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"21st Century Flu Pandemic Insights from 20th Century History." Presentation given 21 April 2009 for the NJ chapter of InfraGard. A look at "lessons learned" from history of …

"21st Century Flu Pandemic Insights from 20th Century History." Presentation given 21 April 2009 for the NJ chapter of InfraGard. A look at "lessons learned" from history of pandemics.

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  • 1. 21st Century Flu Pandemic Insights from 20th Century History Presentation for NJ Chapter Infragard Tuesday 21 April 2009 Jonathan D. Abolins, CHSP
  • 2. I had a little bird, Its name was Enza, I opened the window, And in-flu-enza. -American Skipping Rhyme circa 1918
  • 3. Introduction • Have forms and insurances cards ready. (Just kidding.) • Not speaking as a medical expert. • Gleaning lessons from history to help present planning for the future.
  • 4. Flu by any other name… • Influenza - from Italian “influenza di freddo” – “influence of the cold.” • Grippe - from Old French for “claw” or “quarrel” • Blitzkatarrh or Blitz Katarrh in German. Lit. “Lightning catarrh” or “very fast mucus discharge.”
  • 5. Some technical terms • Pathogen = a disease causing organism. • Epidemic = local or regional outbreak of a contagious disease. • Pandemic = global epidemic. • Isolation = Controlling communicable disease spread by separating persons known to be ill from those who aren’t. • Quarantine = Like isolation, for people exposed to the disease but who may or may not be ill yet.
  • 6. Simplified flu virus nomenclature (designation scheme) Type of Neuramindase nuclear material Hemagglutinin A/Fujian/411/2002 (H3N2) Virus Geographic Strain Year of Virus Type Origin Number Isolation Subtype
  • 7. Typical flu symptoms • Fever (usually high) • Headache • Tiredness (can be extreme) • Cough • Sore throat • Runny or stuffy nose • Body aches • Diarrhea and vomiting – More common among children than adults. NOTE: Other diseases, such as the cold, may have these symptoms.
  • 8. Why the fuss about the flu? • Highly contagious. • Flu can kill. – The elderly and people with certain medical conditions at higher risk. – Some flu strains can be far more lethal than the usual seasonal flu. “I know how not to get AIDS. I don’t know how not to get the flu.” - Alfred W. Crosby, Jr. quoted by Gina Kolata in “Flu”
  • 9. Birds eye view of our timeline • Pre – 20th Century • 1918-1919 “Spanish Influenza” pandemic • 1957-1958 “Asian Flu” pandemic • 1968-1969 “Hong Kong Flu” • 1976 “Swine Flu” potential pandemic • 1997 & 1999 “Avian Flu” cases • The present
  • 10. Pre 20th Century • 431 BCE plague hit Athens. Flu? • 876 flu (?) epidemic slowed Charlemagne’s conquest of Europe. • 1580 flu followed new trade routes. • 1889 – 1890: Severe pandemic. – > 250,000 deaths in Europe – 15-25 Million deaths worldwide.
  • 11. 1918 “Spanish influenza” (H1N1) • Deadliest known outbreak. • 50-100 Million deaths worldwide. 675,000+ US. – Influenza and complications killed 1.0% - 2.5% of the victims. – Dropped 1918 US life expectancy by 12 yrs. – Killed more people in 24 wks than AIDS had in 24 yrs. – Compare with combat deaths: • WW1 9.2 Million; WW2 15.9 Million Remember the human population has grown since then: World 1918 ≈ 1.8 Billion 2009 ≈ 6.7 Billion US 1918 ≈ 103 Million 2009 ≈ 306 Million
  • 12. Symptoms of the 1918 flu • Normal flu symptoms. • But many patients had other symptoms that could include – High fever – Nasty, “rib cracking” cough – Dark spots on cheeks – cyanosis (turning blue), suffocation. – Lungs filling with a frothy, bloody substance, massive pulmonary hemorrhages – Death. • Sometimes, death came hours after the visible onset of illness.
  • 13. 1918 flu hits young adults hard % Mortality for Ages • Flu deaths usually among the very young & the very old. Typical • The 1918 flu tended to kill people 20 to 40 years old. – “W mortality curve” <10 10s 20s 30s 40s 50s 60+ – People age <65 accounted for 99% of the excess mortality of the time. 1918 • Possible reasons: – Damage to the lungs as their healthier immune systems fought the virus. • Acute respiratory distress syndrome (ARDS) <10 10s 20s 30s 40s 50s 60+ – Another factor may be the impact of other infections, including pneumonia or TB, on top of the flu’s viral infection.
  • 14. 3 Waves. 1st – Spring 1918 • Most likely first appeared in Kansas in March. • Seemed mild at the time. • The unusual age & mortality curve unnoticed. – Influenza was not routinely tracked in those days. – “It’s only the flu” view. • By summer, subsided in the US. Went overseas. • The flu went around the world in 4 months. – This is before the era of air travel!
