The 1918 flu pandemic (commonly referred to as the Spanish flu) was an influenza pandemic that was first found in the United States, appeared in Sierra Leone and France, and then spread to nearly every part of the world. It was caused by an unusually severe and deadly Influenza A virus strain of subtype H1N1. Many of its victims were healthy young adults, in contrast to most influenza outbreaks which predominantly affect juvenile, elderly, or otherwise weakened patients. The Spanish flu lasted from March 1918 to June 1920,^[1] spreading even to the Arctic and remote Pacific islands. It is estimated that anywhere from 20 to 100 million people were killed worldwide, or the approximate equivalent of one third of the population of Europe,^[2][3][4] more than double the number killed in World War I.^[5] This extraordinary toll resulted from the extremely high illness rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms.

The disease was first observed at Fort Riley, Kansas, United States, on March 4, 1918,^[6] and Queens, New York, on March 11, 1918. In August 1918, a more virulent strain appeared simultaneously in Brest, France, in Freetown, Sierra Leone, and in the U.S. at Boston, Massachusetts. The Allies of World War I came to call it the Spanish flu, primarily because the pandemic received greater press attention after it moved from France to Spain in November 1918. Spain was not involved in the war and had not imposed wartime censorship.^[7]

Scientists have used tissue samples from frozen victims to reproduce the virus for study. Given the strain's extreme virulence there has been controversy regarding the wisdom of such research. Among the conclusions of this research is that the virus kills via a cytokine storm, which explains its unusually severe nature and the unusual age profile of its victims (the virus caused an overreaction of the body's immune system?the strong immune systems of young adults ravaged the body, while the weaker immune systems of children and middle-aged adults caused less morbidity and mortality).

1918 Flu world progression, display by arrows.

Mortality

The difference between the influenza mortality age-distributions of the 1918 epidemic and normal epidemics. Deaths per 100,000 persons in each age group, United States, for the interpandemic years 1911?1917 (dashed line) and the pandemic year 1918 (solid line).^[8]

Chart of deaths in major cities

An estimated 7 million died in India, about 2.78% of India's population at the time. In the Indian Army, almost 22% of troops who caught the disease died of it . In the U.S., about 28% of the population suffered, and 500,000 to 675,000 died. In Britain as many as 250,000 died; in France more than 400,000. In Canada approximately 50,000 died. Entire villages perished in Alaska and southern Africa. Ras Tafari (the future Haile Selassie) was one of the first Ethiopians who contracted influenza but survived,^[12] although many of his subjects did not; estimates for the fatalities in the capital city, Addis Ababa, range from 5,000 to 10,000, with some experts opining that the number was even higher,^[13] while in British Somaliland one official on the ground estimated that 7% of the native population died from influenza.^[14] In Australia an estimated 12,000 people died and in the Fiji Islands, 14% of the population died during only two weeks, and in Western Samoa 22%.

This huge death toll was caused by an extremely high infection rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms.^[9] Indeed, symptoms in 1918 were so unusual that initially influenza was misdiagnosed as dengue, cholera, or typhoid. One observer wrote, "One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred."^[10] The majority of deaths were from bacterial pneumonia, a secondary infection caused by influenza, but the virus also killed people directly, causing massive hemorrhages and edema in the lung.^[8]

The unusually severe disease killed between 2 and 20% of those infected, as opposed to the more usual flu epidemic mortality rate of 0.1%.^[8][10] Another unusual feature of this pandemic was that it mostly killed young adults, with 99% of pandemic influenza deaths occurring in people under 65, and more than half in young adults 20 to 40 years old.^[15] This is unusual since influenza is normally most deadly to the very young (under age 2) and the very old (over age 70), and was due to partial protection caused by exposure to a previous Russian flu pandemic of 1889.

History

While World War I did not cause the flu, the close troop quarters and massive troop movements hastened the pandemic. Researchers speculate that the soldiers' immune systems were weakened by the stresses of combat and chemical attacks, increasing their susceptibility to the disease.

A large factor of worldwide flu prevalence was increased travel. The modern transportation systems made it easier for soldiers, sailors, and travelers to spread the disease quickly and to communities worldwide.

American Red Cross nurses tend to flu patients in temporary wards set up inside Oakland Municipal Auditorium, 1918

I had a little bird,
Its name was Enza,
I opened the window,
And in-flew-enza.
-American Skipping Rhyme circa 1918

Obey the laws
And wear the gauze.
Protect your jaws
From septic paws.

Patterns of fatality

The influenza strain was unusual in that this pandemic killed many young adults and otherwise healthy victims ? typical influenzas kill mostly infants (aged 0-2 years), the elderly, and the immunocompromised. Another oddity was that this influenza outbreak was widespread in summer and fall (in the Northern Hemisphere). Typically, influenza is worse in the winter months.

People without symptoms could be stricken suddenly and within hours be too weak to walk; many died the next day. Symptoms included a blue tint to the face and coughing up blood caused by severe obstruction of the lungs. In some cases, the virus caused an uncontrollable hemorrhaging that filled the lungs, and patients drowned in their body fluids (pneumonia). In others, the flu caused frequent loss of bowel control and the victim would die from losing critical intestinal lining and blood loss.

