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Flu intervention: then and now

In Biology, Policy on April 27, 2009 at 8:18 pm
Policemen in masks, San Francisco, 1918
Policemen in masks, San Francisco, 1918

In our earlier swine-flu related post, we mentioned that early intervention may well make the difference between an isolated outbreak and a deadly repeat of the 1918 Spanish flu.  Just how important is starting countermeasures early, and what kind of interventions work?  The tragedy of the Spanish flu provides a natural laboratory for public health measures, as cities throughout the US differed both in scale and timing of their interventions.

Medical science in 1918 was still getting on its feet.  The majority of older physicians of the time were not educated under the scientific regimen of the Flexnerian revolution.  The leading bacteriologists of the day mistakenly believed that influenza was a bacterial disease, and it was not until 1943 when it was recognized that a virus was responsible. As a result, medical intervention in the pandemic was of questionable value, not least because most of the best doctors had been drafted to serve in the military for WWI.

However, nonmedical interventions were also employed.  These included quarantines, isolation of the sick in makeshift wards, closure of public gathering places such as churches and schools.  A recent study examined the effects of timing and duration of these measures, with the major findings summarized in two graphs:

C: Mortality vs. time to intervention.  D: Mortality vs. length of intervention

C: Mortality vs. time to intervention. D: Mortality vs. length of intervention

The study examined the experience of 23 cities in implementing various public health measures, and measured the impact of response time and duration of intervention.  They found that quick action (as measured by when flu cases rose to double the baseline number of cases) had a strong correlation with reduced mortality, and that maintaining the measures was important to keep the disease from spreading.

St. Louis, for example, closed schools and canceled public gatherings early, and maintained quarantines for over ten weeks, leading to a significantly lower mortality rate.  However, not all cities were as proactive; the median duration of these interventions was only four weeks, insufficient to protect the population.  Some cities were even counterproductive: Philadelphia hosted a military parade to promote war bonds, over the objections of numerous doctors and public health officials.  Soon afterwards, it became one of the hardest-hit cities in the US.  (Here is more, from the New York Times.)

In a sense, we are both better and worse off than those who experienced the Spanish flu.  On one hand, our medical science is more advanced; we can now produce vaccines against new influenza strains, albeit at a delay of several months.  (Because the flu virus mutates rapidly, older vaccines, including the one prescribed this past winter, are ineffective against emergent strains such as this one.)  We have also learned the importance of quick and sustained public health measures: witness the recent warning against traveling to Mexico as a result of the disease.

However, modern transportation makes it easier for civilians to pass the flu from country to country, making it harder to isolate the disease to a single region.  In 1918 the flow of soldiers throughout the US and between the US and Europe are credited with helping to spreada disease that originated in the Midwest to every corner of the globe.  This time it may be passenger jets, not steamships, that spread this emerging pandemic.

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  1. […] faces. When deciding on what kind of response to take, we should look back to 1976 and to 1948 and 1918, but we shouldn’t base our response solely on those flus (or on Twitter). This is a different […]

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