#216
Conventional wisdom states that the devastating Spanish Flu pandemic of the early part of the last century erupted without warning in the spring of 1918, killed tens of millions of people in 3 successive waves, and then disappeared mysteriously in 1919. And while often quoted, this wisdom appears to be wrong.
Increasingly we are seeing evidence to support the notion that the Spanish Flu had been simmering quietly, and largely unnoticed, for several years before it exploded across the globe. And an analysis of flu outbreaks well into the late 1920’s supports the notion that it did not go away in 1919, but simply returned in smaller, localized outbreaks over the next decade.
Instead of being an 18-month event, the Spanish Flu may well have severely impacted the globe for nearly 15 years. While controversial, and not wholly accepted by the scientific community, this concept has been gaining traction over the past couple of years.
To support this theory, we can look back at historical records from that period, and while not conclusive, they are compelling.
In the Annual Report of the Secretary of the Navy from 1919, we learn that the incidence of a similar flu had been widely reported in various parts of the world in the years preceding 1918.
Quoting:
Prevalence of Influenza in Recent Years.
Influenza appears to have become unusually prevalent again in the United States at least as early as 1916, when the death rate from this cause in the registration area was 26.4 per 100,000. This was an increase of 65 per cent over the rate for 1915, which was 75 per cent higher than that for 1914.
In 1917 the death rate for influenza was lower again--17.2 per 100,000. The rate for influenza, however, does not mean so much in years when the disease is not generally recognized, and it is significant that the death rate for all forms of pneumonia in the registration area in 1917 was 149.3 per 100,000, as compared with 137.3 in 1916, the highest rate since 1900. In 1900 the rate was 180.5, probably an influenza year, although the rate for influenza itself was higher in 1901 when it was 32.2.
The report of the registrar general of England and Wales for the year 1916 shows that the numbers of deaths from influenza reported by years from 1911 were as follows;
1911 4,334
1912 5,352
1913 6,387
1914 5,953
1915 10,471
1916 8,782
Thus the number of deaths reported in 1915 was nearly double that for preceding years.
Influenza was epidemic in various parts of Europe throughout 1918, and undoubtedly the earlier outbreaks were carried over from 1917. The files of The Lancet indicate that a more or less widespread epidemic occurred in England in the spring of 1915. The disease does not appear to have been as prevalent in 1916 as in 1915, but in 1917, among the military forces, cases of so-called "purulent bronchitis" occurred which were fundamentally the same as the rapidly fatal cases of influenzal pneumonia so frequently seen at the height of the pandemic.
An epidemic of purulent bronchitis was reported from a British Army base in northern France in January, 1917, whilst an epidemic of influenza was in progress. This outbreak began in December, 1916. Later, in the spring of 1917, similar cases of purulent bronchitis were treated at Aldershot, England. These cases are noteworthy because they seem to have been similar in all respects to the fatal types of influenzal pneumonia so commonly seen in all parts of the world during the autumn of 1918. The epidemic referred to was reported by Hammond, Rolland, and Shore in The Lancet, July 14, 1917. They remark that although the earlier cases were admitted during December, 1916, it was not until the end of the following January, when exceptional cold prevailed, that the disease assumed epidemic proportions. The disease was very fatal and was the cause of death in 45.5 per cent of 156 consecutive cases coming to necropsy. Clinically, the prominent signs were the characteristic yellow purulent or mucopurulent sputum, tachycardia, and cyanosis. The pathological findings were thick purulent material in the smaller bronchi from which frequently air was excluded; in some cases secondary broncho-pneumonia, edema, and emphysema. The lungs were almost always bulky. The cause of the disease was thought to be the Pfeiffer bacillus because of its almost constant occurrence in the sputum and in the pus in the bronchioles. In some typical cases it occurred apart from the presence of any other microorganism, although more frequently pneumococci or streptococci were associated with it.
