Housefly

April 2006   Planet Earth

I wrote a paper last semester for paramedic school, and I think it is a reasonably quick and easy 5-page read. Your choice, but if this current virus mutates to transmit in the way it has historically, then there is an even chance that it will kill you and half of everyone you have ever met. Food for thought. Grab a plate and dig in!

The Influenza Pandemic of 1918 and the City of San Francisco Response to a Similar Outbreak

In 1918, a fast-moving, fast-mutating influenza virus erupted into a global epidemic, or pandemic, racing around the world within weeks of its initial appearance somewhere in Europe, and often moving ahead of news of itself. In what quickly became the worst human disaster since the Black Plague of 1348, an estimated 40 million people died over a period of three years, with a large majority succumbing during a 4-month stretch of 1918. The worst war in human history was raging at the very time, but even that murderous conflict, with its chemical warfare and machine-weaponry, “only” killed one-third the amount of people. One could say this was a bad year for humanity.

The disease first appeared in the spring of 1918, in Spain, maybe, or France, or possibly the US. So quick was the spread that it seemed simultaneous, even in the days before jet travel. Within the US, for example, where the steam locomotive was the fastest means of travel for the general public, and even a biplane would take days to fly from New York to Los Angeles, this newest plague spanned the continent and most places in between within three weeks. Often, travelers would expire on the way to their destinations, and be left as unwelcome guests to be buried along the way. This is especially true aboard ships, where close quarters and damp, septic environments were ideal for this virus to blossom. With the abundant troopships of the day and freighters and liners crammed with immigrants down in steerage, the disease spread easily from one continent to the next. There were reports of 90% infection on some ships, and as they docked and unloaded the dead and dying, every port city in the world was laid low.

Fleeing the cities only made thing worse, as the previously uninfected rural areas were the next to fall. One town in Ohio held off the disease for weeks by enforcing a strict “no-entry, no-exit” clampdown on the whole town. Only when the townspeople, desperate for news of family on the outside, demanded the mailman be allowed to make a mail drop did the town share in the calamity: the healthy, asymptomatic mailman had carried it in and dispersed the pathogen with each breath. Scores died, and like many towns, the dead lay in the parlors, streets and yards for days and weeks, the town short of coffins, surviving carpenters and undertakers willing to make contact with the bodies. One Alaskan town recorded an 85% mortality within a period of five days.

Fortunately, and similar to the Ebola virus, this one moves so quickly that it runs out of susceptible victims quickly, and just as quickly disappears. The outbreak peaks at about four weeks and is apparently gone within eight weeks. This virus reappeared in the spring and fall of each of the next three years, morphing into a weaker and weaker strain, having less effect on the more resistant survivors, and killing fewer people each time, until finally it retreated back to its unknown reservoir.

Of the 100% exposed, half became symptomatic, 2 – 5% fatally, with a highly disproportionate number of previously healthy males aged 20 – 40. There was a remarkable similarity to the symptoms, varying only in degree of severity: A 26-year-old farmer hauls his produce into town to sell, and is exposed to the airborne virus along the way. Forty-eight hours later, he is stricken by a blinding headache, severe chills and uncontrollable shivering. He is found in the fields and carried home, where he spikes a 104-degree fever, soaks his bed with sweat, and the coughing begins. After a sleepless night, wracked by aching body, head and joints, and unable to stay ahead of his thirst, he starts to cough up blood and huge amounts of dark phlegm. His pulse accelerates throughout the day, as do his increasingly shallow respirations. By nighttime, his extremities are turning blue and cold, and he becomes disoriented and combative. Early the next morning, he has drowned in his own blood. Along the way, he exposed everyone in his family and several neighbors, about half of whom would be useless for the next few days or weeks. This happened hundreds and sometimes thousands of times each day in many cities of the world during that panicked Spring.

