1918 Flu Pandemic Brings Higher Fatalities than World War 1 - Research Paper Example

? 1918 Flu Pandemic Brings Higher Fatalities than World War Lecturer presentation This research paper is aninvestigation of the 1918 flu pandemic that caused more fatalities than the total number of people killed in the First World War. The first section discusses historical background of the Spanish flu followed by an investigation of mortality and morbidity patterns of the flu pandemic. The third section investigates the public health and medical issues at the times of the outbreak. Medical response to the pandemic is investigated in the fourth section and finally, the lessons learned from the outbreak are discussed in the fifth and final section. According to CDC (2006), the 1918 flu pandemic killed 2% of the world’s human population because of lack of sufficient knowledge about the virus and ineffective medical response. The 1918 flu pandemic provides important lessons for effective monitoring and management of flu outbreaks. Flu pandemics are serious threat to human existence, because of viral antigenic drift that produces new variant strains in every two to three years (Michael, 1998). Introduction The world today remains under serious threat of influenza pandemics. The last ten years have been characterized by outbreak of flu in different parts of the world causing deaths and widespread panic. Although the scale of the recent flu outbreaks do not compare with 1918 pandemic in terms of infections and fatalities, it is evident that the world population remains highly vulnerable to the infection. The United States Department of Health and Human Services (2006) classifies influenza into three different categories. These include seasonal flu, avian flu and pandemic flu. Seasonal flu also called common flu is a respiratory infection that affects people frequently. Although there is a vaccine for seasonal flu, the immune system of most people is capable of fighting the infection. Bird or avian flu is a zoonotic infection transmitted from wild birds to human beings. The H5NI virus that causes avian flu is extremely infectious and fatal to domestic birds. The main medical concern of the avian flu is that currently, there is no effective vaccine against the infection and people do not have immunity. Finally, pandemic flu is highly infectious ailment affecting human beings and it has the potential of causing global outbreak and severe diseases (United States Department of Health And Human Services, 2006). People have minimal immunity against flu infection and therefore the disease is transmitted quickly across an expansive geographic area. In the last century, devastating flu pandemics were reported in different parts of the globe. CDC (2006) estimated that over 43 million people in the world died from flu pandemics in the last 20th century alone. Some of the major flu pandemics included the 1918 Spanish flu, the Asian flu pandemic in 1957 and the Hong Kong Flu of 1968. Historical Perspective of the 1918 “Spanish Flu” Pandemic Before investigating the historical background of the 1918 Spanish flu pandemic, it is important to interrogate the meanings of pandemic and influenza. Michael (1998;51) defines pandemic as an “epidemic of human ailment that occurs over a wide geographical area, crossing international boundaries and affecting large number of people”. There are different forms of pathogens that cause pandemics, including the current HIV/AIDS virus, influenza and in the past, the plague that infected and killed numerous people in the world around 14th century. Flu is the short form of influenza and it causes respiratory disorders in human beings. According to Barry (2004), the common symptoms of flu infection includes fever, muscle aches, cough and in rare circumstances, opportunistic infections such as pneumonia occurs in patients infected with the virus. Flu virus is one of the major causes of death and it affects people of all ages. Human beings are the primary hosts of the virus but it can also spread to domestic animals including horses, pigs and poultry (Ann, Jeffrey, & Thomas, 2001. Virologists have also established that some species of waterfowl carries the virus without causing sickness. In most cases, animals infected with the virus do not show any symptom and they could transmit it to human beings. Flu is a highly communicable disease in human beings and it is spread through air and contact with a person or objected with the virus. Moreover, the virus is transmissible even before the actual symptoms become apparent in a patient and this is one of the major factors attributed to its quick transmission (Bullough, et al 1994). The genome composition of the flu virus consists of eight strands of RNA. Flu virus undergoes random mutation that entails rearrangement of the gene segments resulting to formation of many viral strains. The main types of human flu virus are influenza A and B. In human, influenza A is identified by the two surface antigens, namely Neuraminidase (N) and Hemagglutinin (H). Some combinations of both H and N antigens cause infections, such as H5N1 that causes avian flu (Bullough, et al 1994). The 1918 flu pandemic caused approximately 50 million deaths globally, which represented about 2% of the world’s population. Moreover, about 500 million people in the world contracted the virus (Linder & Grove 1943). The disease was uncharacteristically severe, causing death at the rate of 2.5% to the infected persons compared to other flu pandemics that have mortality rates of less than 0.1% (Jeffrey & David 2006). The cause of the pandemic, its unique epidemiologic characteristics and the background of the pathogen remains largely speculative. According