The "Spanish Lady"
by Rod Daniels
http://www.nimr.mrc.ac.uk/millhillessays/1998/influenza1918.htm
Not the "Spanish Lady" of
sea-shanty fame but influenza, which may be older than mankind. Through
written records we can trace outbreaks of influenza-like disease back to
412 BC. More precise descriptions of the disease date from an epidemic
in 1173, since which time there have been numerous outbreaks that have
varied in severity. The most intense, to date, occurred in the last year
of World War 1: the so-called "Spanish Lady" or "Spanish Flu" pandemic
of 1918-19 which infected one billion people, half the world’s
population at that time, and killed between forty and fifty million.
This makes it the most devastating disease of man known, surpassing even
the bubonic plague of the fourteenth century, smallpox in the sixteenth
century and the human immunodeficiency virus/AIDS pandemic that is
happening now.
The given name "Spanish" is a
twist of history that occurred because Spain, not being involved in the
war, had a free Press which could report on the ravages of the pandemic
in their country. In turn, when Russia reported on the situation in
Moscow, Pravda printed "Ispanka (The Spanish Lady) is in town"
and the name has stuck. In fact, the first case can be traced to Camp
Funston, Kansas, USA on 8 March 1918. This heralded the start of the
pandemic which spread around the world in three waves. The first wave,
in March to July of 1918, was relatively mild causing only a small
increase in the death rate, this was followed by the most devastating
wave between September and December 1918, the virus having changed its
character perhaps in the trenches of France, and the final wave of
February to April 1919 which produced intermediate death rates.
In 1918-19 the enormity of
the pandemic was not uppermost in most peoples' minds, due partly to the
tendency of human nature to shut out bad experiences, and the fact that
most were more concerned with the concepts of the war. Indeed, influenza
may have played a role in ending the conflict as soldiers were too sick
to fight and more men, on both sides, died of influenza than were killed
by weapons. In spite of resource commitment to the war, there is a huge
volume of literature on the pandemic in terms of clinical descriptions
of cases, autopsy reports, microbiologic studies, attempts to develop an
animal model for the disease and social history.
The usual symptoms of
influenza, rapid onset with high fever, chills, headache, muscle ache in
back and legs, and dry cough, were reported and the vast majority of
those infected recovered within a week following bed rest, though many
experienced a "depression" which took months to overcome. Some
individuals showed signs of infection and were dead within twenty-four
hours, and there were reports of people who literally dropped dead;
others died within two to three days, essentially by drowning as their
lungs filled with blood and fluid due to haemorrhage; the majority of
those who died did so as a result of pneumonia often caused by secondary
infection with bacteria. Many of those who were to die showed outward
signs of blueing of the lips, ears, face generally, finger tips and
toes, a condition called cyanosis which results from oxygen deprivation.
At autopsy, lung and heart damage was common with frequent occurrence of
bleeding. Other organs, such as liver, spleen and kidney often showed
abnormalities and a few cases showed swelling of the brain.
In 1892, following an
influenza outbreak in 1890, a microbiologist called Pfeiffer isolated
the bacterium Bacillus influenzae which was proposed to be the
cause of influenza. However, in subsequent outbreaks and in particular
that of 1918-19, where extensive bacterial culture from lung specimens
was successful, a wide selection of bacteria were isolated which led to
the proposal that influenza was caused by an undiscovered virus, whilst
bacteria were responsible for the gravity of the secondary complications
of pneumonia. In spite of this proposal, an anti-influenza vaccine
composed of a lethal cocktail of bacteria was prepared but, fortunately,
it was not widely administered as the influenza pandemic ended abruptly,
perhaps as a result of exhausting the supply of individuals that it
could infect in the human population. This abrupt end to the pandemic
also brought experiments in animals, which may have led to the isolation
of the virus, to a stop.
One of the major unusual
features of the 1918-19 pandemic was the age-distribution of those who
died. The majority were between twenty and forty tears old whilst in
preceding and subsequent influenza outbreaks it was young children and
the elderly who were most likely to die. It is possible that in 1918 the
elderly may have benefited from an immunity, having survived attacks by
less deadly influenza viruses in previous epidemics. Less likely is the
idea that the 1918-19 virus was more infectious towards adolescent and
young adult tissues than those of the young and elderly. The gathering
of twenty to forty year olds for the purposes of war, and declining
standards of hygiene and nutrition often associated with crowding, may
have enhanced spread of the virus. However, this explanation is perhaps
too simplistic since similar age-distributions of death were seen in all
countries, not just those involved in the war, and across all social
classes. Maybe the young adult population were taking a more active part
in the preparations for and fighting of the war and their bodies would
have been more stressed than other members of the community. This may
have made them more susceptible to infection and disease development.
Indeed, many of the changes in body chemistry associated with stress
have been shown to match those which give increased probability of
infection by human immunodeficiency virus in the present-day AIDS
pandemic.
The conditions prevailing in
1918, with an unprecedented movement of people around the world, gave
the "Spanish Lady" the best possible chance of spreading. Too late, many
governments and local councils imposed public health measures such as
bans on public meetings, closure of places of mass entertainment, the
compulsory wearing of masks in public and quarantine of ports. The
"Lady" had established herself and spread like wild-fire. Disease spread
could be traced to routes of individual ships, along railway lines and
even to the postman delivering mail to isolated communities. Reports of
whole families dying, up to ninety percent of individual communities,
and sixty percent of the total Eskimo population, can be found. Many
cities and towns ground to a halt as there were insufficient healthy
people to run services; medical facilities were overwhelmed with sick
people and the number of deaths led to a shortage of coffins and
introduction of mass burial in some areas, to remove the chance of
further public health problems.
So what did cause this
outbreak? Viruses had been described, as early as 1898, as infectious
disease-producing agents of small size as shown by their ability to pass
through filters which would hold back ordinary bacteria, but attempts to
isolate and characterise the agent of the 1918-19 pandemic were
unsuccessful. Indeed, influenza was not isolated from humans until 1933,
but since that time we have learned a great deal about influenza viruses
through tracking studies and basic laboratory research. We know that
there are three different types, A, B and C all of which can infect man.
They all cause disease of a more or less serious nature, although modern
day vaccines, made from inactivated virus or virus fragments, offer a
degree of protection. Type A viruses are often associated with the most
severe disease, and show great variation in their properties from year
to year. Type A viruses are also found in birds and there have been
outbreaks of influenza in other species, such as whales, seals and mink.
Horses and pigs are also frequently infected and some researchers have
suggested that the pig holds an important position as a mixing-pot for
bird and human influenza strains resulting in new combinations which may
infect man.
In response to infection with
influenza our defence mechanism, the immune system, produces antibodies
which circulate in the bloodstream and neutralise the virus. Screening
of blood samples for the presence of such antibodies to known influenza
viruses, gives us an idea of the influenza-infection history of any
particular individual. Results of these tests show that, in this
century, there have been three major pandemics the 1918-19 pandemic, the
Asian influenza in 1957 which killed over a million people and the Hong
Kong influenza of 1968 which claimed nearly three quarters of a million
victims.
Armed with the ability to
isolate influenza viruses, detect them by antibody testing, to produce
them in hens eggs and cells in tissue culture for research purposes and
vaccine production, there was new interest in the 1950s in the cause of
the 1918-19 pandemic. Two expeditions were made to the Alaskan Arctic to
retrieve tissue samples from victims of the "Spanish Lady" who had been
buried in permafrost. The United States Army expedition to Nome in
Alaska, called Project-George, proved unsuccessful as the bodies had
been buried in the active layer of the permafrost and decomposed as a
result of successive freezing and thawing over the intervening years.
Iowa State University mounted an expedition to Teller, also in Alaska,
and retrieved tissue specimens from preserved bodies. However, whilst
they were able to recover Bacillus influenzae and
pneumococci from the samples, attempts to revive the "Spanish Lady"
were unsuccessful. More recently, using molecular biological techniques
developed since the 1970’s, there have been attempts to rescue the
genetic information of 1918-19 influenza from autopsy samples taken and
preserved shortly after the victims’ deaths. This approach has yielded
information which confirms that the 1918-19 influenza was like the virus
isolated first from humans in 1933 but it gives no indication as to why
the virus was so harmful. Similar results are emerging from tissue
recovered recently, from a corpse in Teller.
