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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 in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.


The 1918-1920 influenza pandemic was the deadliest pandemic 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 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 Naval Training Station, Yerba Buena Island, California; Gunnison, Colorado; Princeton University, Princeton, New Jersey; Western Pennsylvania Institution for the Blind, Pittsburgh, Pennsylvania; Trudeau Tuberculosis Sanatorium, Saranac Lake, New York; and Fletcher, Vermont (Table). We also studied the college community of Bryn Mawr College, Bryn Mawr, Pennsylvania, which took several intensive NPI 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 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 (9) and the Western Pennsylvania Institution for the Blind (10) were already de facto 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 at Yerba Buena Island in San Francisco Bay (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 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, 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 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 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 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.


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 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.


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, US Department of Defense, DTRA01-03-D-0017.

Dr Markel is the George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases, and Director, Center for the History of Medicine, University of Michigan Medical School at Ann Arbor.


(1.) Jordan EO. Epidemic influenza: a survey. Chicago: American Medical Association; 1927.

(2.) Crosby AW. America's forgotten pandemic: the influenza of 1918. New York: Cambridge University Press; 2003.

(3.) Byerly CR. Fever of war: the influenza epidemic in the U.S. Army during World War 1. First ed. New York: New York University Press; 2005.

(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. 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, 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@
Table. Six communities that along with Bryn Mawr College escaped
influenza pandemic, 1918-1920

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;

Ordinary or Primarily a Ordinary
special military population
population population; composed of
 [approximately equal native-born and
 to] 1,000 civilian immigrant
 family residents
 and workers
 were present

Period of Sep 23- Oct 31, 1918-
protective Nov 21, Jan 20, 1919
sequestration 1918 (countywide);
 public closures
 and imposed
 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)

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

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

Period of Never under a Early Oct-
protective full protective late Nov
sequestration sequestration, 1918
 as recruits and
 arrived and left;
 restrictions on
 travel (with
 imposed Oct 8-
 Dec 21, 1918

Cases and 68 cases, 12 cases,
 deaths 0 deaths 0 deaths
 0 deaths
 in student

Characteristics Sanatorium, NY Fletcher, VT

Population 356 patients 737
 admitted in
 1918; 259
 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

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

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

Ordinary or All-female
special student body

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.
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Author:DiGiovanni, Cleto, Jr.
Publication:Emerging Infectious Diseases
Geographic Code:1USA
Date:Dec 1, 2006
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