Jeffrey and David (2006), the effects of the flu were not restricted to 1918 and other deadly flu outbreaks that followed later originated from the viral strains of the 1918 pandemic. Long after the 1918 flu pandemic, the source of the flu that caused the outbreak was not yet known and its relationship with swine and bird flu were not yet established. Even today, over 90 years later after the pandemic, many researchers question whether the extremely high fatality rate in the pandemic was caused by influenza. However, in 1930, H1N1 virus that had close resemblance with the 1918 flu was isolated from pigs and later in human beings. This discovery resulted to scientists concluding that the virus was responsible for 1918 flu pandemic. However, in 1950, a new flu pandemic caused by H2N2 strain appeared and according to Jeffrey and David (2006), the virus was a direct descendant of the 1918 flu pandemic. With the emergence of the H2N2 strain, the H1N1 descendants of the 1918 flu pandemic disappeared from the human population, but it still existed in pigs without causing infection. In 1977, H1N1 strains suddenly remerged and they continue circulating in humans and animals. The H1N1 virus persists and several other strains have emerged from it. However, these descendant strains such as H3N1 and H1N1 are not as infectious and fatal as the 1918 flu pandemic (CDC, 2006). The current fatality rates of the H1N1 are lower than H3N2. However, both H1N1 that originated from the 1918 pandemic and the H3N2 persist in the world without showing any sign of getting extinct (David& Peter, 2007). Although virologists discovered these new strains and made connections with the 1918 pandemic, research had failed to establish why the pandemic was so fatal. The two strains, H1N1 and H3N2 considered as the descendants of the 1918 flu pandemic cause relatively mild human flu. After the outbreak, medical research on the virus showed that the viral strain changed immediately after two years causing a reduced death rate and epidemicity. According to Crosby, (1989, frequent flu outbreaks are caused by viral antigenic drift, whereby an antigenic variant virus emerges to become a dominant one every two to three years. In this case, antigenic drift ensures survival of influenza virus that would otherwise become extinct once the body attains optimum immune threshold to fight the flu infection. In this case, it is likely that a genetic change of the highly infectious occurred that resulted into a mild H1N1 viral strain. Gene sequencing of the 1918 flu pandemic begun in 1995 and they have established that the 1918 flu is the most likely ancestor of four different types of human and pig flu viruses of the H1N1 and H3N2 lineage (Ann, Jeffrey, & Thomas, 2001). However, no viral mutation of the flu virus associated with 1918 pandemic has been found from the genome of the highly deadly pandemic so far. Therefore, the gene sequencing of the 1918 flu has not established the origin of the fatal virus and the epidemiology of the pandemic. Prior to the 1918 flu outbreak, the previous flu pandemics originated in Asia and transmitted to the other parts of the world. However, the 1918 pandemic puzzled many scientists about its geographical source because within a period of about 12 months, the virus had spread simultaneously in three continental regions mainly in Europe, Asia and North America (Jeffrey, & David, 2006). In this case, there is no historical evidence establishing the exact geographical origin of the virus. Another defining characteristic of the 1918 flu pandemic was that it affected human and pigs simultaneously. Crosby (1989) argues that the flu could most likely have originated from an avian flu virus that had not spread widely in human and pigs several decades before the 1918 flu pandemic. Recent findings of the pandemic show that the probable ancestor of the 1918 flu was not widely confined in human beings and pigs several decades prior to the 1918 pandemic. In this regard, the exact origin of the pandemic remains largely unknown and speculative. The spacing and timing of flu pandemics has been a subject of controversy for many years. Researchers attribute the varying degree of infection across different geographical regions to varying herd immunity that restricts the spread of the virus in the most favorable conditions. Some of the environmental factors that favor flu pandemics include lower environmental temperatures, human nasal temperature, increased overcrowding, optimum humidity, poor ventilation and increased level of overcrowding especially in public places (CDC, 2006). Morbidity and Mortality Patterns of the 1918 Flu Pandemic The first case of 1918 flu pandemic was recorded in the spring of the same year at an army camp in Kansas. When the United States army was deployed in France the same year, a highly infectious influenza had started spreading among the allied soldiers in France. This was later followed by amore virulent form of virus that spread in southern France and Spain. By August 1918, the flu pandemic had spread widely in Europe, infecting and killing millions of people. At the same time, it spread to other parts of the world simultaneously causing more fatalities (Frost, 1920). According to Frost (1920), the infection pattern of the 1918-19 pandemic occurred in three waves. The first wave was in March 1918 and was transmitted intermittently in United States, Europe, and Asia within the next six months. The wave was characterized by high infection rates and average death rates. The second wave of the flu pandemic occurred between Septembers to November of 1918. The wave spread across the world and it was characterized by very high fatalities. Finally, a third wave of the