In San Francisco, things were better and worse. By luck of distance, mountain ranges and prevailing winds, the pandemic did not arrive until September, part of the second, weaker wave of the flu now rolling across the globe. It is possible that the first-wave virus had mutated into a nearly harmless form by the time it was carried by the still-healthy travelers on their way to San Francisco. Despite the one-month warning for this second wave, and still-fresh news of national carnage the previous spring, SF was woefully unprepared. City residents were in denial, having dodged it once, and sure that the worst had passed. After all, epidemics were not uncommon at the turn of the century and people had some knowledge of the ebb and flow of disease. Many seemed more concerned with individual rights than the wisdom of germ mask ordinances, quarantines, and crowd dispersal. City health officials dropped the ball too, allowing business owners to persuade them to keep markets, theatres and ballparks open. According to John Barry, author of The Great Influenza, “Government response is colored by the politics of the moment.” Dr. William Hassler, Chief of the Department of Public Health, had been an early advocate of strict public health measures such as these, with plans in place before the outbreak. However, he appeared to buckle under local administration and business-lobby pressure, re-asserting himself only after the plague had taken hold.

Within three weeks of the first local report, 4,000 people were known to be infected, with many more cases likely in the immigrant slums around the city. Finally, the original containment plans were put into place: shut all schools, concert halls, theatres, markets, and sports facilities. It was too late. The city was sectioned off into twenty pieces, each with its own phones, water, medical staff, beds and supplies contained in their own tent cities. Face-mask usage was strictly enforced, with one man shot twice for refusing to comply. (These masks were later found to be ineffective, especially when many cut holes in them for cigarettes, pipes and chewing tobacco.) In the meantime, though, the DPH, local hospitals, undertakers and the Red Cross all admitted that they were “overwhelmed.”

At San Francisco General Hospital, the city’s largest, a Dr. Russell Lee recalled in his memoir that “My very first night as a resident, I was in the ward where I had six patients die…65% of admissions to that ward died. Our morgue was completely swamped with the number of dead, and we finally piled the coffins with the corpses in them along the walls until they reached ceiling.” One doctor in San Jose reported seeing 525 patients in one day. With up to 580 new infections each day, and a fresh corpse every hour, the Red Cross was only able to respond to half the requests for help. Telephones and other utilities faltered as workers fell ill or refused to go to work. Many ambulance drivers, fire and police officers were too sick to work, or worse.

By mid-December, there were a total of 30,000 symptomatic flu victims and 3500 dead in San Francisco, out of a total population of around 300,000. In today’s population, this would equate to 75,000 sick and nearly 9,000 dead. This 1.2% death rate again reflects the weakness of the second wave and the length of time it took to arrive in the Bay Area. Just as suddenly, it was gone, with only a few new cases reported in January. As in the rest of the country and the world, there were diminishing recurrences over the next three years. San Francisco got off easy.

Although there is a flu season every year in which many people fall ill or die, it is mostly the young, the old and the weak that bear the brunt. Most influenza strains are many times more benign, slower-acting and only distantly related to the pandemic strains. There were two more severe Influenza pandemics in the twentieth century, in 1957 and in 1968, neither of which approached the severity of the 1918 episode. Thanks to 1996 research performed on preserved 1918 remains and a breakthrough as recently as October 2005, it is now known that these three pandemics were caused by the particularly vicious Avian Flu. It is also widely agreed within the epidemiology community that each influenza epidemic in known history has a very similar behavior to all others. The historic record going back over 500 years shows an average of three severe influenza epidemics each century, or one every thirty-three years. It has now been thirty-seven years since the last one. Much like a Northern California earthquake, it is not a question of if, but of when and how severe the next one will be.

Bird Flu is so named because it is believed that migratory wildfowl are the natural reservoir for the virus. In order to become epidemic, several things must happen: The always-mutating virus must opportunistically infect swine, then mutate again and make the smaller jump to a human host. Finally, a still-smaller leap to person-to-person-to-person transmission is required. That newly mutated virus has the right mix every time, historically: Avian influenza that defeats pig immune systems, with or without symptoms, then jumps to people and finds a way to be quickly and easily transmitted to the next person. This all happens randomly, of course, but like a million monkeys relentlessly banging on typewriters, one of them will crank out a masterpiece.

