Nonpharmaceutical influenza mitigation strategies, US communities, 1918-1920 Pandemic. (DISPATCHES].We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic
********* The 1918-1920 influenza pandemic was the deadliest pandemic pandemic /pan·dem·ic/ (pan-dem´ik) 1. a widespread epidemic of a disease. 2. widely epidemic. pan·dem·ic adj. Epidemic over a wide geographic area. n. in human history (1 6). We undertook a historical evaluation of nonpharmaceutical interventions (NPIs) during that pandemic (7), with an emphasis on American communities during the second wave (September-December 1918). The full report and a digital archive of primary sources for this study can be accessed online (available from http://www.med.umich.edu/ medschool/chm/influenza). The Study We selected 6 US communities that reported relatively few, if any, cases of influenza and no more than 1 influenza-related death while NPIs were enforced during the second wave of the 1918 pandemic: San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden Naval Training Station, Yerba Buena Island Yerba Buena Island, 300 acres (121 hectares), W Calif., in San Francisco Bay. It is the midpoint of the San Francisco-Oakland Bay Bridge, which crosses the island through a tunnel. , California; Gunnison, Colorado Gunnison is a city in Gunnison County, Colorado, United States. As of the 2000 census, the city had a total population of 5,409. It is the county seat of Gunnison CountyGR6. The city was named after John W. ; Princeton University Princeton University, at Princeton, N.J.; coeducational; chartered 1746, opened 1747, rechartered 1748, called the College of New Jersey until 1896. Schools and Research Facilities , Princeton, New Jersey
Princeton, New Jersey is located in Mercer County, New Jersey, United States. Princeton University has been sited in the town since 1756. ; Western Pennsylvania Western Pennsylvania consists of the western third of the state of Pennsylvania in the United States. Pittsburgh is the largest city in the region, with a metropolitan area of about 2.4 million people, and is the cultural center for Western Pennsylvania. Institution for the Blind, Pittsburgh, Pennsylvania “Pittsburgh” redirects here. For the region, see Pittsburgh Metropolitan Area. Pittsburgh (pronounced IPA: /ˈpɪtsbɚg/) is the second largest city in the Commonwealth of Pennsylvania. ; Trudeau Tuberculosis Sanatorium sanatorium /san·a·to·ri·um/ (san?ah-tor´e-um) an institution for treatment of sick persons, especially a private hospital for convalescents or patients with chronic diseases or mental disorders. , Saranac Lake Saranac Lake, village (1990 pop. 5,377), Essex and Franklin counties, N N.Y., in the Adirondacks; settled c.1819 as a lumbering town, inc. 1892. It is a year-round resort community; tourism is the main industry. It developed as a health center after Edward L. , New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of ; and Fletcher, Vermont Fletcher is a town in Franklin County, Vermont, United States. The population was 1,179 at the 2000 census. Geography According to the United States Census Bureau, the town has a total area of 98.4 km² (38.0 mi²). 98.0 km² (37.8 mi²) of it is land and 0.4 km² (0. (Table). We also studied the college community of Bryn Mawr College Bryn Mawr College, at Bryn Mawr, Pa; undergraduate for women, graduate coeducational; opened 1885 by the Society of Friends, with a bequest from Joseph W. Taylor of Burlington, N.J. Modeled on a group curriculum plan at Johns Hopkins Univ. , Bryn Mawr, Pennsylvania Bryn Mawr is a census-designated place (CDP) in Lower Merion Township, Montgomery County, Pennsylvania, just west of Philadelphia along Lancaster Avenue (US-30) and the border with Delaware County. , which took several intensive NPI NPI National Provider Identifier, see there measures and experienced no deaths during the second wave but did encounter a high case rate (25% of its student body). We identified these sites first by consulting Jordan's 1927 text, Epidemic Influenza (1). We then verified and modified this list by reviewing 240 federal, 92 state (from 40 states), and 25 special local reports and documents. We conducted in situ In place. When something is "in situ," it is in its original location. archival research at 34 locations and examined >1,400 newspaper and contemporary medical and scientific journal articles for the 1918 1920 period. The communities we identified were diverse and had unique characteristics. Fletcher, Vermont (population 737), was simply too small to suggest that its success resulted from anything more than remote location, good fortune, or the ways in which the virus skipped some communities altogether for unknown reasons (8-10). The Trudeau Tuberculosis Sanitarium sanitarium /san·i·tar·i·um/ (-tar´e-um) an institution for the promotion of health. san·i·tar·i·um n. See sanatorium. (9) and the Western Pennsylvania Institution for the Blind (10) were already de facto [Latin, In fact.] In fact, in deed, actually. This phrase is used to characterize an officer, a government, a past action, or a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate. quarantine