  • 15. 2nd Wave – Late August 1918 • The flu changed into new strain or strains. • First hit 3 ports – Boston; Brest France; Freeport, Sierra Leone • Really bad! Got people’s attention. • Now, we’ll look at the conditions & responses… Boston  Brest, France  Freeport, Sierra Leone 
  • 16. Wartime conditions • Collision of public heath & the war effort. • This was a WORLD war. – High mobility. – Push to get “doughboys” to Europe ASAP. – Military demand for doctors & more nurses. Shortages. • Highly crowded conditions. • Liberty Loan drives and other patriotic gatherings. • Some people suspected German germ warfare. • Wartime censorship. – Why “Spanish” Flu?
  • 17. Social & economic impacts • Many people panicked by the symptoms. • While some helped the ill, others fled. – Some of the sick died from starvation, etc. – Sometimes, it was hard to recruit volunteers. • The pandemic may have cost the US >$600 Billion (est. in present day dollars) – Including decreased business & closings.
  • 18. Medical services overwhelmed • Example: San Francisco Hospital – By end of Oct 1918, had 1,100 pneumonia patients, overflowing capacity. – Admitted 3,509 respiratory cases during the pandemic. Of these, 26% died – 78% of nurses fell ill. – Others may have been ill but soldiered on. Emergency hospital set up in an auditorium in Oakland.
  • 19. Measures varied across the US Among measures used: – Prohibited or restricted public gatherings. – Quarantine & isolation. – Education campaigns. – Deploying public health doctors & nurses. – Vaccinations (ineffectual) – Mask laws and laws against spitting, etc. • Stiff fines for “mask slackers,” spitters, etc. A “mask slacker” barred from getting onto a streetcar.
  • 20. Philadelphia & the 1918 flu • 26% of doctors & even more nurses in military. • 75% hospital staff overseas. • Sep18th: Flu first appeared at the naval base. • Campaign against coughing, sneezing, and spitting. Days after Philadelphia’s Liberty Loan parade in • Oct 3rd: public gathering ban issued. September 1918, which was attended by 200,000 people, • Firemen, garbage collectors & other hundreds of cases of influenza were reported. city employees fall sick. [Credit: Naval Historical Center] • City morgue overflowing. Convicts dig graves. City opens 5 more morgues. • Oct 27th: public gathering ban lifted.
  • 21. What to tell the public? • Officials sought to keep up morale. – Full information was not given. – Emphasized a “do not fear” message. – “Fear Kills More Than the Disease.” – Said that one’s safe if following recommended precautions. • But the public was seeing a drastically different reality. – That may have increased fear. • Challenge of communications to gain compliance, keep up morale, etc. without “cognitive dissonance” or disillusionment.
  • 22. Racing for a vaccine - 1918 • Viral cause unknown until 1930s. – Flu though to be caused by bacteria. “Pfeiffer’s Bacillus” (Haemophilus influenzae) • Vaccine research was on the wrong track. – Viral cause of flu discovered later. • Dr. Joseph Goldberger’s experiment to get 39 volunteers infected. – Pfeiffer’s Bacillus doses, contact with flu patients, etc. It fails! Non caught the flu. (Murphy’s Law at work.)
  • 23. 3rd Wave – Spring 1919 • Not as bad as the 2nd wave. • Much of the world exposed. • Still, many people got ill. – Many communities had lifted measures. – In many places, public balked at renewed restrictions. • Afterwards – Some people had some debilitation. – Possible impact upon Versailles Treaty negotiations. – Scientific progress in understanding flu.
  • 24. Vaccines after 1918 • 1930s-1940s – Techniques for making flu vaccines start to be developed. – Viruses can be grown in embryonated chicken eggs. – US military develops & tests vaccines in the 1940s. • Time factors: – At least 6 months to develop, test, and produce vaccines for commercial distribution. – ≈3 weeks after injection to have immunity. • Obstacles – Early vaccines had common side effects. Fever and sore arms. – Economic issues (liability, profitability)
  • 25. 1957-1958 Asian Flu (H2N2) • Unlike 1918 flu, this one’s quickly identified. • Despite advance in medicine, still killed. – Worldwide ≈ 2 Million deaths. – US ≈ 70,000 deaths, mostly among the elderly. • Vaccine available but too little too late. – Asian Flu detected in February. – Vaccine approved in July. Production begins. – Not ready until winter. – By mid October, ≈7 Million people vaccinated. – Many unused doses left after flu had passed.
