The Great Influenza
The Epic Story of the Deadliest Plague in HistoryeBook - 2005
From the critics
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"Closing saloons and theaters and churches meant nothing if significant numbers of people continued to climb onto streetcars, continued to go to work, continued to go to the grocer. Even where fear closed down businesses, where both store owners and customers refused to stand face-to-face and left orders on sidewalks, there was still too much interaction to break the chain of infection. The virus was too efficient, too explosive, too good at what it did. In the end the virus did its will around the world."
"It was as if the virus were a hunter. It was hunting mankind. It found man in the cities easily, but was not satisfied. It followed him into towns, then villages, then individual homes. It searched for him in the most distant corners of the earth. It hunted him in the forests, tracked him into jungles, pursued him onto the ice."
Epidemiological evidence suggests that a new influenza virus originated in Haskell County, Kansas, early in 1918. Evidence further suggests that this virus traveled east across the state to a huge army base, and from there to Europe. Later it began its sweep through North America, through Europe, through South America, through Asia and Africa, through isolated islands in the Pacific, through all the wide world. In its wake followed a keening sound that rose from the throats of mourners like the wind.
All subsequent quotes are excerpts from the updated 2009 AFTERWORD:
But in 1997, an H5N1 avian influenza virus, the so-called bird flu, killed six of eighteen people in Hong Kong. Millions of fowl were slaughtered in an unsuccessful effort to wipe it out, and it reemerged with a vengeance in 2003.
Since then, H5N1 and more recently an H7N9 avian virus have been infecting humans at previously unknown rates. Between 2003 and 2017 — the latest numbers as I write this — these viruses have infected 2,342 people and killed 1,053 of them — a case fatality rate of 44.9 percent.
In 1918 such a virus did infect humans. Since the original publication of this book, scientists have found evidence (the question is not settled) that seven of the eight segments of the 1918 virus are of avian origin, and the virus jumped species to humans probably after a reassortment (see 112) with another virus in which it acquired a human hemagglutinin gene — the gene which allows the virus to bind to and thus infect cells. And even that eighth segment had recent avian roots. This reassortment would have occurred when the avian virus infected a mammal — human, horse, pig, whatever — that was simultaneously infected by another influenza virus carrying that gene.
In 1918, the world population was 1.8 billion, and the pandemic probably killed 50 to 100 million people, with the lowest credible modern estimate at 35 million. Today the world population is 7.6 billion. A comparable death toll today would range from roughly 150 to 425 million.
Chiefly because antibiotics would slash the toll from secondary bacterial infections, if a virus caused a 1918-like pandemic today, modern medicine could likely prevent significantly more than half of those deaths — assuming adequate supplies of antibiotics, which is quite an assumption — but tens of millions would still die. And a severe influenza pandemic would hit like a tsunami, inundating intensive-care units even as doctors and nurses fall ill themselves and generally pushing the health care system to the point of collapse and possibly beyond it. Hospitals, like every other industry, have gotten more efficient by cutting costs, which means virtually no excess capacity
— on a per capita basis the United States has far fewer hospital beds than a few decades ago. Indeed, during a routine influenza season, usage of respirators rises to nearly 100 percent; in a pandemic, most people who needed a mechanical respirator probably would not get one. (The strain influenza puts on health care was driven home to me in a personal way on my book tour.
In Kansas City, a flare-up of ordinary seasonal influenza forced eight hospitals to close emergency rooms, yet this was only a tiny fraction of the pressure a pandemic would exert.) This and similar problems — such as if a particular secondary bacterial invader is resistant to antibiotics, or shortages of such seemingly trivial items as hypodermic needles or bags to hold IV fluids (a severe shortage of these bags is a major problem as I write this) — could easily moot many medical advances since 1918. Disease impact would also ripple through the economy to disastrous effect.
With everyone from air traffic controllers to truck drivers out sick, just-in-time inventory systems would crash, supply chains would collapse, for lack of some part production lines would shut down, while schools and day-care facilities might close for weeks, and an overburdened “last mile” would limit the ability of people to work from home.
With the emergence of H5N1, the threat of just such a scenario got the attention of large companies and governments; businesses began working on supply chains and continuity plans; government in developed countries began pouring money into pandemic preparedness, including basic research, vaccine production, and stockpiling certain drugs. In addition, since manufacturing and distributing a vaccine would take months at best, and since no antiviral drugs are very effective, they also asked public health officials to devise policies to mitigate the impact of a pandemic using non-pharmaceutical interventions, or NPIs —
i.e. , what to do without drugs. Since most of these were based on an analysis of events in 1918, I was asked to join in the effort that brought together people with backgrounds in history, laboratory science, public health, international relations, mathematical modeling, and politics. My involvement continued for several years, and I worked with others through the National Academy of Sciences, national security entities, other state and federal agencies, think tanks, and officials in the Bush and Obama White Houses.
Planners prepared for a Category 5 hurricane. The 2009 H1N1 swine flu pandemic, not even a tropical storm, threw them off-balance. This pandemic, the mildest ever known, taught new lessons, including some that required rethinking NPI policy.
The 2009 pandemic killed “only” an estimated 150,000 to 575,000 worldwide, with probably about 12,000 U.S. deaths. (However, if one looks at the 2009 pandemic in terms of total years of life lost, not just deaths, it was much more severe: the average age of victims was only forty, and 80 percent of victims were younger than sixty-five. In seasonal influenza, only 10 percent of deaths occur in those under sixty-five.) By comparison, ordinary seasonal influenza kills up to 650,000 people worldwide annually, and in the United States the disease kills between 3,000 and 56,000 a year, depending mainly on the virulence of the virus and to a lesser extent on the efficacy of that year’s vaccine. The 2009 experience should reassure no one. It seems likely that throughout history many such outbreaks occurred but escaped notice; only modern surveillance and molecular biology allowed us to recognize it as a pandemic.
When the Washington Post asked Tom Frieden, then head of the Centers for Disease Control and Prevention, what scared him the most, what kept him up at night, he replied, “The biggest concern is always for an influenza pandemic. .. [ It ] really is the worst-case scenario.” So where are we now ? What are the lessons ?
Before addressing those questions, we need to understand the commonalities of the few pandemics we have information about: 1889, 1918, 1957, 1968, and 2009. First, all five came in waves. (A few scientists argue that the difference in lethality between 1918 ’ s first and second waves mean that these were caused by different viruses, but evidence showing otherwise seems overwhelming. For one thing, exposure to the first wave provided as high as 94 percent protection against the second wave, far better protection than the best modern vaccine affords, and that’s just one piece of the evidence that the same virus caused both waves.)
In fact, some investigators now speculate that the 1918 virus circulated in humans for several years before mutations allowed it to spread easily. If true, this would of course explode the hypothesis that Haskell was the origin. The 1889 pandemic virus did follow this pattern, generating two and a half years of sporadic outbreaks around the world, including in such large cities as London, Berlin, and Paris, before becoming fully pandemic, blanketing the world in the winter of 1891 – 92.
We also know that every wave of every pandemic has been at least a little different. In 1918, of course, that difference was dramatic, but 1968 may be more puzzling. In the United States, 70 percent of pandemic deaths occurred in the 1968 – 69 influenza season, with the rest in 1969–70. Europe and Asia were the opposite, with few deaths in 1968 – 69 and the overwhelming majority in 1969–70 — even though a vaccine was available by then.
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