Spanish flu

"When the first wave of the pandemic arrived, it was not particularly deadly. The only notice British officials took of it was its effect on some workers. A report noted, “As the season for cutting grass began … people were so weak as to be unable to do a full day’s work.” By September, the story began to change. Mumbai was still the center of infection, likely due to its position as a commercial and civic hub. On Sept. 19, an English-language newspaper reported 293 influenza deaths had occurred there, but assured its readers “The worst is now reached.” Instead, the virus tore through the subcontinent, following trade and postal routes. Catastrophe and death overwhelmed cities and rural villages alike. Indian newspapers reported that crematoria were receiving between 150 to 200 bodies per day. According to one observer, “The burning ghats and burial grounds were literally swamped with corpses; whilst an even greater number awaited removal.” But influenza did not strike everyone equally. Most British people in India lived in spacious houses with gardens and yards, compared to the lower classes of city-dwelling Indians, who lived in densely populated areas. Many British also employed household staff to care for them – in times of health and sickness – so they were only lightly touched by the pandemic and were largely unconcerned by the chaos sweeping through the country. In his official correspondence in early December, the Lieutenant Governor of the United Provinces did not even mention influenza, instead noting “Everything is very dry; but I managed to get two hundred couple of snipe so far this season.”"

"Spanish Flu victims suffered massive pneumonia and fatal pulmonary complications: they literally drowned in their own body fluids. Lungs filled with fluid and their skin became markedly discolored from the lack of oxygen. Mysteriously, it killed more young than old. The death rate was greatest among ages 15 to 40."

"As bad as a bout of real seasonal influenza is, the H1 strain was far worse. It killed two percent or more of those stricken. In 1918, postmortem examinations helped understand if it was a case of flu. The performance of those autopsies was harrowing. Influenza defiled the lungs with bloody, frothy fluid. Instead of floating, the lungs plummeted to the bottom of water buckets during autopsies. The bronchials were fluid-filled, which explains the air hunger patients experienced. They frequently died from suffocation within 24–48 hours of developing symptoms. Some died later from secondary infections."

"Maternal mortality rates peaked in 1918 with 916 per 100,000 births. That means one per 1,000 births. The multiplying factor is enormous. There is not, however, a lot of specific data about pregnancy during that time."

"There are two great tragedies: The death of a child, or the death of a young child’s parent. Society saw a lot of both in 1918. There were many orphans in 1918. Several states put together orphan trains for adoption stops, which led to the establishment of the Child Welfare Department."

"The founding 1918 pandemic virus is truly the “mother” of all subsequent influenza pandemics, and we are still in its “pandemic era” today. Its descendants are still evolving, still killing tens of thousands of people every year, with no end in sight."

"The 1918 influenza pandemic offers the worst-case planning scenario for public health officials because it resulted in unparalleled numbers of deaths. The virus, an A(H1N1) subtype, may have infected half the world’s population and caused at least 50 million deaths, according to estimates; 675,000 deaths are thought to have occurred in the United States. The source of the 1918 H1N1 virus is unknown; avian and swine origins have been proposed. Although 3 later pandemics, in 1957, 1968, and 2009, resulted in much lower estimated rates of morbidity and death, the threat of a 1918-like severity pandemic remains, because reports of human infections with novel influenza A viruses (generally of avian or swine origin) that pose pandemic potential have increased in recent years. In particular, Asian lineage avian influenza A (H7N9) viruses caused 1,557 reported human infections and at least 605 deaths during 5 epidemics in China during 2013–2017. Now, 100 years after the 1918 pandemic, is an important time to recall the significant impact of the pandemic and to reflect on the current state of readiness to respond to the next influenza pandemic."

"The virulence of the 1918 H1N1 virus intensified the situation. Epidemiologic parameters of the 1918 pandemic, which include an attack rate of 28% and an estimated basic reproduction number of 1.8, were similar in subsequent influenza pandemics of 1957 and 1968. However, the estimated case fatality proportion of 1.7% in the 1918 pandemic was more than 10 times higher than in the 1957 and 1968 pandemics. Pandemic influenza in 1918 often presented with an unusually severe and swift clinical course. Disease frequently progressed to extensive organ involvement, primary viral pneumonia, and secondary bacterial pneumonia and empyema. Some military physicians reported a rapid clinical course, with death occurring within 24–48 hours after hospital admission. Pneumonia was the cause of death for the vast majority of the deceased. The unprecedented death rate exceeded the capacity of many morgues and funeral homes, and bodies were often “stacked like cord wood” in the halls of both military and civilian hospitals. Ultimately, the death toll, particularly among previously healthy young adults, reduced life expectancy in the United States by 12 years."

"In 1918, the childhood mortality rate for children under five-years-old was one in five. Every household knew of a child who died at a very young age, often of a contagious disease or dehydration issues. Back then, the care of the ill was almost exclusively at home. Today, death has been taken out of the household. Very few people have seen someone die today. In 1918, it was probably 90%. Death issues need to be talked about. For example, what should we do if public gatherings for funerals are cancelled? How will that affect people? There are social effects of quarantine, although now we have some resources to mitigate the effects. Public health departments (municipal, state, and federal) are all funded very differently. Post 9-11, bioterrorism preparedness efforts have been good for public health, because they are not mutually exclusive problems. Whether man-made or ecological, the strategies we need to use to address these problems are not that different."

"Treatment for influenza and its complications was mostly supportive care. Palliatives from pharmacies and vendors were encouraged, if not presented as cures. No antivirals or antibiotics were available; penicillin was not discovered until 1928. One potentially effective therapy for reducing the risk of death was use of convalescent sera collected from patients after their infection and administered to patients with current infection. Many more physicians, however, attempted to treat patients with “vaccines”. At the time, Haemophilus influenzae was the presumed etiologic agent for influenza, referred to as Pfeiffer’s bacillus. Vaccines were made from culture of the bacillus and may have been effective at reducing some secondary bacterial coinfections."

"Remarkably, miniscule degraded viral RNA fragments recovered from just a few of the pandemic’s many millions of victims are now yielding, a century after their deaths, new insights into influenza virus biology and pathogenesis and are providing important lines of investigation into the prevention, treatment, and control of future pandemics."

"While the 1918 H1N1 virus has been synthesized and evaluated, the properties that made it so devastating are not well understood. With no vaccine to protect against influenza infection and no antibiotics to treat secondary bacterial infections that can be associated with influenza infections, control efforts worldwide were limited to non-pharmaceutical interventions such as isolation, quarantine, good personal hygiene, use of disinfectants, and limitations of public gatherings, which were applied unevenly."