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It could happen again; 1918 flu pandemic killed thousands in Mississippi, millions around the world

Northeast Mississippi Daily Journal - 11/4/2018

Nov. 04--A century ago, the world faced down the fiercest influenza pandemic in history. Striking in the waning days of World War I, the virus sickened 500 million people around the world and killed 50 million. In the United States, estimated deaths are as high as 675,000. Mississippi wasn't immune, with thousands dying over the course of months. Even with advances in modern medicine, the world and Mississippi are still vulnerable."We definitely would have our own set of challenges if there's a pandemic similar to 1918," said Mississippi state epidemiologist Dr. Paul Byers.

A pandemic flu, by definition, involves a new strain of the virus that the population has little or no immunity against and spreads around the globe. It's not a question of if a pandemic flu will come again, it's when.

"We've already had a pandemic this century," with a novel H1N1 virus in 2009, Byers said.

That pandemic was relatively mild, with about 12,000 estimated deaths in the United States. By contrast, last year's severe seasonal flu saw an estimated 80,000 and 90,000 deaths in the nation, including 183 children.

"Even after 100 years, the flu is still unpredictable," said Tupelo infectious disease specialist Dr. Mindy Prewitt. "Pandemics, by definition, sneak up on you."

The flu is like a hurricane, Prewitt said. As tornadoes and flooding follow a hurricane, pneumonia and other complications follow the flu, doing much of the damage. But major hurricanes and virulent strains of the flu are powerful on their own.

"The (1918) flu itself was bad enough to kill," Prewitt said.

Mother of all flu pandemics

Influenza has been with humans for thousands of years. In the spring of 1918, a novel virus emerged and would go on to infect roughly a third of the world's population.

In 1918, they didn't have many of the resources we rely on today to combat the flu. The flu virus wasn't isolated until 1933 and there were no effective vaccines. Penicillin wasn't discovered until 1928, and antibiotics didn't come into wide use until the 1940s, so physicians didn't have a primary weapon against one of the most deadly complications of flu, bacterial pneumonia. Ventilators weren't invented until 1928 and weren't widely used until the 1950s. Trained doctors and nurses were in short supply.

In Northeast Mississippi, hospitals were scarce. Amory'sGilmore Memorial Hospital opened as a sanitarium in 1916, the first modern hospital in the region. There wouldn't be a hospital in Tupelo until 1920.

"Your best chance was a good nurse and good supportive care," Prewitt said.

The spring wave hit sporadically with the first U.S. cases reported in military camps as the United States ramped up to send troops across the Atlantic to fight in World War I. Between September and November, a second, far deadlier wave hit the United States.

The CDC estimates 195,000 Americans died from influenza in October 1918 alone.

"We can't grasp how big it was," Prewitt said, noting whole villages in Alaska were wiped out by the pandemic.

In Mississippi, the first Spanish flu case was recorded at a military base in West Point. Thousands of cases were reported every week in Mississippi in October 1918, according to the Mississippi Encyclopedia. An estimated 6,200 Mississippians died between October and the end of December 1918.

"The October wave really blasted everybody," Prewitt said.

Across the country, public health officials, including those in Mississippi, closed schools, cancelled public meetings, shut down county fairs and theaters. Funerals were ordered to be held privately.

The widespread, severe disease prompted panic. Because there was no medical treatment beyond supportive care, quack cures and treatments were widely circulated.

Into the winter and early spring 1919, Spanish flu continued to leave a mark. Stories in the Tupelo Journal record the flu wiping out five members in a family the same week a member of the board of health spoke to the community and lobbied the Lee County Board of Supervisors to hire a county health official.

The 1918 pandemic was unusual not just for its severity, but also because of who was hit hardest, Byers said. The very young and the very old are typically most vulnerable to flu. But the Spanish flu hit young adults between 20 and 40 the hardest.

It's hard to know exactly what made the 1918 pandemic so deadly, Prewitt said. Bacterial pneumonia following the flu remains dangerous today. But autopsy records from 1918 also note bleeding in the lungs that suggests the flu itself, not complications, was the culprit.

"By itself, flu can devastate the lungs," Prewitt said.

Lessons learned

One of the most important lessons people can learn from 1918 is to take influenza seriously, Byers said. Because most healthy people experience flu as an uncomfortable inconvenience, it doesn't get a lot of respect. But it can and does kill people every year.

"It's not something to take lightly," Byers said. "The flu is here. We have it every year."

National and international public health agencies put a lot of effort into monitoring seasonal flu and watching for emergence of new flu viruses that could spark a pandemic, Byers said.

"All it takes is a little bit of a change in the virus," Byers said. "The flu viruses change very easily."

They have particularly watched flu viruses that developed in other birds and can pass to people. So far those avian flu viruses haven't been easily passed person to person.

Modern medicine has more tools to fight flu epidemics, but there isn't the capacity to fully defend against a pandemic of both the scope and severity of 1918.

"We think of ourselves as protected by antibiotics and highly specialized medical equipment," Byers said. "That's not true for the rest of the world."

Having an awareness and rapid response is an important step to limit the spread of the infection, said Dr. Bhagyashiri Navalkele, infectious disease specialist at University of Mississippi Medical Center.

"There needs to be ongoing education about how people can protect themselves," Navalkele said.

Best defense

The flu vaccine is the best weapon medicine has against seasonal influenza and provides protection on two fronts. It's not perfect, but it does reduce the risk of getting infected at all. It also reduces the risk of hospitalization, complications and deaths.

"People who get the vaccine fare better than those who don't," Prewitt said.

Flu shots work by exposing the immune system to dead flu viruses, Navalkele said. The immune system will produce antibodies so it can respond quickly when the live virus comes.

"You need to have some amount of immunity so the body can respond and won't transmit the virus to others," Navalkele said.

Flu shots are recommended for nearly everyone over six months, but are especially important for vulnerable groups, young children, seniors, pregnant women and those with chronic conditions. For families anticipating the arrival of newborns or caring for someone with a compromised immune system, flu vaccination should be a priority.

"We really need to get the flu shot for ourselves and them," Byers said.

The consequences of not vaccinating can be tragic. When public health researchers look at pediatric flu deaths, 80 percent of them occur in children who were not vaccinated, Byers said.

"We have a lot of work to do," Byers said.

Next time

When the next flu pandemic emerges, there likely won't be a vaccine ready in the early waves. Healthy habits and an understanding of how the flu spreads can help people reduce their risk of pandemic and seasonal influenza, Navalkele said.

People with the flu can spread it to others from about six feet away, according to the CDC. That's why it's so important for people who are sick to stay home, public health leaders stress.

The virus is believed to spread by droplets dispersed when infected people cough, sneeze or talk. The droplets land in the mouths or noses of those nearby.

Practicing good cough etiquette can help reduce the spread of droplets. Sneeze and cough into an elbow or tissue.

It's also possible for people to pick up the virus by touching a surface with the flu virus on it and then touching their own mouth or nose. People can spread the flu before they have symptoms and usually are still contagious for a week or so after they get sick.

Any place where large numbers of people are in close quarters together -- airplanes, grocery stores, theaters, churches -- are places that flu can easily spread, Navalkele said. Washing your hands when you come home from a public place is a smart strategy.

"You really need to wash your hands frequently," Navalkele said.

michaela.morris@journalinc.com

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