The Flu Pandemic of 1918: A Nurse's Story

ABSTRACT

In the spring of 1918, a virus swept across the world, killing approximately 50 million people by the summer of 1919. My grandmother, Kathryn ("Katie") Ann Darmody-an Irish immigrant who settled in New York State in 1904-was among the nurses who responded to this pandemic, which became known as the 1918 influenza pandemic (or, erroneously, the Spanish flu). Today, as the world contends with the COVID-19 pandemic, my grandmother's experiences resonate with new meaning-a reminder of how, then as now, nurses have been at the forefront of public health. Her story, transmitted across generations, is one I now share with a new generation of nurses.

The 1918 Influenza Pandemic Versus COVID-19: A Historical Perspective From an Italian Point of View

The ongoing COVID-19 pandemic has a major precedent almost exactly a century ago: the world-famous H1N1 influenza virus pandemic, sometimes known to the general public as the Spanish flu. From a history of medicine perspective, it is possible to underline many potential common traits between the two. In this article, hygiene and prophylaxis strategies are analyzed in a review of the most popular Italian general medical journals at the time of Spanish flu, Il Policlinico being the most representative of them. The analysis included 40 original journal articles as well as important references to the most influential coeval national manuals and international journals. The main issues in the context of public hygiene are prophylaxis with quinine and quinine derivatives, vaccinations, face masks, disinfection, and social distancing. We draw a comparison between these and the most recent international World Health Organization and Italian national guidelines on the topic. Sadly, little has changed since those times in terms of most of the prevention techniques, even with technical improvements, showing how shortsighted doctors and physicians can be when dealing with medical history. (Am J Public Health. 2021;111(10):1815-1823. https://doi.org/10.2105/AJPH.2021.306412).

Will prenatal exposure to SARS-CoV-2 define a birth cohort with accelerated aging in the century ahead?

The 1918 Influenza pandemic had long-term impacts on the cohort exposed in utero which experienced earlier adult mortality, and more diabetes, ischemic heart disease, and depression after age 50. It is possible that the Coronavirus Disease 2019 (COVID-19) pandemic will also have long-term impacts on the cohort that was in utero during the pandemic, from exposure to maternal infection and/or the stress of the pandemic environment. We discuss how COVID-19 disease during pregnancy may affect fetal and postnatal development with adverse impacts on health and aging. Severe maternal infections are associated with an exaggerated inflammatory response, thromboembolic events, and placental vascular malperfusion. We also discuss how in utero exposure to the stress of the pandemic, without maternal infection, may impact health and aging. Several recently initiated birth cohort studies are tracking neonatal health following in utero severe acute respiratory syndrome virus 2 (SARS-CoV-2) exposure. We suggest these cohort studies develop plans for longer-term observations of physical, behavioral, and cognitive functions that are markers for accelerated aging, as well as methods to disentangle the effects of maternal infection from stresses of the pandemic environment. In utero exposure to COVID-19 disease could cause developmental difficulties and accelerated aging in the century ahead. This brief review summarizes elements of the developmental origins of health, disease, and ageing and discusses how the COVID-19 pandemic might exacerbate such effects. We conclude with a call for research on the long-term consequences of in utero exposure to maternal infection with COVID-19 and stresses of the pandemic environment.

How to Best Protect People With Diabetes From the Impact of SARS-CoV-2: Report of the International COVID-19 and Diabetes Summit