islands because of the era's prevailing views toward confinement of the contagious and the disabled. Princeton University provided a good example of how a social institution with some measure of control over its population might implement NPIs to protect itself (11). The US Naval Base A naval base primarily for support of the forces afloat, contiguous to a port or anchorage, consisting of activities or facilities for which the Navy has operating responsibilities, together with interior lines of communications and the minimum surrounding area necessary for local at Yerba Buena Island in San Francisco Bay San Francisco Bay, 50 mi (80 km) long and from 3 to 13 mi (4.8–21 km) wide, W Calif.; entered through the Golden Gate, a strait between two peninsulas. (12) and the mining town of Gunnison, Colorado (13), also offer potential lessons for contemporary pandemic influenza preparedness planning. Under the direction of public health officers, the still-healthy island and mountain town essentially cut off all contact with the outside world to shield themselves from the incursion in·cur·sion n. 1. An aggressive entrance into foreign territory; a raid or invasion. 2. The act of entering another's territory or domain. 3. of influenza. The 2 sites saw almost no cases of infection and thus experienced no deaths, for 2 and 4 months, respectively. Most important, these communities enacted a policy we have termed protective sequestration sequestration In law, a writ authorizing a law-enforcement official to take into custody the property of a defendant in order to enforce a judgment or to preserve the property until a judgment is rendered. , or the measures taken by the authorities to protect a defined and still-healthy population from infection before it reaches that population. These measures include the following: 1) prohibitions on members of the community from leaving the site; 2) prohibitions against visitors from entering a circumscribed circumscribed /cir·cum·scribed/ (serk´um-skribd) bounded or limited; confined to a limited space. cir·cum·scribed adj. Bounded by a line; limited or confined. perimeter; 3) typically placing in quarantine those visitors who are allowed to enter for a period of time before admission; and 4) if available, taking advantage of geographic barriers, such as an island or remote location. Several themes emerged from our historical research. First, coordination among public agencies is essential to any effective public health response. Despite some tension among city, county, and state officials in Gunnison, their relatively smooth cooperation may have played a role in their implementing and maintaining strict public health measures. Second, neither Gunnison nor Yerba Buena yerba buena (yĕr`bə bwā`nə), trailing evergreen perennial (Micromeria chamissonis) of the family Labiatae (mint family). It is native to W North America and especially common to woodland areas along the Pacific coast. could have escaped the flu without full cooperation from the local population. Gunnison's low population density and self-sufficient ranching lifestyle made it easier for residents to bide bide v. bid·ed or bode , bid·ed, bid·ing, bides v.intr. 1. To remain in a condition or state. 2. a. To wait; tarry. b. their time (Figure 1). At Yerba Buena, the military chain of command mandated the cooperation of sailors and allowed the island's commander to close off the base from the outside world with little interference (Figure 2). Finally, these communities had the advantage of early warnings to prepare their populations. Both tracked influenza's westward movement from August to September and, unlike communities along the East Coast, could implement protective health strategies before cases appeared at their doorsteps. [FIGURES 1-2 OMITTED] One would like to think that the 6 communities we identified fared better than others because of the NPIs they enacted. While we cannot prove this for any of them, the case is perhaps strongest for Yerba Buena and possibly Gunnison. Further complicating our task, in addition to the uneven quality and quantity of information available for study, is that some of these communities were sparsely populated and geographically isolated, and all of them were subject to the vagaries of how the influenza virus influenza virus n. Any of three viruses of the genus Influenzavirus designated type A, type B, and type C, that cause influenza and influenzalike infections. affected populations. Indeed, these communities represent the exception rather than the rule in terms of how most American communities experienced the influenza pandemic of 1918-1920 (14.15). This leads to several intriguing questions regarding what these escape communities can teach us about pandemic preparations today, let alone the question of whether such measures can even be replicated. Conclusions First, protective sequestration, if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved, and continued for the lengthy time period in which the area is at risk, stands the best chance of guarding against infection. Second, available data from the second