In fast-progressing cases, mortality was primarily from pneumonia, by virus-induced consolidation. Slower-progressing cases featured secondary bacterial pneumonias, and there may have been neural involvement that led to mental disorders in a minority of cases. Some deaths resulted from malnourishment and even animal attacks in overwhelmed communities.

Devastated communities

Street car conductor in Seattle not allowing passengers aboard without a mask in 1918.

Even in areas where mortality was low, those incapacitated by the illness were often so numerous as to bring much of everyday life to a stop. Some communities closed all stores or required customers not to enter the store but place their orders outside the store for filling. There were many reports of places with no health care workers to tend the sick because of their own ill health and no able-bodied grave diggers to bury the dead. Mass graves were dug by steam shovel and bodies buried without coffins in many places.

Unaffected locales

In Japan, 257,363 deaths were attributed to influenza by July 1919, giving an estimated 0.425% mortality rate, much lower than nearly all other Asian countries for which data are available. The Japanese government severely restricted maritime travel to and from the home islands when the pandemic struck. The only sizeable inhabited place with no documented outbreak of the flu in 1918–1919 was the island of Marajó at the mouth of the Amazon River in Brazil . In the Pacific, American Samoa^[16] and the French colony of New Caledonia ^[17] also succeeded in preventing even a single death from influenza through effective quarantines. In Australia, only 12,000 perished compared to higher rates in other countries.

Government Response

The Great Influenza was the source of much fear in citizens around the world. Further inflaming that fear was the fact that governments and health officials were downplaying the influenza. While the panic from WWI was dwindling, governments attempted to keep morale up by spreading lies and dismissing the influenza. On Sept. 11, 1918, Washington officials reported that the Spanish Influenza had arrived in the city. The following day, roughly thirteen million men across the country lined up to register for the war draft, providing the influenza with an efficient way to spread. However, the influenza had little impact upon institutions and organizations. While medical scientists did rapidly attempt to discover a cure or vaccine, there were virtually no changes in the government or corporations. Additionally, the political and military events were fairly unaffected due to the impartiality of the disease, affecting either side likewise. ^[18]

Cultural Impact

In the United States, despite the relatively high morbidity and mortality rates that resulted from the epidemic in 1918-1919, the Spanish flu remained a relatively obscure event until the rise in public awareness of bird flu and other pandemics in the 1990s and 2000s. This has led some historians to label the Spanish flu a ?forgotten pandemic.? ^[19] Indeed, one of the only major works of American literature written after 1918 that deals directly with the Spanish flu is Katherine Anne Porter?s Pale Horse, Pale Rider. More recently (2006), author Thomas Mullen wrote a novel called The Last Town on Earth, about the impact of the Spanish flu on a fictional mill town in Washington and author Myra Goldberg wrote a novel called Wickett's Remedy that is set in Boston during the pandemic.

Several theories have been offered as to why the Spanish flu may have been ?forgotten? by historians and the public over so many years, including the rapid pace of the pandemic (it killed most of its victims in the United States in a period of less than nine months), Americans' familiarity with pandemic disease in the late 19th and early 20th centuries, and the distraction of the First World War.^[20] Another explanation is shown when observing the age group affected by the disease. The majority of fatalities, in both World War One and by the Spanish Flu, were young adults. The deaths caused by the flu were overlooked due to the deaths from the war. When people would read the obituaries they would see the deaths from war and the deaths from the influenza side by side. Seeing the figures right next to each other lessened the impact the influenza had on individual people. ^[21] The fact that the disease would usually only affect a certain area for a month before leaving, left little time for the disease to have a significant impact on the economy. During this time period pandemic out breaks were not uncommon, the terror of typhoid, yellow fever, diphtheria, and cholera all occurred near the same time period. These outbreaks lessened the impact the Influenza pandemic had on Americans. ^[22]

Spanish flu research

One theory is that the virus strain originated at Fort Riley, Kansas, by two genetic mechanisms ? genetic drift and antigenic shift ? in viruses in poultry and swine which the fort bred for local consumption, but evidence from a recent reconstruction of the virus suggests that it jumped directly from birds to humans, without traveling through swine.^[23]

An effort to recreate the 1918 flu strain (a subtype of avian strain H1N1) was a collaboration among the Armed Forces Institute of Pathology, Southeast Poultry Research Laboratory and Mount Sinai School of Medicine in New York; the effort resulted in the announcement (on October 5, 2005) that the group had successfully determined the virus's genetic sequence, using historic tissue samples recovered from a female flu victim buried in the Alaskan permafrost and samples preserved from American soldiers.^[24]

On January 18, 2007, Kobasa et al. reported that monkeys (Macaca fascicularis) infected with the recreated strain exhibited classic symptoms of the 1918 pandemic and died from a cytokine storm^[25] ? an overreaction of the immune system. This may explain why the 1918 flu had its surprising effect on younger, healthier people, as a person with a stronger immune system would potentially have a stronger overreaction.^[26]

Victims

Albertan farmers wearing masks to protect themselves from the flu.

