Friday, March 27, 2020

Influenza Pandemic of 1918-19 (Maynard, MA)

Revisiting a column written in 2018, so much more germane now.

Since the influenza pandemic of 1918-19 there have been smaller pandemics – the Asian flu of 1958-59 and the Hong Kong flu of 1968-69 each killing on the order of one million people worldwide. And now, COVID-19, a coronavirus pandemic of uncertain severity and duration.

Fort Devens, MA: Influenza epidemic afflicted thousands of soldiers. No
 ventilators. No antibiotics. Click on photos to enlarge.
September 1918, Camp Devens (later renamed Fort Devens), west of Littleton, was a major staging area for tens of thousands of U.S. Army troops preparing to ship off to Europe, we having entered into World War I in April of that year. Fort Devens was also one of the two earliest stateside sites of the “Spanish Flu”, the other being among Navy personnel stationed in Boston. At Devens, the first case was reported September 8. By September 23 the number of men ill exceeded 10,500. Deaths reached 100/day. Nationwide, more than 675,000 Americans died (out of a total population 1/3 of what it is today). Worldwide, within little over two years, the flu infected an estimated one-fourth of the world’s population, killing between fifty and one hundred million.

Deaths were unevenly distributed by age and by region of the world. In developed countries – those with hospitals and nursing care – deaths were on the order of one percent of the population. With poorer medical care, more like five to ten percent, and in remote reaches of the earth where people had fewer prior exposures to any strains of influenza, exceeding twenty percent. Influenza typically kills the young and the old. What was unique about this flu was that there was a high risk of death for people ages 15-35 years, the reason being that their immune systems responded too vigorously.

Town of Maynard, Annual Report for 1918, shows the impact in late Sept.
and early Oct. The number columns are age in years, months, days. 
The fact that World War I was ongoing contributed to the speed the flu spread worldwide. Troops were constantly being moved. War-time censorship hindered knowledge of the extent of the problem. This censorship was why the popular name was the “Spanish flu,” as Spanish newspapers, in a country neutral in WWI and hence not censored, produced lots of headlines and articles about the disease, whereas in countries at war, bad news was censored. Without real-time information, communities within these countries were slow to institute isolation and quarantine.

Viruses have been described as being a bit of bad news (in the form of a strand of DNA or RNA) wrapped in proteins. For the influenza pandemic damage was threefold: 1) the virus getting into cells, replicating and then killing those cells so as to re-enter the blood stream to find new cells, 2) the patient’s immune system reaction to the foreign proteins coating the outside of the virus, causing more damage than the actual virus, and 3) viral infection damage creating an opportunity for bacterial pneumonia. The flu caused so much damage because it reached deep into the lungs (as does COVID-19), rather than just the upper respiratory system, and because it triggered a massive inflammation response. In effect, many people were dying of collateral damage as their immune system over-reacted while trying to neutralize the virus. At autopsy, lungs were often blueish, signifying oxygen deprivation, and filled with fluid. Those the virus-triggered reaction did not kill outright were at high risk of succumbing to bacterial pneumonia.

Glenwood Cemetery, Maynard, MA. People dying from
influenza who had no families to claim them were buried
 in unrecorded and unmarked graves. 
Locally, the arrival of influenza is documented in the Town of Maynard Annual Report, which reported deaths with causes noted. The first death identified as either influenza or “la grippe” dates to September 22, 1918, the last on July 21, 1919. In that interval there were 38 deaths identified as influenza and another 18 attributed to pneumonia. Combined, a bit under one percent of the population. Likely, twenty times that number had become ill but recovered. Schools were closed for five weeks. Theaters, movie houses, dance halls and places of worship were ordered closed.

Then and now, the goal of prohibiting public gatherings and closing businesses was to slow the rate at which a contagious disease spread. Slow, not stop. Slowing allows healthcare facilities to keep ahead of the demands for staff, equipment, supplies and hospital beds. Slowing gives time to test existing and new drugs, even time for work on a vaccine. Back in 1918 there being no antibiotic drugs to combat the bacterial pneumonia. Influenza vaccines were first mass-produced during World War II, used primarily to protect military personnel.

Surface proteins on influenza virus change so quickly that a new vaccine is developed every year. Preliminary research on corona viruses suggests that the mutation rate is lower, so that a successful vaccine could be good for years, and also that people who survived an initial infection with this corona virus will be resistant to reinfection.

Not in the newspaper column:
Interestingly, deaths in the U.S. may have been in part caused by a recommendation from the the US Surgeon General, the US Navy, and the Journal of the American Medical Association to treat the flu with very high doses of aspirin (8-30 grams). The theory, poorly tested, was that aspirin would lower fever and blunt the immune over-response, but it was not understood that aspirin itself could cause pulmonary edema. An example of too-hasty, try-anything treatment. Starko KM. Salicylates and pandemic influenza mortality, 1918–1919 pharmacology, pathology, and historic evidence. Clinical Infectious Diseases, 49(9);2009:1405–10. 

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