There is a bird flu making the rounds in South-East Asia right now, where down on the farm, yard birds mingle with wild birds, pigs ramble among them both and farmers sometimes bring their most valuable property to sleep in or under the houses. This flu is known as H5N1, and it is causing some alarm among the contagious-disease scientists of the world. According to the genetic sequencing of this virus, it has the many of the same unusual features of the 1918 virus, and is only two mutations removed from it. It has been around since 2003, and though it hasn’t exploded, it hasn’t gone away, either, and seems to be moving in an ominous direction.

So far, there have been 122 confirmed cases and 62 deaths in the region ranging from Vietnam to China, demonstrating a tremendous 50% mortality. That equates to a twenty-fold increase over the 1918 virus. They seem to have been bird-to-human contacts, with possibly two bird-human-human cases. Swine involvement remains inconclusive, and the virus is still considered inefficient. Once again, the incubation period is 2-4 days and it is resistant to anti-virals. According to SFDPH, “If H5N1 continues to circulate widely among poultry, the potential for emergence of a pandemic strain remains high.” Most of these rural people make a few hundred dollars a year, and governments are reluctant once more to admit a problem, but under UN and CDC pressure, over 150 million domestic birds have been slaughtered since 2003 in very successful attempts to contain SARS and other strains of influenza.

Still, normally conservative organizations and publications are nearly pronouncing Doom:

“H5N1 might be acquiring some of these same changes (that allow bird-person-person tx)…might be going down a similar path that ultimately led to 1918.”

-JAMA, 11/16/05

“Never in the history of the disease have so many countries been simultaneously affected, resulting in the loss of so many birds….The world is now closer to another epidemic than at any time since 1968…This is an especially tenacious virus…nobody will have immunity to H5N1… H5N1-2005 is the most lethal virus yet and is now killing mammalian species previously thought resistant to infection.”

-WHO, 11/2005

The World Health Organization goes on with the rosy prediction that 7.5 million people worldwide will expire, based on predictions of the severity of the strain. Not to be outdone, the United Nations in October 2005 predicted 5 million dead if the strain is as lethal as the 1957 strain, or 150 million dead if it is as lethal as the 1918 strain. Extrapolated to the US population, that means as few as 250,000 dead or up to 7 million dead based on these boundary conditions. In California, that would mean from 30,000 to 900,000 dead. For reference, about 36,000 people die in the US each year of non-avian influenza each year.
Nowhere do these organizations claim that pandemic is imminent, of course – most likely there is only a small chance each season that Humanity will roll snake eyes. Keeping things in context is Dr. Peter Sandman, an infectious disease management specialist and consultant to WHO. “H5N1 probably won’t blow up. Maybe a 10% chance.”

Now what? The planned public health response around the world will range from woefully inadequate to non-existent, no matter the severity. Due to limitations of current science and an ever-changing virus, WHO expects a lag time of “several months” for a vaccine to be developed and produced after the start of the next pandemic. Each previous epidemic has swept the globe within weeks, and faster each time. Though WHO predicts 100% infection, some fraction symptomatic, their recommendations are uncomfortably vague: “Delay international spread…Strengthen international preparedness…” Also, “Most countries will have no access to antivirals and vaccines at all throughout an epidemic…(there will be) no capacity to fill antiviral and vaccine orders anyway.”

Back home, HHS Secretary Mike Leavitt on November 19th said “The United States is unprepared to provide 300 million doses of vaccine for the next 3-5 years.” Right now, there are 4.3 million doses on hand according to the Associated Press. Presumably that means 4.3 million doses of anti-virals, such as Tamiflu, since it is not possible to create an actual vaccine without the actual virus, which still exists somewhere in the future. The other half of the plan is voluntary quarantine, social distancing, rapid distribution of (unproven) anti-virals, and pushing for strict personal hygiene. On November 1st, President Bush asked for $7 billion to vaccinate 20 million Americans, with priority going to health care workers, first responders, military and government workers.

Don’t look to San Francisco for any magic bullets. According to Lann Wilder, Hospital Disaster Coordinator at SF General Hospital, “There is so much we can’t do” because of the current limits of science. Just as in the earliest days of virology, a vaccine is created by injecting a chicken egg with the pathogen, given time to multiply, then harvested, weakened, and packaged into individual doses. This helps explain the tremendous lag time between virus and vaccine. Even then, it is not a cure for those infected – it must be administered days to weeks in advance of exposure in order for a person to build immunity.

Wilder went on to explain that “There is no availability of anti-virals at this time,” adding that “they are extremely expensive” and finally, that “some anti-virals may not always work against H5N1,” according to recent field evidence in Asia. A lack of funding does not seem to be the issue.

Wilder did offer to explain the four-point epidemic plan developed by SFDPH and SFGH. First, surveillance. This is the classic first-line defense, involving the education of all primary health-care patient care providers about current threats and symptoms, and directing them to notify DPH immediately, no more than one hour after observation. This will help to minimize patient contact with others and limit disease spread.

Second, vaccine. This point assumes either that one has been created for the virus at hand, or that a wide-spectrum vaccine is on hand that may at least offer resistance and minimize severity of symptoms, or that anti-virals are widely available and effective by the time the next one arrives.

Third, containment. “This is the hardest part of (epidemic) management,” according to Wilder, because of human nature, non-compliance, communication, and of course, civil rights issues. Use of the ‘Q’-word, quarantine, is “touchy,” especially in the Bay Area, where memories of quarantine threats against the spread of HIV in the 1980’s still strikes a chord with many. “Voluntary self-confinement” might be encouraged instead, and it is doubtful that many people will be shot on sight for not wearing a mask. Initially, anyway.

Fourth, treatment (of the epidemic, not the individual infection.) This last point involves a massive public health campaign before and during the event, encouraging frequent hand-washing, enhanced personal hygiene, and minimal public gatherings.

On the subject of public-health workers, Wilder once again emphasized personal hygiene, staying home from work if symptomatic, and wearing modern, virus-trapping N-95 masks, “which are 95% effective. Give or take 10%.” She was adamant about each worker creating a close, nearly custom fit for their mask, citing SARS-infected medical workers in Asia over the past few years.

Even in Northern Europe, where socialized medicine is the norm and cost is not king, no city can afford to build and staff the massive facilities required to provide beds, nursing care and oxygen therapy to thousands of patients at once. After all, it could be vacant for decades, but then the need will be sudden. When the next severe epidemic arrives, health care will likely begin and end at home: tending to the sick and comforting the dying, very much as it was done in 1918.

Sources

Journal of the American Medical Association

Clues to Deadly 1918 Flu Revealed, 4/07/05

1918 Killer Flu Reconstructed, 11/16/05

www.jama.ama-assn.org

American Journal of Hygiene

Monograph Series # 1, 1921

Journal of Military Medicine,

Col. W. Ivy

V 119, 1956

Journal of Irish Medicine

MacNamara

V 208, Oct 1954

San Francisco Department of Public Health

Mary Magoscy

Office of Community Health and Epidemiology

www.dph.sf.ca.us

San Francisco General Hospital

Lann Wilder

Hosptital Disaster Coordinator

Dr. Peter Sandman,

Infectious Disease Management Specialist

Risk Communications Specialist

SARS consultant to WHO

www.petersandman.com

Dr. Russell V. Lee

Founder, Palo Alto Medical Foundation

memoir excerpt

America’s Forgotten Pandemic: The Influenza of 1918, Alfred Crosby 2003

The Great Influenza, John Barry 2004

Epidemic Influenza, A Survey, Edwin Jordan, PhD, 1927

Influenza: An Epidemiological Study

Warren T. Vaughn, MD 1925

United States Census data, 1920

The New York Times

1/6/1919

Los Angeles Times

10/23/1925

World Health Organization

www.who.int/en

Public Broadcasting Service

www.pbs.org/wgbh/amex/influenza

Tags: Bird Flu, pandemic

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