Influenza Epidemic of 1918

            In light of the current concerns about the SARS (Severe Acute Respiratory Syndrome) pandemic it helps to put the spread of this disease and the resultant deaths into perspective.  The world is not new to infectious pandemics.  One only has to look to one of the most recent pandemics –  HIV  – to realize their incapacitating effects.  During 2002 alone, 3.1 million people worldwide died from AIDS.  But, even this number is tiny when compared to the influenza pandemic of 1918.

            The influenza pandemic of 1918-1919 killed between 20-40 million people worldwide.  It began to appear at the end of World War I.  At first it may have seemed like a simple cold, much like our current experience with influenza, but it was not so simple.  In the two years that it took to encompass the world it infected one-fifth of the world’s population – including 28% of all Americans.  It reached a mortality rate of 2.5% which was 25 times the rate of previous influenza epidemics.  In fact the effect was so severe that the life span of the average US citizen was decreased by 10 years.

            Stories abound of the rapidity of its spread.  It struck quickly and killed rapidly.  A previously healthy person could fall ill at noon and be dead by nightfall.  Symptoms included labored breathing, terrible coughs and projectile nosebleeds.  Many who did not die from the initial infection died of the complications such as bacterial infections.  Autopsy showed widespread hemorrhage and swelling of the lungs.  It took about three months to cover the globe and about seven days to cross America.  A children’s rhyme of the time illustrates the ease with which it spread:

I had a little bird,
Its name was Enza.
I opened the window,
And in-flu-enza.

            Influenza was also known by the name the “Spanish Flu” and “La Grippe.”  The name of Spanish Flu came from the widely publicized 8 million deaths suffered in Spain in May 1918.  The first case occurred in the United States at Camp Funston in Kansas.  In the March 1918 the soldiers at the Fort were burning horse manure creating a dust storm.  Two days later 107 soldiers had been diagnosed with the flu.  Two days after that 522 cases were reported.  By July 1918 the epidemic had reached Europe, Africa, India, China and Australia.  The first wave died down by August just in time for the second wave to begin.  This too spread quickly.  Both waves, but especially the second, were aided by World War I with extensive troop movements along railroads and shipping lanes that had been improved by the war.  The second wave had spread to all but the remotest areas of the world by January 1919.

            Years later, the Armed Forces Institute of Pathology in Washington, D.C. found the lungs of an infected soldier from 1918 in formaldehyde.  From this they were able to determine that this particular strain of influenza began in birds and then traveled through pigs to humans.

            Among the victims were the medical personnel who were enlisted to care for infected patients.  The needs of the war caused physicians to be in short supply for domestic concerns.  Consequently much of the medical care of patients fell on the shoulders of third and fourth year medical students.  Non-medical staff were also used in containing the spread of the virus by distributing gauze masks for use in the public..

            The core functions of society were also affected.  Businesses closed because of lack of staff members.  Large gatherings were not allowed because of the risk of too many people in a confined space; stores could not hold sales and funerals were limited to 15 minutes.  Bodies had to be disposed of because of the large pile-up that ensued, but the lack of coffins and people to process the dead bodies, such as morticians and grave diggers, could not keep up with the massive numbers of deaths.  The staggering numbers of deaths hit every sector of society and further stretched already strained resources. 

            Through the efforts to contain the spread of influenza by public health officials and the compliance of the general public with these efforts for the good of the nation, the pandemic eventually saw its death in 1919.  An exact number of deaths can never be known because of inaccurate, incomplete or lack of reporting.  One estimate for world wide deaths gives a range of 24.7-39.2 million deaths with a rate of 13.6-21.7 deaths per 1,000 (worldwide population of about 1.8 billion).  The preponderence of deaths were in India with 12.5-20.0 million deaths (or 42-67 deaths per 1,000).  United States estimates are 550,000 deaths or 5.2 deaths per 1,000.  The deaths from the influenza pandemic in the United States were more than its total military deaths in World War I and II, the Korean War and the Vietnam Conflict combined.

            The influenza pandemic of 1918 was devastating to the entire planet.  This particular strain of influenza was the worst infectious agent in terms of total deaths that the planet had ever seen.  To compare, analysis of the SARS epidemic as of July 2003 show 8,439 people infected and 812 dead in 30 countries on 5 continents. 

            We now live a time when diagnosis and prevention are faster and more efficient.  This is evidenced by the unprecedented rapidity with which the characterization of the virus behind the SARS infection was made and the subsequent containment measures were instituted.  Given our current knowledge and skill, it is unlikely that the influenza epidemic of 1918 would be as catastrophic in 2003.

 References:

Patterson, K. David and Gerald F. Pyle. "The geography and mortality of the 1918 influenza pandemic." Bulletin of the History of Medicine 1991 65:4-21.

International Herald Tribune (printed in Belgium), 7 July 2003.

“The Influenza Pandemic of 1918.”  http://www.stanford.edu/group/virus/uda/index.html.  May 11, 2003.

CDC, Divisions of HIV/AIDS Prevention, International Statistics.  http://www.cdc.gov/hiv/stats.htm.  May 11, 2003.