. The CFR closely matches the rate of pneumonia, and does not follow the first chart, which is attack rate by age.



If virulence of the virus were the causative agent in most deaths, then the authors argue that 5 to 9 year-olds should have experienced a higher fatality ratio than victims in their mid-20's.







This is a fascinating study, reasonably easy to read, and worth taking the time to review in detail. I've just selected a few of the highlights.





While it may not completely answer the question as to the causes of the virulence of the 1918 pandemic, it does provide plenty of food for thought.






Based on this study, the authors have proposed the following recommendations (again, Reparagraphed for readability):





We suggest that preparations for the next influenza pandemic should focus on more than preventing and treating influenza virus infections. A modified influenza pandemic plan might include the following components:

1) Before a pandemic, expand indications for and decrease barriers to receipt of vaccination against S. pneumoniae (36?38,40).




2) During a pandemic, in communities not yet affected, universally vaccinate with a safe and effective strain-specific influenza vaccine, if available.



3) During local epidemics, treat all serious clinical cases with an antibacterial agent that is effective against S. pneumoniae, S. pyogenes, H. influenzae, and S. aureus (including methicillin-resistant S. aureus); isolate patients with clinical cases from other patients and as many others as possible (35,37?39).



4) Conduct pandemic-related surveillance that tracks the incidence, nature (e.g., species, affected sites, antimicrobial drug sensitivities), and outcomes of bacterial infections that complicate influenza cases.
posted by FLA_MEDIC @ 2:24 PM
 
Re: AFD - 1918 Pandemic Histories

we also had this ARDS, where people often died immediately
within a few days because of an (over)reaction of the immune-system.

Also, I didn't hear that pneumonia did spread independently of
influenza causing pneumonia epidemics with no influenza involved.

We had different curves in other pandemics.
It had been argued that older people had some immunity
from before 1890
 
Re: AFD - 1918 Pandemic Histories

Video: The Forgotten Pandemic



# 2299



A look back at the 1918 Spanish Flu, prepared by the Canadian Press, may be viewed here.


Survivor accounts, 90 year old pictures, and information about how the 1918 pandemic was downplayed by newspapers are just some of the highlights of this 6 minute video.

Well done and highly recommended
 
Re: AFD - 1918 Pandemic Histories

Branswell On The Spanish Flu Of 1918



# 2300




While I'm a blogger, I'm also smart enough to shut up and get out of the way when someone who really knows how to write, produces a must-read article.




Ninety years after deadly Spanish flu outbreak: millions killed, but few remember


Provided by: Canadian Press
Written by: Helen Branswell, Medical Reporter, THE CANADIAN PRESS
Sep. 15, 2008



TORONTO - The Allied Forces were gaining hard-earned ground in the late summer of 1918, carving a path that would shortly lead to an armistice for the First World War.

As those armies battled over the blood-soaked fields of Europe 90 years ago, another enemy was on the move. This adversary didn't choose sides. It didn't restrict itself to Europe. It didn't spare civilians.

By the time it was through rampaging around the globe, this assailant - the Spanish flu - had killed between 50 million and 100 million people, several times more than had lost their lives in the soon-to-be-concluded War to End All Wars.


Yet despite the scope of the death and illness, the fear and social disruption, amazingly - inexplicably - the history books made little mention of what is now viewed as the deadliest outbreak of infectious disease in recorded history.


(Continue reading . . . )





 
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