  • 26. 1968-1969 Hong Kong Flu (H3N2) • Detected in July. • All out vaccine production effort. – But 1st lot not available until mid-Nov, 3 weeks after 1st US outbreak in California. – At peak of outbreak, only 10M doses distributed and ≈6M people protected. • Again, vaccine was too little too late. • Milder than previous pandemics. • Still, ≈ 34,000 deaths in the US.
  • 27. 1976 Swine Flu (H1N1) • January: Pvt. David Lewis at Ft. Dix dies. – Soon, 300 other soldiers ill. • Indications that the flu might be related to the 1918 pandemic. – Similar strain had been found in pigs since 1920s. – Legionnaires' disease thought to be the flu. • This time, the push was to have enough vaccines in time. • The National Influenza Immunization Program
  • 28. Swine Flu vaccination snarls • Challenges of public perceptions of risks vs. benefits, unrealistic expectations, and bad press coverage. • 3 elderly people died soon after the flu shot. • Cases of Guillain-Barré syndrome (GBS) among some flu shot recipients. – Many possible factors for GBS. – But some people blamed the flu shot for GBS • Dec 16th, US suspends the program. – 40 Million people vaccinated for flu that didn’t come. • Fallout from the “Swine Flu Fiasco” – Cynicism about govt. health programs. – For decades afterwards, pandemic flu was a topic best to avoid.
  • 29. But it couldn’t be avoided forever
  • 30. 1997 & 1999 Avian Flu cases • 1997: H5N1. Hong Kong. – Several hundred people ill. 18 hospitalized, of which 6 died. – The more severe illness in young adults resembled the 1918 flu. – All chickens in Hong Kong killed to prevent virus spread. – No further human infections found. • 1999: H9N2. Hong Kong. – Caused illness in couple of Hong Kong children. • Direct Bird to Human transmission in both cases. – No pig intermediary. – No Human to Human transmission. • Concerns: – The viruses presence in birds. Several other cases since 2000. – Flu viruses ability to change & become transmissible among humans. – Avian flu is being monitored. • That brings us to today.
  • 31. Time factors are critical • Time to detect & isolate virus. • Time to decide to make vaccine. • Time to enact the decision (legal, PR, liability hurdles) • Time to develop, test, and manufacture vaccine (6 mos) • Time to vaccinate people. • Time to develop immunity after vaccination. • Time for the pandemic to reach your part of the world. • Might not have vaccine until after the flu passed. Hypothetical present day: 180 days 1968: 342 days
  • 32. Other lessons • Time is critical. Yet difficult to commit. – Value of medical surveillance & early detection. • Value of volunteers & public cooperation. • Murphy’s Law can (will) apply. – Other things can compete for attention. – Medical people & responders getting sick. – People may act in unexpected ways. • Challenge of communications – Maintaining morale without losing trust. • We’ve been through this before & survived.
  • 33. Thank you. Jonathan D. Abolins Jon.Abolins@gmail.com jonathan.d.abolins@infragard.org Blog: http://jabolins.livejournal.com Certified Homeland Security Professionals [CHSP] Certification & Learning Portal: http://www.sighls.org/learning/
  • 34. Bibliography • “1918 Influenza A (H1N1) Fact Sheet.” Federation of American Scientists. <http://www.fas.org/programs/ssp/bio/factsheets/H1N1factsheet.html> • “Author Brings quot;The Great Influenzaquot; to the School.” Johns Hopkins Bloomberg School of Public Health. <http://www.jhsph.edu/publichealthnews/articles/2005/great_influenza.html> • Barry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Penguin Books, 2004. ISBN 0670-8947347. • The Great Pandemic: The United States in 1918-1919. Office of the Public Health Service Historian. <http://1918.pandemicflu.gov/> • Homeland Security – Consequence Management: Pandemic Flu. GlobalSecurity.org. <http://www.globalsecurity.org/security/ops/hsc-scen-3.htm> • Iezzoni, Lynette. Influenza 1918: The worst epidemic in American history. New York: TV Books, L.L.C., 1999. ISBN 157500108X • Kolata, Gina. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It. New York: Farrar, Straus and Giroux, 1999. ISBN 0374157065. • Osborn. June, ed. History, Science, and Politics: Influenza in America 1918-1976. New York: PORDIST, 1977. ISBN 0882021761. • PandemicFlu.gov. US Department of Health & Human Services. <http://www.pandemicflu.gov/> • “Philadelphia, Nurses, and the Spanish Influenza Pandemic of 1918.” US Navy Historical Center. <http://www.history.navy.mil/library/online/influenza%20phil%201918.htm> • Tracking the Next Killer Flu. National Geographic. October 2005. Print edition and Online edition. <http://ngm.nationalgeographic.com/ngm/0510/feature1/index.html> • With Every Epidemic, Tough Choices, by Lawrence K. Altman, MD. New York Times; March 28, 2006. <http://www.nytimes.com/2006/03/28/health/28docs.html>