Ahead by a Century? It has been 100 years since the Spanish flu pandemic, but our influenza efforts are still lacking.

Flu victims 1918 pandemic 

Spit Spreads Death

This past weekend marked 100 years since the end of  the First World War.

It has also been a century since the 1918 Spanish flu pandemic tore through Europe and North America, leaving behind more corpses than the ravages of combat. Conservative estimates number 21 million flu fatalities, but recent numbers point to an astronomically greater count well into the 50 -100 million range.

The Great War, considered one of the deadliest conflicts in human history, took 16 million lives. It’s devastating to think that it’s death toll pales in comparison: that a virus ripped through more people than thousands of bullets.

H1N1, a strain of the influenza A virus, was to blame for the illness that burned through one third of the world’s population. An astonishing 500 million people were infected with the virus. To put that into perspective, today’s population has grown exponentially since 1918— jumping from a meager 1.6 billion to 7.7 billion.

There were significantly less people mulling about when the pandemic broke out 100 years ago and yet, 500 million sick people is a substantial number for any decade. In comparison, if every single person in North America came down with an illness today — the 450 million of Canada, the United States and Mexico combined — we would still be 16 million people short from the 500 million mark.

In 1918, North America had a modest population of 93 million, with roughly 700,000 of those people — from the United States and Canada — killed by the virus.

A century has passed, and our booming population has brought about advances in science, medicine and technology. Public health measures have strengthened significantly since the pandemic of the century, with the rise of better sanitation, vaccinations and general education campaigns.

Although, attempts by public health departments at the time still leave quite the lasting impression — such as the frank signage stating in big, bold letters, “SPIT SPREADS DEATH”

1918 public health warning

But, despite our general advances in medicine, greater understanding of illness, and vaccinations against the virus, influenza still surfaces— mouth a gape—devouring lives every year.

Shifting and Drifting

H1N1, the strain that tore through the world, isn’t a relic of history. Versions of this strain creep up every so often and they are deadly. In 2009, H1N1 was behind the outbreak referred to as the Swine Flu. It too was branded a pandemic and hit the population harder and faster than most seasonal flus. It, like it’s ancient cousin, spread though young, healthy individuals often causing complications like pneumonia. The death toll, fortunately, wasn’t nearly as grievous: yet still over 60 million, in the United States alone, were thought to be infected.

Influenza A is a small, evolutionarily clever virus. Inside its enveloped virion, it contains a segmented RNA genome. The individual segments allow for mutations and the reassortment of genes among different strains — like shuffling a deck of cards, you will end up with a different hand every time.

Small genetic drifts—mutations— cause epidemics, or small pockets of illness. This is what you see with your regular seasonal influenza outbreaks. 1918 was the product of something much more insidious: a much larger mutation, referred to as a genetic shift, where genes from different strains of influenza virus are exchanged. This genetic reassortment creates novel, or new, viruses.

Influenza A virus

The virus is named after the combination of two different proteins— hemagglutinin (HA) and neuraminidase (NA) — which line the outer envelope. Both proteins are important in viral replication. The combination of these proteins leads to names, like H1N1 or H3N2 and, they appear to play a role in the powerful pandemic punch.

In both the 1918 and the 2009 pandemics, H1N1 strains were viruses never seen before in circulation. This is problematic as it leaves our immune system to respond in unpredictable and sometimes even detrimental ways.

Novel H1N1 subtypes appear to proliferate and replicate significantly faster than their seasonal counterparts. It overwhelms the body with virus particles leading to a dramatic immune response. This high viral load can also increase the likelihood of spreading the disease faster and further than normal. The more virus particles one sheds, the more likely these particles are to find a new, warm human to replicate inside of.

Face of Death

Originally thought to be epidemic of pneumonic plague, the symptoms of the the 1918 illness were drastic and devastating. Debilitating pneumonia raged within the lobes of the lungs. Reports circulated of those infected frothing at the mouth with an eerie cyanosis rapidly engulfing their skin.

It was nicked named “the Blue Death”  in some military camps. When army physicians noted this spreading blue tinge across the skin of those infected, death was said to be near. Lungs were significantly injured but there were also reports of other dramatic complications. Mucous membranes lost their integrity and were prone to massive bleeding: those suffering from the flu looking more like victims of a strange hemorrhagic sickness than of a seasonal viral illness.

Damaged lung of a 1918 flu casualty via Smithsonian

The terrifying and unusual symptoms were thought to be result of a massive immune reaction, leading to an overwhelming  inflammatory response, referred to as a cytokine storm. Cytokines are the normal part of the immune response and are delegated to the forefront at the first sign of a foreign invader. They are messengers that recruit pro-inflammatory cells, which generally helps to arouse the immune system so it can mount an attack.

In general, a healthy cytokine response leads to symptoms we know well — like muscle aches and a runny nose — but a hyperactive immune response can be detrimental. It can strip the epithelial cells of the lungs, injure tissue, and cause systemic inflammation, triggering a cascade of reactions that may lead to death. A prevalent theory of why so many young and healthy individuals died, at such an astounding pace, can be attributed to a chaotic immune response.

The 1918 pandemic was dubbed the Spanish flu although, it is now apparent that Spain was not ground zero for this virus— it was merely a stop along it’s path. 100 years later, we still have no conformation of the origin point but we can narrow it down to three places on three different continents:  an army camp in Kansas, the deadly trenches in France and Shanxi province in Northern China.

Wherever the origin, the virus did not discriminate— burning through people across countries and dramatically changing the world in its wake.

Camp Funston, possible birth place of the pandemic

Sick Season

And yet, what have we learned?

Currently, influenza vaccination counts are too low: it was reported that only 38% of Canadian’s received the shot last year. The reason for the low number of rolled up sleeves was chalked up to people not thinking they were at risk — therefore unnecessary— and those that did not believe in the efficacy of the vaccine.

This leaves many susceptible people unprotected and makes room for more of the virus to circulate among the population.

According to some Canadian news outlets, early predictions peg this year’s flu season to be relatively mild. This sounds reassuring but contributes to the prevalent, yet inaccurate, image of influenza being a minor illness — nothing more than a really bad cold. But that isn’t the case. Influenza can still cause serious illness and complications. On average, it kills just over 3,000 Canadians a year.

Last year’s flu season was particularly deadly in North America — sending 900,000 American’s to the Emergency Room and 80,000 to the morgue.

This virus still comes crashing in to the population each and every year. We are leaving ourselves just a vulnerable as our 1918 counterparts, yet we have the means to prepare and protect ourselves from many of the viral onslaughts that plague us.  Increasingly, we are simply choosing not to.

Perhaps we need to look back to past public health campaigns  with their candid and devastatingly clear messages.

Spit spreads death. Vaccines save lives. It’s a simple, powerful narrative but it appears to fall just short of public attention.

Public health notice 1918

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