Famous

• Guillaume Apollinaire, French poet (? November 9, 1918)
• Felix Arndt, American pianist (? October 16, 1918)
• George Freeth, father of modern surfing and lifeguard (? April 7, 1919)
• Sophie Halberstadt-Freud, daughter of Austrian psychoanalyst Sigmund Freud, (? 1920)
• Harold Gilman, British painter (? February 12, 1919)
• Henry G. Ginaca, American engineer, inventor of the Ginaca machine (? October 19, 1918)
• Charles Tomlinson Griffes, American composer (? April 8, 1920)
• Joe Hall, Montreal Canadiens defenceman, a member of the Hockey Hall of Fame (? April 6, 1919).
• Phoebe Hearst, mother of William Randolph Hearst, (? April 13, 1919)
• Francisco Marto, Fátima child (? April 4, 1919)
• Jacinta Marto, Fátima child (? February 20, 1920)
• Alan Arnett McLeod, Victoria Cross winner, (? 6 November, 1918)
• Sir Hubert Parry, British composer, (? October 7, 1918)
• William Leefe Robinson, Victoria Cross winner, (? December 31, 1918)
• Edmond Rostand, French dramatist, best known for his play Cyrano de Bergerac, (? December 2, 1918)
• Egon Schiele, Austrian painter (? October 31, 1918). His wife Edith, who was six months pregnant, succumbed to the disease only three days before.
• Yakov Sverdlov, Bolshevik party leader and official of pre-USSR Russia (? March 16 1919)
• Mark Sykes, British politician and diplomat (? February 16, 1919)
• Max Weber, German political economist and sociologist (? June 14, 1920)
• Prince Erik, Duke of Västmanland (Erik Gustav Ludvig Albert Bernadotte), Prince of Sweden, Duke of Västmanland (? September 20, 1918)
• Vera Kholodnaya, The first star of Russian silent cinema (? February 16, 1919)
• Dark Cloud (actor), aka Elijah Tahamont, American Indian actor, in Los Angeles (1918).
• Franz Karl Salvator (1893-1918), son of Archduchess Marie Valerie of Austria and Archduke Franz Salvator, grandson of Empress Elisabeth of Bavaria and Emperor Franz Joseph I of Austria, died unmarried and childless.
• Anaseini Takip?, Queen of Tonga from 1909, consort of King George Tupou II of Tonga, survived by one daughter, (? November 26, 1918)
• Louis Botha, first Prime Minister of the Union of South Africa, (? August 27, 1919)^[27]
• Harry Elionsky, American champion long-distance swimmer^[28]
• "Admiral Dot" (1864-1918), circus performer under P. T. Barnum^[29]
• Irmy Cody Garlow, daughter of Buffalo Bill Cody^[30]
• Harold Lockwood, silent film star, (? October 19, 1918)^[31]
• Larry Chappell, American baseball player, (? November 8, 1918)
• Angus Douglas, Scottish international footballer, (? December 14, 1918)

Fictional

• Hazel Forrest Bellamy, a fictional character in the television series "Upstairs, Downstairs" (played by Meg Wynn Owen) (? 1918)
• William Krichinsky, a fictional character in the film "Avalon", directed by Barry Levinson
• Fanny and Jemma Macgregor in If I Die Before I Wake by Jean Little
• Elizabeth Masen and Edward Anthony Masen Sr., fictional characters in the Twilight series by Stephenie Meyer. (? 1918) Main character Edward Cullen was saved from a similar influenza death by being bitten by a vampire.

References

Further reading

• . A popular history.

External links

• Video from Expert Panel Discussion on Avian Flu
• ''Nature'' "Web Focus" on 1918 flu, including new research
• Influenza Pandemic on stanford.edu
• Article: The Deadliest Fall
• Influenza 1918 in the United States on pbs.org
• Secrets of the Dead: Killer Flu (PBS)
• Flu by Eileen A. Lynch. The devastating effect of the Spanish flu in the city of Philadelphia, PA, USA
• Dialog: An Interview with Dr. Jeffery Taubenberger on Reconstructing the Spanish Flu
• The Deadly Virus - The Influenza Epidemic of 1918, by the National Archives and Records Administration (see actual pictures and records of the time).
• The 1918 Influenza Pandemic in New Zealand - includes recorded recollections of people who lived through it
• Experts Unlock Clues to Spread of 1918 Flu Virus - The New York Times
• PBS - recovery of flu samples from Alaskan flu victims
• An Avian Connection as a Catalyst to the 1918-1919 Influenza Pandemic
• Alaska Science Forum - Permafrost Preserves Clues to Deadly 1918 Flu
• Pathology of Influenza in France, 1920 Report
• "Deadly secret of 1918 flu virus unmasked", Cosmos magazine, September 2006
• Yesterday's News blog, 1918 newspaper account on impact of flu on Minneapolis
• "Lethal secrets of 1918 flu virus" BBC News, January 2007
• "Study uncovers a lethal secret of 1918 influenza virus" University of Wisconsin - Madison, January 17, 2007
• "The site of origin of the 1918 influenza pandemic and its public health implications" Journal of Translational Medicine, January 20, 2004

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