flu pandemic happened from January to April 1919 causing more deaths but not as high as the second wave (Frost, 1920). The flu pandemic in 1918 affected both the young and the old. However, contrary to expectations of most disease outbreaks, it killed an abnormally high toll of unlikely group aged from 18 to 30 years. Many theories have been brought forward to explain the strange phenomenon; however, one theory holds that army recruitment during the peak of this outbreak contributed to the phenomenon. The United States army recruited many young soldiers of the affected age group from very diverse backgrounds. A combination of poor hygienic state, poor ventilation and overcrowding accelerated the rate of infection leading to high death toll (Crosby, 1989). In the graphical representation shown in figure 1 the dashed line represents the typical mortality pattern of flu pandemic in United States from 1911-1917. However, at the outbreak of the flu pandemic in 1918, shown by the solid line, the mortality rate of young adults from 18-34 years shot up unexpectedly. In normal circumstances, young adults are not affected severely, but during the pandemic, majority of them serving in the First World War were heavily afflicted. Usually, the previous flu pandemics showed predictable pattern of killing children below one year and elderly persons with low death rates at all ages between. However, in the case of 1918 flu pandemic, young people between the ages of 20-40 years accounted to about 50% of deaths caused by the flu. Fig 1: Joint influenza and pneumonia mortality by age at death per 100,000 persons in each age group, in United States, 1911-1918. Influenza and pneumonia specific death rates are plotted for the inter-pandemic years, from1911 to1917 (dashed line) and pandemic year, 1918(solid line) (Linder and Grove, 1943) The 1918 flu pandemic has several distinct mortality traits. To begin with, the death rates among all age groups were between 5-20 times higher than the average death that had occurred from previous flu pandemics. In clinical perspective, the higher mortality rate occurred from the emergence of other respiratory infections, notably pneumonia and bronchitis but not from the direct effects of influenza pandemic. In addition, the pandemic had disproportionately higher mortality rate on young adults than any other previous flu outbreak (Crosby, 1989). Figure 2: Prevalence of respiratory infections in the United States military from April 1917 to December 31, 1919 (Frost, 1920). Hospital admission influenza Bronchitis Broncho- pneumonia Lobar pneumonia Total Hospital admission(US army) 533,649 169,426 16,500 29,429 749,004 Hospital admission(Army in Europe) 218,718 74,458 14,847 14,225 321, 248 Total 24853 469 10,341 11,329 46,992 From the number of infections shown above, it is apparent that the flu pandemic had a huge impact on the military personnel during the First World War. According to Linder and Grove (1943), the flu cost the American military about nine million days because of sickness, deaths and hospitalizations in 1918 alone. The flu drastically reduced the number of troops available for duty, and this was one of the most demoralizing incidents in the American warfare that distracted the military and politicians from the war to fighting the disease. The total number of American soldiers killed by the flu pandemic exceeded those killed in the actual combat. According to Frost (1920), the number of soldiers killed by the flu pandemic was about 57,460, while those killed in combat were about 50,280. The United States military was one of the hardest hit institutions by the influenza whereby in one ten-week period in 1918, over 43,000 soldiers died from the pandemic (Frost, 1920). The total number of Americans killed by the flu pandemic was over 675,000, a figure that exceeds the fatalities in the Civil War, the First and Second World War the Korean and Vietnam wars in addition to Iraq war that in total killed about 423,000 (David &Peter 2007). Public Health Issues and Interventions The flu pandemic coincided with the onset of the First World War and this played a significant role in diverting the attention of the public health authorities. However, shortly before the war during the first wave of the flu pandemic, Rosenow (1919) noted that doctors were generally ignorant of the impending outbreak, despite the ominous warnings of increasing respiratory infections such as pneumonia. In this respect, the first wave of the attack received little public attention. Another issue that undermined quick intervention from the public health department was that no cases of influenza were reported because most doctors attributed the deaths to pneumonia. However, it emerged later that influenza infections were soon followed by pneumonia attacks soon after the body was weakened by the flu infection. Poor coordination of the federal, state and local public health departments also hindered sharing of information and a concerted action to address the pandemic (Rosenow, 1919). When the second wave of the flu pandemic hit Boston and Massachusetts, public health response was still uncoordinated and the public knowledge about the infection was very limited. As a result, there was no meaningful response from the government and the public was distracted with other events at the time including the First World War. According to Miles, et al (2007), the United States Public Health Service (USPHS) was not properly prepared to handle the pandemic mainly because it did not receive updated medical reports from other states. The severity of the second wave of attack jolted the public health department into action, and the first intervention was to create public awareness about