wave of the 1918-1920 influenza pandemic fail to show that any other NPI (apart from protective sequestration) was, or was not, effective in preventing the spread of the virus. Despite implementing several NPIs, most communities sustained considerable illness and death. We could not assess how the timing of NPI implementation across the nation affected disease mitigation efforts nor whether these NPIs lessened what might have been even higher rates had these measures not been in place in various locations. Moreover, we could not locate any consistent, reliable data supporting the conclusion that face masks, as available and as worn during the 1918-1920 influenza pandemic, conferred any protection to the populations that wore them (16). In fact, evidence suggests that in most American communities NPIs did not prevent the spread of virus in 1918. What remains unclear is the extent to which they may have been partially effective in reducing spread or mitigating community impact. However inconclusive the data from 1918 are, the collective experiences of American communities from the pandemic are noteworthy, especially in light of the fact that, if faced with a pandemic today, we would likely rely on many of these same NPIs to attempt to mitigate the spread of the infection until pharmacological supplies of vaccine and antiviral agents were available (17-19). It is true that the United States of today is a much different nation than it was in 1918, with a larger, more mobile, and more complex society. It is equally true that the communities we examined were all small and relatively isolated (or isolatable). Nevertheless, in the event of another influenza pandemic, many specific subcommunities (e.g., military installations, college and university campuses, nursing homes) may wish to consider protective sequestration measures as potential means to prevent or delay the onset of epidemic influenza in their populations. This study was funded by a contract from the Defense Threat Reduction Agency The Defense Threat Reduction Agency (or DTRA) is a combat support agency of the United States Department of Defense (DoD) whose primary function is to analyze potential threats to the United States, both homeland and abroad, and provide contingency plans for all such , US Department of Defense, DTRA DTRA Defense Threat Reduction Agency DTRA Dirt Track Racing Association DTRA Deseret Towers Recreation Area (Utah) DTRA Data Terminal Ready A DTRA Defense Technical Review Agency DTRA Defense Technical Review Activity 01-03-D-0017. Dr Markel is the George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases communicable diseases, illnesses caused by microorganisms and transmitted from an infected person or animal to another person or animal. Some diseases are passed on by direct or indirect contact with infected persons or with their excretions. , and Director, Center for the History of Medicine, University of Michigan (body, education) University of Michigan - A large cosmopolitan university in the Midwest USA. Over 50000 students are enrolled at the University of Michigan's three campuses. The students come from 50 states and over 100 foreign countries. Medical School at Ann Arbor Ann Arbor, city (1990 pop. 109,592), seat of Washtenaw co., S Mich., on the Huron River; inc. 1851. It is a research and educational center, with a large number of government and industrial research and development firms, many in high-technology fields such as . References (1.) Jordan EO. Epidemic influenza: a survey. Chicago: American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. ; 1927. (2.) Crosby AW. America's forgotten pandemic: the influenza of 1918. New York: Cambridge University Press Cambridge University Press (known colloquially as CUP) is a publisher given a Royal Charter by Henry VIII in 1534, and one of the two privileged presses (the other being Oxford University Press). ; 2003. (3.) Byerly CR. Fever of war: the influenza epidemic influenza epidemic caused 500,000 deaths in U.S. alone (1918–1919). [Am. Hist.: Van Doren, 403] See : Disease in the U.S. Army during World War 1. First ed. New York: New York University Press New York University Press (or NYU Press), founded in 1916, is a university press that is part of New York University. External link
(4.) Hoehling AA. The great epidemic. Boston: Little, Brown and Company; 1961. (5.) Kolata G. Flu: the story of the great influenza pandemic of 1918 and the search for the virus that caused it. New York: Farrar, Straus and Giroux; 1999. (6.) Barry JM. The great influenza: the epic story of the deadliest plague in history. New York: Viking; 2004. (7.) World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, international measures. Emerg Infect Dis. 2006;12:81-94. (8.) Vermont state board of health. Twenty-second [twelfth biennial] report of the state board of health of the state of Vermont from January 1, 1918, to December 31, 1919. Rutland (VT): The Turtle Company, Marble City Press Publishers; 1920. (9.) Taylor R. Saranac: America's magic mountain. Boston: Houghton-Mifflin; 1986. (10.) Johnston JI. History and epidemiology of influenza. In: University of Pittsburgh School of Medicine The University of Pittsburgh School of Medicine is the medical school of the University of Pittsburgh, located in Pittsburgh, PA. As of 2007, the University of Pittsburgh School of Medicine consists of 589 medical students - 53% men and 47% women. . Studies on epidemic influenza. Pittsburgh: University of Pittsburgh School of Medicine; 1919, (11.) Taylor JM. An exploit in control of influenza. Boston Med Surg J. 1920;182:601. (12.) Annual reports of the Navy Department for the fiscal year 1919. Washington: Government Printing Office, 1920; 2482-6. (13.) Leonard SJ. The 1918 influenza epidemic in Denver and Colorado. Essays in Colorado History. 