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has rapidly involved the entire world and exposed the pressing need for collaboration between public health and other stakeholders from the clinical, scientific, regulatory, pharmaceutical, and medical device and technology communities. To discuss how to best protect people with diabetes from serious outcomes from COVID-19, Diabetes Technology Society, in collaboration with Sansum Diabetes Research Institute, hosted the "International COVID-19 and Diabetes Virtual Summit" on August 26-27, 2020. This unique, unprecedented real-time conference brought together physicians, scientists, government officials, regulatory experts, industry representatives, and people with diabetes from six continents to review and analyze relationships between COVID-19 and diabetes. Over 800 attendees logged in. The summit consisted of five sessions: (I) Keynotes, (II) Preparedness, (III) Response, (IV) Recovery, and (V) Surveillance; eight parts: (A) Background, (B) Resilience, (C) Outpatient Care, (D) Inpatient Care, (E) Resources, (F) High-Risk Groups, (G) Regulation, and (H) The Future; and 24 sections: (1) Historic Pandemics and Impact on Society, (2) Pathophysiology/Risk Factors for COVID-19, (3) Social Determinants of COVID-19, (4) Preparing for the Future, (5) Medications and Vaccines, (6) Psychology of Patients and Caregivers, (7) Outpatient Treatment of Diabetes Mellitus and Non-Pharmacologic Intervention, (8) Technology and Telehealth for Diabetes Outpatients, (9) Technology for Inpatients, (10) Management of Diabetes Inpatients with COVID-19, (11) Ethics, (12) Accuracy of Diagnostic Tests, (13) Children, (14) Pregnancy, (15) Economics of Care for COVID-19, (16) Role of Industry, (17) Protection of Healthcare Workers, (18) People with Diabetes, (19) International Responses to COVID-19, (20) Government Policy, (21) Regulation of Tests and Treatments, (22) Digital Health Technology, (23) Big Data Statistics, and 24) Patient Surveillance and Privacy. The two keynote speeches were entitled (1) COVID-19 and Diabetes-Meeting the Challenge and (2) Knowledge Gaps and Research Opportunities for Diabetes and COVID-19. While there was an emphasis on diabetes and its interactions with COVID-19, the panelists also discussed the COVID-19 pandemic in general. The meeting generated many novel ideas for collaboration between experts in medicine, science, government, and industry to develop new technologies and disease treatment paradigms to fight this global pandemic.

Politics, Pushback, and Pandemics: Challenges to Public Health Orders in the 1918 Influenza Pandemic

During the first wave of the COVID-19 pandemic in the United States, many state governors faced an increasing number of acts of defiance as well as political and legal challenges to their public health emergency orders. Less well studied are the similar acts of protest that occurred during the 1918-1919 influenza pandemic, when residents, business owners, clergy, and even local politicians grew increasingly restless by the ongoing public health measures, defied public health edicts, and agitated to have them rescinded. We explore several of the themes that emerged during the late fall of 1918 and conclude that, although the nation seems to be following the same path as it did in 1918, the motivations for pushback to the 2020 pandemic are decidedly more political than they were a century ago.

Fighting the War Against COVID-19 via Cell-Based Regenerative Medicine: Lessons Learned from 1918 Spanish Flu and Other Previous Pandemics

The human population is in the midst of battling a rapidly-spreading virus- Severe Acute Respiratory Syndrome Coronavirus 2, responsible for Coronavirus disease 2019 or COVID-19. Despite the resurgences in positive cases after reopening businesses in May, the country is seeing a shift in mindset surrounding the pandemic as people have been eagerly trickling out from federally-mandated quarantine into restaurants, bars, and gyms across America. History can teach us about the past, and today's pandemic is no exception. Without a vaccine available, three lessons from the 1918 Spanish flu pandemic may arm us in our fight against COVID-19. First, those who survived the first wave developed immunity to the second wave, highlighting the potential of passive immunity-based treatments like convalescent plasma and cell-based therapy. Second, the long-term consequences of COVID-19 are unknown. Slow-progressive cases of the Spanish flu have been linked to bacterial pneumonia and neurological disorders later in life, emphasizing the need to reduce COVID-19 transmission. Third, the Spanish flu killed approximately 17 to 50 million people, and the lack of human response, overcrowding, and poor hygiene were key in promoting the spread and high mortality. Human behavior is the most important strategy for preventing the virus spread and we must adhere to proper precautions. This review will cover our current understanding of the pathology and treatment for COVID-19 and highlight similarities between past pandemics. By revisiting history, we hope to emphasize the importance of human behavior and innovative therapies as we wait for the development of a vaccine. Graphical Abstract.

May the analysis of 1918 influenza pandemic give hints to imagine the possible magnitude of Corona Virus Disease-2019 (COVID-19)?

BACKGROUND

In 1918 an unknown infectious agent spread around the world infecting over one-third of the general population and killing almost 50 million people. Many countries were at war, the First World War. Since Spain was a neutral country and Spanish press could report about the infection without censorship, this condition is commonly remembered as "Spanish influenza". This review examines several aspects during the 1918 influenza pandemic to bring out evidences which might be useful to imagine the possible magnitude of the present coronavirus disease 2019 (COVID-19).

METHODS

In the first part of this review we will examine the origin of the SARS-Coronavirus-2 and 1918 Spanish Influenza Virus and the role played by host and environment in its diffusion. We will also include in our analysis an evaluation of different approaches utilized to restrain the spread of pandemic and to treat infected patients. In the second part, we will try to imagine the magnitude of the present COVID-19 pandemic and the possible measures able to restrain in the present environment its spread.

RESULTS

Several factors characterize the outcome in a viral pandemic infection. They include the complete knowledge of the virus, the complete knowledge of the host and of the environment where the host lives and the pandemic develops.

CONCLUSION

By comparing the situation seen in 1918 with the current one, we are now in a more favourable position. The experience of the past teaches us that their success is linked to a rapid, constant and lasting application. Then, rather than coercion, awareness of the need to observe such prevention measures works better.

Pandemics throughout the centuries

Pandemics have ravished the globe periodically, often associated with war, at times commencing as fever and rash, beginning in recorded history in the crowded walled city of Athens during the Peloponnesian War as described in great detail by the Athenian historian and military general Thucydides in 430 BCE. As the world now faces the first major pandemic of the 21st century, we focus on the "plague" commencing in Athens in 430 BCE and the 2 pandemics of the more recent century, which killed more than one million, the Spanish flu of 1918 and the Asian flu of 1957. The latter linked with successful vaccine development thanks to the heroic efforts of microbiologist Maurice Hilleman. We now look back and then forward to the viral infection coronavirus disease 2019 now devastating the world.

[Public health measures during the flu pandemic in the period 1918-1920 in Spain.]

BACKGROUND

The 1918 influenza epidemic was an event of great social and health resonance, which caused high morbidity and mortality in the population. The rapidity in the development of symptoms, the extension to very large groups of the population and the lack of knowledge of the causative agent, were the factors that, added together, made the flu a major public health problem. The objective of this study was to review, through the Spanish written press, of the public health measures adopted as a consequence of the influenza epidemic of 1918.

METHODS

A selection of the Spanish press was carried out through the Digital Newspaper Library of the National Library (HDBN) of Spain, from January 1, 1918 to December 31, 1920; and the concept "flu" was searched, selecting those units of analysis that made reference to the public health measures adopted during the flu epidemic of 1918.

RESULTS

The newspapers analyzed reported the public health measures adopted by the health authorities of the different countries in order to reduce the spread of the epidemic, such as the closure of schools and the postponement of the opening of the academic year, disinfection of premises, quarantines, isolation, suspension, popular celebrations, disinfection and hygiene, border control, suspension of communications by train, as well as the creation and use of different vaccines and serums to immunize the population.

CONCLUSIONS

The poor management of the epidemic could be one of the causes of the great impact of influenza in the first half of October 1918, as the decisions of the administration to promote public health measures were adopted with some delay.

[A new Spanish enemy; the Spanish flu in the Netherlands in the period 1918-1920]

The Dutch example shows that there are not only differences but also several similarities between COVID-19 and the Spanish flu, although risk of infection and death toll were much higher than they are now, especially at the end of 1918. These similarities include emphasis on the importance of hand washing, prohibition of gatherings (and disregard of these rules), disruption of public life, uncertainty about the nature of the cause, praise of and warnings against ineffective medication as well as debate on use and necessity of certain measures. There is also the social context in which the disease and the measures taken to combat it are happening, with the poor paying the highest price, now as well as then.

COVID-19 and Other Pandemics: How Might They Be Prevented?

Pandemics such as influenza, smallpox, and plague have caused the loss of hundreds of millions of lives and have occurred for many centuries. Fortunately, they have been largely eliminated by the use of vaccinations and drugs. More recently, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and now Coronavirus Disease 2019 (COVID-19) have arisen, and given the current absence of highly effective approved vaccines or drugs, brute-force approaches involving physical barriers are being used to counter virus spread. A major basis for physical protection from respiratory infections is eye, nose, and mouth protection. However, eye protection with goggles is problematic due to "fogging", while nose/mouth protection is complicated by the breathing difficulties associated with non-valved respirators. Here, we give a brief review of the origins and development of face masks and eye protection to counter respiratory infections on the basis of experiments conducted 100 years ago, work that was presaged by the first use of personal protective equipment, "PPE", by the plague doctors of the 17th Century. The results of the review lead to two conclusions: first, that eye protection using filtered eye masks be used to prevent ocular transmission; second, that new, pre-filtered, valved respirators be used to even more effectively block viral transmission.

Safe Villages during the 1918-1919 influenza pandemic in Spain and Portugal

The 1918-1919 influenza pandemic had a significantly different impact on mortality rates in Spanish and Portuguese provinces and cities. In this study, several small villages have been identified which were not affected at all by the Spanish influenza pandemic.

These all shared a number of features in common: their villages were very small, comprising only a few hundred inhabitants; they were located in mountainous regions, with very poor transport infrastructure; and they were self-sufficient and capable of fulfilling their basic alimentary needs. Their inhabitants were conscious of the problem and acted together, effectively isolating themselves from surrounding villages. Since these villagers managed to avoid direct contact with ill people from other municipalities, the flu was not transmitted and the pandemic did not arise in their villages.

In this paper, it is proposed that the human habitability spaces that meet these characteristics, I call them “Safe Villages” or “Shelter Village”. Knowledge of the circumstances in which the 1918-1919 flu pandemic developed and of the means employed to resist it can help us to take relevant measures when faced with future pandemics.

The 1918/19 Spanish Flu in Pisa (Tuscany, Italy): Clinical, Epidemiological and Autoptic Considerations

The Spanish flu pandemic spread in 1918-19 and infected about 500 million people, killing 50 to 100 million of them. People were suffering from severe poverty and malnutrition, especially in Europe, due to the First World War, and this contributed to the diffusion of the disease. In Italy, Spanish flu appeared in April 1918 with several cases of pulmonary congestion and bronchopneumonia; at the end of the epidemic, about 450.000 people died, causing one of the highest mortality rates in Europe. From the archive documents and the autoptic registers of the Hospital of Pisa, we can express some considerations on the impact of the pandemic on the population of the city and obtain some information about the deceased. In the original necroscopic registers, 43 autopsies were reported with the diagnosis of grippe (i.e. Spanish flu), of which the most occurred from September to December 1918. Most of the dead were young individuals, more than half were soldiers, and all of them showed confluent hemor agic lung bronchopneumonia, which was the typical feature of the pandemic flu. We believe that the study of the autopsy registers represents an incomparable instrument for the History of Medicine and a useful resource to understand the origin and the evolution of the diseases.

[Pandemic and Epidemic History as Nursing History?]

This paper is part of Forum COVID-19: Perspectives in the Humanities and Social Sciences. In the current COVID 19 pandemic, the importance of professional nursing is widely recognized. In German-speaking and international research, the history of nursing during pandemics and epidemics is largely unwritten. This paper gives an overview of questions and results in this research area and discusses the potential of a pandemic nursing history.

Truth and transparency in a time of crisis

Lessons from history underline the importance of having direct lines of communication to and from public health officials, who must remain free from policital bias in times of crisis.

The Dramaturgy of Epidemics

My essay focuses on Charles Rosenberg's provocative and enduring ideal type of epidemic drama in three acts, which he assembled from a vast knowledge of disease history that stretched from the end of the seventeenth century to his then-present pandemic, HIV/AIDS of the 1980s. Reaching back to the Plague of Athens, my essay elaborates on Rosenberg's dramaturgy by questioning whether blame, division, and collective violence were so universal or even the dominant "acts" of epidemics not only before the nineteenth century but to the present. Instead, with certain pandemics such as yellow fever in the Deep South or the Great Influenza of 1918-20, unity, mass volunteerism, and self-abnegation played leading roles. Finally, not all epidemics ended "with a whimper" as attested by the long early modern history of plague. These often concluded literally with a bang: lavish planning of festivals of thanksgiving, choreographed with processions, innumerable banners, commissions of paintings, ex-voto churches, trumpets, tambourines, artillery fire, and fireworks.

[Spanish Flu in the Neretva Valley]

The Spanish flu is a pandemic that was neglected even though it killed more people than World War I. At the end of 1918, newspaper reports are scarce due to war events, press cen-sorships, and burst political events. For decades after the epidemic was over, the Spanish flu was not the subject of scientific research. By analysing the entry from the registers of the six Neretva parishes (Borovci-Nova Selo, Desne-Bagalovići, Dobranje, Opuzen, Metkovic, Vidonje,and Vid), statistical data on the scale of the epidemic were reconstructed as well as the time course of the spread of the disease in the valley. The sex and age structure of the deceased were also analysed. The disease was spreading from Opuzen throughout the valley. The peak of the epidemic was in the second half of November and late December. The villages of the Desne and Vidonje were the most affected. Vid was also captured by the third wave in 1920, which was as deadly as that in 1918. The most affected were women, which fits in Croatian statistics. Comparing the timeline of epidemics in Zagreb and Neretva valley, it is visible that Zagreb was affected earlier by an epidemic. The third wave did not affect Zagreb as much as it did Neretva, especially the village of Vidonje. In these Neretva parishes, people under twenty were mostly affected. This deviates from the general rules and statistics of the Spanish flu, which stated that the most affected population was between the ages of twenty and forty. The article deals with data on the Spanish Neretva flu cases, while the number of infections remains unknown.

Marking the 1918 influenza pandemic centennial: addressing regional influenza threats through the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies

The Western Pacific Region (WPR) is home to nearly 1.9 billion people. Over the past decades, the Region has experienced a number of significant emerging infectious disease events, including human infections with avian influenza viruses. Health security threats continue and become even more complex in this highly interconnected world. With humans and animals living in close proximity, the Western Pacific region provides an ideal environment for influenza viruses to pass from animals to humans, potentially mutate and spread globally in a rapid manner. In efforts to prevent or mitigate the next pandemic, WPR has been working together to ensure a strong regional human-animal-environmental influenza surveillance system is in place for rapid detection, identification, reporting and response to any events with pandemic potential.

Race and 1918 Influenza Pandemic in the United States: A Review of the Literature

During epidemics, the poorest part of the population usually suffers the most. Alfred Crosby noted that the norm changed during the 1918 influenza pandemic in the US: The black population (which were expected to have higher influenza morbidity and mortality) had lower morbidity and mortality than the white population during the autumn of 1918. Crosby's explanation for this was that black people were more exposed to a mild spring/summer wave of influenza earlier that same year. In this paper, we review the literature from the pandemic of 1918 to better understand the crossover in the role of race on mortality. The literature has used insurance, military, survey, and routine notification data. Results show that the black population had lower morbidity, and during September, October, and November, lower mortality but higher case fatality than the white population. The results also show that the black population had lower influenza morbidity prior to 1918. The reasons for lower morbidity among the black population both at baseline and during the herald and later waves in 1918 remain unclear. Results may imply that black people had a lower risk of developing the disease given exposure, but when they did get sick, they had a higher risk of dying.

Using cultural, historical, and epidemiological data to inform, calibrate, and verify model structures in agent-based simulations

Agent-based simulation models are excellent tools for addressing questions about the spread of infectious diseases in human populations because realistic, complex behaviors as well as random factors can readily be incorporated. Agent-based models are flexible and allow for a wide variety of behaviors, time-related variables, and geographies, making the calibration process an extremely important step in model development. Such calibration procedures, including verification and validation, may be complicated, however, and usually require incorporation of substantial empirical data and theoretical knowledge of the populations and processes under study. This paper describes steps taken to build and calibrate an agent-based model of epidemic spread in an early 20^th century fishing village in Newfoundland and Labrador, including a description of some of the detailed ethnographic and historical data available. We illustrate how these data were used to develop the structure of specific parts of the model. The resulting model, however, is designed to reflect a generic small community during the early 20^th century and the spread of a directly transmitted disease within such a community, not the specific place that provided the data. Following the description of model development, we present the results of a replication study used to confirm the model behaves as intended. This study is also used to identify the number of simulations necessary for high confidence in average model output. We also present selected results from extensive sensitivity analyses to assess the effect that variation in parameter values has on model outcomes. After careful calibration and verification, the model can be used to address specific practical questions of interest. We provide an illustrative example of this process.

The Spanish Influenza Pandemic: a lesson from history 100 years after 1918

In Europe in 1918, influenza spread through Spain, France, Great Britain and Italy, causing havoc with military operations during the First World War. The influenza pandemic of 1918 killed more than 50 million people worldwide. In addition, its socioeconomic consequences were huge.

“Spanish flu”, as the infection was dubbed, hit different age-groups, displaying a so-called “W-trend”, typically with two spikes in children and the elderly. However, healthy young adults were also affected.

In order to avoid alarming the public, several local health authorities refused to reveal the numbers of people affected and deaths. Consequently, it was very difficult to assess the impact of the disease at the time.

Although official communications issued by health authorities worldwide expressed certainty about the etiology of the infection, in laboratories it was not always possible to isolate the famous Pfeiffer’s bacillus, which was, at that time, deemed to be the cause of influenza.

The first official preventive actions were implemented in August 1918; these included the obligatory notification of suspected cases and the surveillance of communities such as day-schools, boarding schools and barracks.

Identifying suspected cases through surveillance, and voluntary and/or mandatory quarantine or isolation, enabled the spread of Spanish flu to be curbed. At that time, these public health measures were the only effective weapons against the disease, as no vaccines or antivirals were available.

Virological and bacteriological analysis of preserved samples from infected soldiers and other young people who died during the pandemic period is a major step toward a better understanding of this pandemic and of how to prepare for future pandemics.

Social Class and Excess Mortality in Sweden During the 1918 Influenza Pandemic

Consensus is lacking in the literature about the role of socioeconomic factors on influenza-associated deaths during the 1918 pandemic. Although some scholars have found that social factors were important, others have not. In this study, we analyzed differences in excess mortality by social class in Sweden during the 1918 pandemic. We analyzed individual-level mortality of the entire population aged 30-59 years by combining information from death records with census data on occupation. Social class was measured by an occupation-based class scheme. Excess mortality during the pandemic was measured as the number of deaths relative to the number occurring in the same month the year before. Social class differences in numbers of deaths were modeled using a complementary log-log model that was adjusted for potential confounding at the family, the residential (urban/rural), and the county levels. We found notable class differences in excess mortality but no perfect class gradient. Class differences were somewhat larger for men than for women.

Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic

Mortality estimates of the 1918 influenza pandemic vary considerably, and recent estimates have suggested that there were 50 million to 100 million deaths worldwide. We investigated the global mortality burden using an indirect estimation approach and 2 publicly available data sets: the Human Mortality Database (13 countries) and data extracted from the records of the Statistical Abstract for British India. The all-cause Human Mortality Database was used to estimate mortality annually for 1916-1921 for detailed age groups. Three different calculation methods were applied to the data (low, medium, and high scenarios), and we used a multilevel regression model to control for distorting factors (e.g., war and the underlying time trend in mortality). Total pandemic mortality was an estimated 15 million deaths worldwide in 1918 (n = 2.5 million in 1919) after including the rates for British India and controlling for wars and the underlying mortality trend. According to our validity analysis, simulations of total number of deaths being greater than 25 million are not realistic based on the underlying mortality rates included in Human Mortality Database and in British India. Our results suggest the global death impact of the 1918 pandemic was important (n = 17.4 million) but not as severe as most frequently cited estimates.

Spatiotemporal Patterns and Diffusion of the 1918 Influenza Pandemic in British India

The factors that drive spatial heterogeneity and diffusion of pandemic influenza remain debated. We characterized the spatiotemporal mortality patterns of the 1918 influenza pandemic in British India and studied the role of demographic factors, environmental variables, and mobility processes on the observed patterns of spread. Fever-related and all-cause excess mortality data across 206 districts in India from January 1916 to December 1920 were analyzed while controlling for variation in seasonality particular to India. Aspects of the 1918 autumn wave in India matched signature features of influenza pandemics, with high disease burden among young adults, (moderate) spatial heterogeneity in burden, and highly synchronized outbreaks across the country deviating from annual seasonality. Importantly, we found population density and rainfall explained the spatial variation in excess mortality, and long-distance travel via railroad was predictive of the observed spatial diffusion of disease. A spatiotemporal analysis of mortality patterns during the 1918 influenza pandemic in India was integrated in this study with data on underlying factors and processes to reveal transmission mechanisms in a large, intensely connected setting with significant climatic variability. The characterization of such heterogeneity during historical pandemics is crucial to prepare for future pandemics.

Pathologica in the time of "Spanish flu"

The pandemic "Spanish flu", that in a few weeks of the autumn 1918 caused in Italy a number of deaths between 350.000 and 600.000, was widely discussed by the scientific community, although very little of that debate leaked out, because of the military censorship. In the present article we comment on the original papers describing the hemorrhagic pneumonia, and on discussions about the ideas of the origin of the pandemic infection (Pfeiffer bacillus, vs streptococcus or other bacteria vs a "viral hypotesis") that occurred in Pathologica during and soon after that ominous pandemia.

The Physician's Duty to Treat During Pandemics

Physicians assume a primary ethical duty to place the welfare of their patients above their own interests. Thus, for example, physicians must not exploit the patient-physician relationship for personal financial gain through the practice of self-referral. But how far does the duty to patient welfare extend? Must physicians assume a serious risk to their own health to ensure that patients receive needed care? In the past, physicians were expected to provide care during pandemics without regard to the risk to their own health. In recent decades, however, the duty to treat during pandemics has suffered from erosion even while the risks to physicians from meeting the duty has gone down. After exploring the historical evolution of the duty to treat and the reasons for the duty, I conclude that restoring a strong duty to treat would protect patient welfare without subjecting physicians to undue health risks.