the flu pandemic. During that time, there was no vaccine available to inoculate people against the flu. Because of limited knowledge about the flu pandemic at that time, numerous cures and preventive and conflicting measures emerged from the public and medical fraternity as well. The public was warned against overcrowding, the importance of covering their mouth while coughing and sneezing and maintaining high level of hygiene. Advertisements printed in the daily newspapers encouraged people to wear facemasks, avoid coughing sneezing and spitting in public places. Moreover, doctors who failed to report flu cases were fined heavily. In most states, in the US, authorities imposed heavy fines on people who failed to observe the prescribed preventive measures (Rosenow, 1919). Sports and other public functions were banned in severely hit regions Medical Response The flu pandemic caught the medical fraternity by surprise and in initial stages, doctors were not aware of the pandemic and how to address it. Therefore, some medical authorities denied the existence of the pandemic in their areas of jurisdiction, while others underrated the high rate of transmission of the flu virus. Most doctors and healthcare personnel were engaged in the First World War and hence there was severe shortage of medical professionals. Doctors initially thought bacteria caused the pandemic because electron microscope was yet to be discovered to indentify the viruses. In this case, the initial medical response involved treating the infection with antibiotics. Other doctors prescribed inappropriate medicines to the patients. Rosenow (1919) noted that the medical fraternity developed contradicting remedial treatments that did little to control the pandemic. Therefore, it is apparent that the high fatality rate of 1918 flu pandemic was accelerated by poor medical interventions from doctors and heath personnel. Lack of knowledge about the flu virus was therefore a major cause of the unsatisfactory response from the medical fraternity. Lessons Learned from the 1918 Flu Pandemic The flu pandemic demonstrated the heavy economic and social damage that flu pandemic could inflict on humanity because of high fatalities rate and hospitalization. Consequently, the national and global policy makers became more aware of the need to implement effective public health measures in preparedness for flu pandemics that remain a latent threat to human race. At the time of the outbreak, it is apparent that lack of appropriate knowledge about the flu contributed to poor medical and public response. In view of these shortcomings, many countries including the United States and global health organizations such World Health Organization (WHO) became cognizant of the need to implement pandemic flu planning activities and enhancing surveillance of the virus across the globe (Miles, et al 2007). These measures were enhanced by better monitoring methods resulting from increased resource allocation to monitor the flu virus in different parts of the globe. Many resources have since been invested in research and development of new vaccines to address the highly mutating flu virus. Conclusion The 1918 flu pandemic is one of the most disastrous outbreaks in the last century. The pandemic killed about 2% of the global population, and inflicted heavy economic damage and social disorder. Although the exact source and cause of the pandemic remains unknown, scientists later established that H1N1 flu virus was a probable descendant of the flu virus that caused the 1918 pandemic. The flu virus undergoes viral antigenic drift that produces variant pathogenic viruses. These viruses cause periodic flu infectious of differing severity. Flu virus lives in other animals besides human beings such as birds and pigs. In this case, some viral strains are transmitted from infected animals to human beings resulting to flu infection. The 1918 flu pandemic highlighted the need for mobilizing the public and planning for pandemics from local to international levels. Moreover, it is important to undertake continuous monitoring of the flu virus in order to indentify the emerging strains as soon as they appear. References Ann, R., Jeffrey, K., & Thomas, G. (2001). The 1918 Spanish Influenza: Integrating history and biology. Microbes and Infection, 3(1): 34-90. Barry, J. (2004). The great influenza: The epic story of the deadliest plague in history. New York, N.Y.: Viking. Bullough, P, et al (1994). Structure of influenza haemagglutinin at the pH of membrane fusion. Nature 371(6492): 37–43. CDC (2006). Emerging infectious diseases, 12 (1). Crosby, A. (1989). America’s forgotten pandemic: The influenza of 1918. Cambridge: Cambridge University Press. David, S., and Peter, D.(2007). New approaches to confronting an imminent influenza Pandemic. The Permanente Journal, 11(3): 50-73. Frost, W.(1920). Statistics of influenza morbidity. Public Health Report, 35: 531-597. Jeffrey, K., & David, M. (2006). 1918 influenza: The mother of all pandemics. Emerging Infectious Diseases, 12(1): 15-22. Linder, F., and Grove, R.(1943). Vital statistics in the United States: 1900-1940. Washington, DC: Government Printing Office. Michael B. (1998). Virus, plagues, and history. New York, N.Y.: Oxford University Press Miles, O., et al. (2007). Lessons learned from the 1918-1919 influenza pandemic in Minneapolis and St. Paul, Minnesota. Public Health Report, 122(6): 803-810 Rosenow, E.(1919). Prophylactic inoculation against respiratory infections during the present pandemic of influenza: Preliminary report. JAMA, 72: 37-49. United States Department of Health and Human Services (HSS)(2006). Flu terms defined. Accessed on 15 June 2011, from http://www.pandemicflu.gov Read More