Abrahams, Hallows, Eyre, and French in The Lancet, September 8, 1917, reported their observations of scores of similar cases in the Aldershot command. Their conclusions were almost identical with those recorded above. Case fatality rates were approximately 50 per cent. Stress was laid upon a peculiar dusky heliotrope type of cyanosis of the face, lips, and ears, as a characteristic sign. They found that whether cultures were made from the sputum itself or from material obtained by lung puncture, or from the blood or organs post mortem, influenza bacilli and pneumococci were constantly found and they conjectured that the disease started as an influenza bacillus infection, terminating in fatal cases as a pneumonococcus septicemia, the pneumococcus increasing its virulence by growth in symbiosis with B. Influenzae.
It would appear then that localized outbreaks of a particularly severe form of influenza were occurring at least 3 years before the pandemic of 1918, and this flu carried with it a very high mortality rate. The descriptions of the most critical patients, the heliotrope cyanosis, match the descriptions of patients that would emerge from the 1918 Spanish Flu.
What we cannot know with certainty is whether these earlier outbreaks were the H1N1 virus that caused the Spanish flu. We didn’t even understand that influenza was caused by a virus back then, and had no method of testing. Still, the evidence points to a much earlier beginning to the pandemic, and that the `pandemic years’ of 1918-1919 were simply the peak of the bell curve.
Just at the lead up to the 1918 outbreak appears to have been longer than previously thought, the end of the pandemic may not have been as abrupt as commonly thought.
In this extract from:
REVIEW AND STUDY OF ILLNESS AND MEDICAL CARE WITH SPECIAL REFERENCE TO LONG-TIME TRENDSPublic Health Monograph No. 48, 1957 (Public Health Service Publication No. 544) by SELWYN D. COLLINS, Ph.D.
Published in 1957, we find this chart showing the Excess annual death rates from influenza and pneumonia in the population of various States and groups of cities in the United States, 1887-1956.
At the top level of the chart, the pandemic of 1889-1890 is clearly represented. Another significant spike in influenza occurred in the 1899-1900 period, although the scale is different on this chart, and the spike is not nearly as high as in 1889.
Influenza like illnesses were on the decline for the next 15 years but began to bubble up again in 1915 and again in 1917. It should be noted that these numbers are from 35 large cities in the United States, and would not necessarily reflect the incidence of influenza in other parts of the world. The Pandemic peaks of 1918-1919 are off the charts.
For the next 10 years, reports of spikes of localized, and severe influenzas occurred around the world, most likely resurgences of the H1N1 virus. The 4th level of the chart covers the years 1922-1932, and while the scale is roughly half that of the one used in the 1918 strip, it clearly shows sharp, short outbreaks. These numbers come from 90 cities across the United States.
After 1930, influenza in the United States entered a quiescent period which lasted for more than two decades, presumably because our population had acquired herd immunity to the H1N1 strain.
We know that the H1N1 virus remained the dominant strain until the 1957 Asian Flu pandemic, when it acquired genetic changes from an unknown avian strain and changed to the H2N2 strain. While it is thought to have moderated its severity after 1919, it was obviously capable of inflicting much pain and death in susceptible populations after that time.
What then does all of this mean to us in 2006, with the H5N1 Avian (aka Bird flu) virus on our doorsteps? Does knowing any of this help?
Perhaps.
Among skeptics of the pandemic potential of the H5N1 virus, are many who say it has been around for nearly 10 years, and it hasn’t yet found a way to become a pandemic. If the H1N1 virus simmered for years before eventually exploding, then so too could the current strain of avian flu.
Although less compelling, the spikes in the episodes of severe influenza up until 1929 suggest that as a seasonal influenza, the H1N1 virus remained a serious threat. And that could have serious implications in the next pandemic, as well.
The question before us is, in respect to the next pandemic, are we sitting in 1915, with 3 years before the avian flu explodes? Or are we entering the spring of 1918, and about to witness another viral storm rage across our planet?
While answers to these questions are in short supply, hopefully the things we learn from our observations of the H5N1 virus today will be of use to those who will face the pandemic-after-next.
For now, all we can do is prepare, watch, wonder, and wait.
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