We continue to look for
further samples from the 1918-19 pandemic. A study of death records for
the winter of 1918, from Alaska, northern Canada and northern Europe,
has identified sites where the grave locations of victims of the
"Spanish Lady" are known and permafrost conditions provide a good
probability of body preservation. Such a site was in Longyearbyen, on
the island of Spitsbergen, in the Norwegian Arctic archipelago of
Svalbard. Seven Norwegian miners aged between nineteen and twenty eight,
typical of those afflicted by the Spanish Flu, became ill en route to
Longyearbyen, died of influenza between September and October 1918 and
were buried in permafrost. The resident community at Longyearbyen was
probably protected as they had already experienced the first wave of the
pandemic as indicated by a newspaper entry of August 21, 1918: "Things
have looked very grim here recently, especially the last few days. The
Spanish influenza has gained territory. Only six or seven out of eighty
men have been working for the last fortnight. The others have all been
attacked by the flu."
Ground Penetrating Radar was
used to identify a mass grave, coinciding with grave markers of the
seven victims. This survey indicated ground disturbance to a depth of
one-and-a-half to two-and-a-half metres with the permafrost active layer
extending to a depth of no more than one metre. This information
suggested that the bodies were probably below the active layer such that
they would have remained in a frozen state since interment. However,
exhumation carried out this summer showed that the bodies had been
buried in the active layer and that the quality of samples available was
not as good as hoped for. Nevertheless, samples have been taken and
transported to a special containment laboratory, which provides the
highest level of biological safety. There, attempts are being made to
generate more information on the 1918 virus and a general
microbiological analysis of the samples is being undertaken. With some
luck, and a lot of hard work, the "Spanish Lady" may drop her veil
further and give up secrets held for eighty years.
From written records and
ongoing surveillance studies in the twentieth century, periodicities of
influenza outbreaks of thirty to forty and eleven years have been
proposed and many scientists predict that we are overdue another
pandemic influenza outbreak. In some ways, conditions prevail as they
did in 1918: there is a huge volume of international travel due to the
development of transport, there are a number of war-zones with their
inherent problems of malnutrition and poor hygiene, the world population
has grown to six and a half billion and a greater proportion of this
population is living in urban situations many of which have decaying
infrastructures in terms of waste disposal. There have been three scares
in the last twenty-five years. In 1976, a soldier died at Fort Dix, New
Jersey, USA and the virus recovered was identified as a descendant of
the influenza virus 1918-19 pandemic; a massive vaccine production and
administration campaign was initiated but fortunately the virus did not
spread. In 1977 the Russian influenza appeared and was shown to be a
virus closely related to viruses circulating in the 1950’s; escape from
a laboratory has been suggested as the cause of its reintroduction. In
1997 a new Hong Kong influenza emerged to become the first documented
case of direct transmission between birds and man. The implications of
this event were potentially catastrophic as there was no established
immunity to this virus in the human population. Fortunately, only
eighteen cases of infection have been confirmed with six deaths and
there is no evidence for human to human transmission. In order to
contain the outbreak the Hong Kong authorities ordered the destruction
of over a million chickens. Their prompt action may have saved the lives
of many millions of human beings. The surveillance programme in humans
and chickens continues and steps towards preparing a vaccine have been
taken in case this limited outbreak represents the opening shot in the
development of a full pandemic.
It was written in 1927: "In
the face of the almost certain recurrence some day of another world-wide
pandemic, we remain nearly as helpless to institute effective measures
of control as we were before 1918." Today we are in a much better
position and many national authorities are formulating contingency plans
for a new pandemic of influenza. We have anti-influenza drugs which
prevent or delay infections to allow production of the required vaccine,
and there is an arsenal of antibiotics to deal with secondary bacterial
infections. Continued research on the "Spanish Lady" and the recent Hong
Kong virus will hopefully give new insights into what determines the
severity of an influenza outbreak and allow testing of our defence
strategies on viruses that have such devastating potential.
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