1989:9:9. (14.) Sydenstricker E. Preliminary statistics of the influenza epidemic. Public Health Rep. 1918;33:2305-21. (15.) Frost WH. The epidemiology of influenza. Public Health Rep. 1919;34:1823-36. (16.) Kellogg WH. Influenza: a study of measures adopted for the control of the epidemic. California State Board of Health, Special bulletin no. 31. Sacramento (CA): California State Printing Office; 1919. (17.) Ferguson NM. Cummings DA, Fraser C, Cajka CJ, Cooley PC, Burke DS. Strategies for mitigating an influenza pandemic. Nature. 2006;442:448-52. (18.) Ferguson NM, Fraser C, Donnelly CA, Ghani AC, Anderson RM. Public health risk from the avian H5N1 influenza epidemic. Science. 2004;304:968-9. (19.) Longini IM, Nizam A, Xu S, Ungchusak K, Hanshaoworakul W, Cummings DA, et al. Containing pandemic influenza at the source. Science. 2005;309:1083-7. Howard Marke, * Alexandra M. Stern, * J. Alexander Navarro, * Joseph R. Michalsen, * Arnold S. Monto, ([dagger]) and Cleto DiGiovanni Jr ([double dagger]) * The University of Michigan Medical School, Ann Arbor, Michigan  “Ann Arbor” redirects here. For other uses, see Ann Arbor (disambiguation). Ann Arbor is a city in the U.S. state of Michigan and the county seat of Washtenaw County. , USA, ([dagger]) The University of Michigan School of Public Health, Ann Arbor, Michigan, USA; and ([double dagger]) US Department of Defense, Fort Belvoir, Virginia, USA Address for correspondence: Howard Markel, University of Michigan Center for the History of Medicine, 100 Simpson Memorial Institute, 102 Observatory, Box 0725, Ann Arbor, MI 48109-0725; email: howard@ umich.edu
Table. Six communities that along with Bryn Mawr College escaped
influenza pandemic, 1918-1920
Yerba
Characteristics Buena, CA Gunnison, CO
Population [approximately 1,329 in town,
equal to] 6,000 5,590 in county
Geographic Small island Small mountain
isolation off coast of community in
San western
Francisco Colorado;
commercial,
educational,
and
transportation
hub
Ordinary or Primarily a Ordinary
special military population
population population; composed of
[approximately equal native-born and
to] 1,000 civilian immigrant
family residents
members
and workers
were present
Period of Sep 23- Oct 31, 1918-
protective Nov 21, Jan 20, 1919
sequestration 1918 (countywide);
public closures
and imposed
social
distancing as of
Oct 8, 1918
Cases and 0 cases, 0 cases,
deaths 0 deaths 0 deaths in
during town (2 cases,
protective 1 death in
sequestration county)
Princeton
Characteristics University, NJ WPIB, PA *
Population 1,142 179 students;
faculty and staff
also lived on-site
Geographic Student body in Located in a
isolation a small college busy residential
town; campus Pittsburgh
somewhat neighborhood but
separated from somewhat
from isolated by
the town standards of the
day
Ordinary or All-male Student body
special student body; was blind and
student body 92% of thus isolated by
students were standards of the
members of a day
military training
corps
Period of Never under a Early Oct-
protective full protective late Nov
sequestration sequestration, 1918
as recruits and
cadets
continually
arrived and left;
restrictions on
off-campus
travel (with
perimeter
control)
imposed Oct 8-
Dec 21, 1918
Cases and 68 cases, 12 cases,
deaths 0 deaths 0 deaths
0 deaths
in student
population
([dagger])
Trudeau
Characteristics Sanatorium, NY Fletcher, VT
Population 356 patients 737
admitted in
1918; 259
discharged;
average daily
patient census
of 150
Geographic A small Very small
isolation institute on the rural
outskirts of a community
very small in upstate
mountain Vermont
community in
upstate New
York
Ordinary or Patients and Ordinary
special staff were rural
population tubercular and population
were thus
isolated by
standards of
the day
Period of A de facto Not
protective protective applicable
sequestration sequestration
existed due to
its geographic
and
institutional
isolation
Cases and 0 cases, 2 cases,
deaths 0 deaths 0 deaths
Bryn Mawr
Characteristics College, PA
Population 465
Geographic Student body
isolation in a small
college town;
only 10 miles
from
Philadelphia
Ordinary or All-female
special student body
population
Period of [approximately equal to]
protective Oct 1-Nov 7
sequestration 1918
Cases and 110 cases,
deaths 0 deaths
* WPIB, Western Pennsylvania Institution for the Blind.
([dagger]) One professor died.
|
|
||||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion