1918 Flu Epidemic Teaching Valuable Lessons

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1918 Flu Epidemic Teaching Valuable Lessons

Actions Taken Apparently Were Effective

By Brown

Washington Post Staff Writer

Wednesday, December 13, 2006; A04

New analysis of how American cities responded to the killer Spanish

flu of 1918 suggests that closing schools, banning large gatherings,

staggering work hours and quarantining households of the ill may have

saved tens of thousands of lives.

Which of the many non-pharmaceutical interventions was especially

effective in reducing mortality is unknown, but all would

theoretically be available should pandemic influenza again sweep the

country.

The new findings run counter to previous research that concluded that

the public health measures instituted in 1918 may have delayed or

dampened the epidemic in many cities but probably had little effect on

the ultimate death toll.

The new data were presented this week to Centers for Disease Control

and Prevention experts, who are helping to draw up guidelines for what

local health departments might do during the early stage of an

influenza pandemic, when a vaccine would be unavailable and there

would be too few antiviral drugs to go around.

" There is reason for optimism. Even almost 100 years ago, with some

very simple tools, there may have been an effect of these measures, "

said Cetron, a physician who directs global migration and

quarantine at the CDC.

Many epidemiologists think the time is ripe for an influenza pandemic:

the outbreak of a novel, contagious strain of the virus capable of

infecting virtually everyone on Earth.

The H5N1 strain of avian influenza, which since 2003 has killed

millions of birds and 154 people, mostly in Asia, is considered by

many experts to have pandemic potential. The latest victim was a

35-year-old Indonesian woman who died Nov. 28 -- the 57th fatal case

out of 74 in that country.

In 1918, the public health responses included isolating the ill,

quarantining houses, closing schools, canceling worship services,

restricting the size of funerals and weddings, closing saloons and

theaters, restricting door-to-door sales, discouraging the use of

public transportation, staggering the hours of business and factory

operations, imposing curfews and, in some places, recommending the use

of face masks in public.

Markel, a physician and historian at the University of Michigan

Medical School, is leading a project to analyze the experience of 45

American cities, looking for relationships among flu cases, mortality

and public health measures.

The researchers used a model to determine what the epidemic would have

looked like had no measures been taken and compared that result with a

city's actual experience.

St. Louis closed its schools at a time when flu was causing 21 more

deaths per 100,000 people per week than what had been seen in previous

years. That step -- the earliest taken by any of 33 cities analyzed so

far -- appears to have reduced St. Louis's flu mortality by 70 percent.

Cincinnati responded less quickly, invoking public health measures

when excess deaths from flu were 46 per 100,000. It reduced its

potential flu mortality by 45 percent. Philadelphia was extremely

late, not acting until its excess death rate was 250 per 100,000. That

reduced mortality by 28 percent, Markel and his colleagues found.

How U.S. communities would react to a sudden closure of schools is

uncertain, although the experience this past fall of one rural

Appalachian county suggests that there may be little opposition over

the short term.

Yancey County, in rural and mountainous western North Carolina, closed

its 2,559-student school system from Nov. 2 to 13 because of an

outbreak of influenza B. A random survey of households found that 91

percent supported the school board's decision.

In half of those households, all the adults worked outside the home.

During that period, one-quarter of them had to take time off from

work, mainly because they were ill themselves or had to care for a

sick family member, and not simply to stay with children not in

school, said April J. of the CDC's Epidemic Intelligence

Service, who investigated the outbreak.

In only two of 220 households did adults have to pay for extra child

care when schools were closed. In most cases, relatives and friends

stepped in to help, found.

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