100 Years of Medical Countermeasures and Pandemic Influenza Preparedness

The 1918 influenza pandemic spread rapidly around the globe, leading to high mortality and social disruption. The countermeasures available to mitigate the pandemic were limited and relied on nonpharmaceutical interventions. Over the past 100 years, improvements in medical care, influenza vaccines, antiviral medications, community mitigation efforts, diagnosis, and communications have improved pandemic response. A number of gaps remain, including vaccines that are more rapidly manufactured, antiviral drugs that are more effective and available, and better respiratory protective devices.

The long-run effects of pandemic influenza on the development of children from elite backgrounds: Evidence from industrializing Japan

This study estimates the lingering effects of fetal exposure to the 1918 influenza pandemic on the development of secondary school and girls' high school students in industrializing Japan. In order to refine the verification of the fetal origins hypothesis, we tried not only to focus on children from elite schools but also to construct the continuous influenza mortality measure using monthly variations in the number of births and influenza deaths. By utilizing a nationwide multidimensional physical examination dataset, we found that fetal exposure to influenza in the pandemic years reduced the heights of boys and girls by approximately 0.3 cm and 0.1 cm, respectively. While the strongest negative magnitude was observed in the pandemic period, the lingering relapses in the post-pandemic period still had considerable adverse effects on height. In relation to the lowest decile group which experienced normal influenza mortality in non-pandemic years, the heights of the boys and girls who experienced pandemic influenza in the womb are approximately 0.6 and 0.3 cm lower. The lingering influenza relapse in the post-pandemic period has an adverse effect on the boys' height, accounting for roughly 80% of the maximum pandemic effect.

Waiting for the flu: cognitive inertia and the Spanish influenza pandemic of 1918-19

This study looks at public awareness and understanding of the Spanish flu in the United States between June 1918, when the flu became "Spanish," and the end of September when the deadly second wave reached the majority of the country. Based on an extensive reading of local newspapers, it finds a near universal lack of preparation or panic or other signs of personal concern among those in the unaffected areas, despite extensive and potentially worrying coverage of the flu's progress. The normal reaction to news of the inexorable approach of a pandemic of uncertain virulence is anxiety and action. The Spanish flu produced neither in the uninfected areas for a month. The most likely reason appears to be cognitive inertia-the tendency of existing beliefs or habits of thought to blind people to changed realities. This inertia grew out of the widespread understanding of flu as a seasonal visitor that while frequently unpleasant almost never killed the strong and otherwise healthy. This view of the flu was powerful enough that it blinded many in the unaffected regions to the threat for weeks even in the face of daily or near daily coverage of the pandemic's spread.

The first announcement about the 1918 "Spanish flu" pandemic in Greece through the writings of the pioneer newspaper "Thessalia" almost a century ago

A local pioneer newspaper, "Thessalia", was the first to announce the arrival of "Spanish Flu" in Greece. It was July 19th 1918 when an epidemic outbreak occurred in the city of Patras. Until then, "Thessalia" had dealt in depth with the flu pandemic in the Greek district of Thessaly, informing the readers of the measures taken, as well as the social and economic aspects of the flu.

[The "Spanish flu" pandemic of 1918-1919 in La Réunion (Indian Ocean)]

Brought in by the ship Madonna, which was taking local survivors of World War I back to Reunion, the 1918 Spanish flu pandemic reached the island in March 1919 and lasted for three months. The controversies between doctors and between doctors and the colonial administrators, officials' desertion of their posts, and food shortages together caused a major panic. The epidemic appears to have ravaged people under the age of 40 and the most disadvantaged neighborhoods, at a period when the economy was already in the doldrums and the population had been declining since the late 19th century. Estimates indicate 2000 deaths in the capital of Saint-Denis, among a population of 25,000 inhabitants, and 7 to 20,000 deaths on the island as a whole, representing 4-11% of the population - far more than the 949 local soldiers killed on the battlefields of Europe. According to legend, salvation came from the sky as a small cyclone on May 11, 1919: it lasted an hour, swept away the "miasmas" and washed the island clean of all its impurities.