Once You Have Influenza a Can You Get It Again
Public Health Rep. 2007 Nov-Dec; 122(six): 803–810.
Lessons Learned from the 1918–1919 Flu Pandemic in Minneapolis and St. Paul, Minnesota
Miles Ott
Miles Ott is a Public Health Graduate Student Worker, Shelly F. Shaw is an Epidemiologist, Richard N. Danila is a Deputy State Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Wellness Communicable diseases Epidemiology, Prevention and Control Sectionalisation, in St. Paul, Minnesota.
Shelly F. Shaw
Miles Ott is a Public Health Graduate Student Worker, Shelly F. Shaw is an Epidemiologist, Richard N. Danila is a Deputy Land Epidemiologist, and Ruth Lynfield is a Medical Managing director and State Epidemiologist. All are with the Minnesota Section of Health Communicable diseases Epidemiology, Prevention and Control Division, in St. Paul, Minnesota.
Richard Due north. Danila
Miles Ott is a Public Health Graduate Student Worker, Shelly F. Shaw is an Epidemiologist, Richard N. Danila is a Deputy Country Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Wellness Infectious Disease Epidemiology, Prevention and Control Sectionalization, in St. Paul, Minnesota.
Ruth Lynfield
Miles Ott is a Public Health Graduate Pupil Worker, Shelly F. Shaw is an Epidemiologist, Richard N. Danila is a Deputy State Epidemiologist, and Ruth Lynfield is a Medical Manager and State Epidemiologist. All are with the Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, in St. Paul, Minnesota.
Those who cannot call up the past are condemned to repeat information technology.
— George Santayana
Spanish Influenza of 1918–1919 killed more than 50 meg people worldwide over the course of 2 years.1 The true origin of the 1918 influenza pandemic is unknown. During Earth War I, propaganda in war-engaged countries just permitted encouraging news, so as a neutral party, Spain was the first country to publicly report on the health crisis.1 Thus, Castilian Influenza became a popular term. Even so, historical inquiry has shown that Kingdom of spain was an unlikely candidate as the initial source and some suggest that it originated in Kansas in the spring of 1918.
Flu pandemics have occurred regularly every 30 to 40 years since the 16th century. Today, influenza experts consider the possibility of another influenza pandemic, not in terms of if but when. Due to the high likelihood of an influenza pandemic, planning is underway in many U.S. states and other countries. We reviewed the responses of two neighboring Minnesota cities during the 1918–1919 pandemic to gain insight that might inform planning efforts today.
Many of the components of current pandemic influenza plans were utilized to some caste in Minneapolis and St. Paul during 1918–1919. Coordination between different levels and branches of government, improved communications regarding the spread of flu, hospital surge chapters, mass dispensing of vaccines, guidelines for infection control, containment measures including instance isolation and closures of public places, and disease surveillance were all employed with varying degrees of success. Nosotros focus on medical resources, community disease containment measures, public response to customs containment, infection control and vaccination, and communications.
PANDEMIC BEGINNINGS IN MINNESOTA
Minnesota's commencement Spanish Influenza cases were identified in the final week of September 1918. Equally in the residuum of the state, Minnesota'due south first cases "were direct traceable to soldiers, sailors, or [their] friends."ii Every military base and military hospital in the Minneapolis-St. Paul expanse was severely affected. Case isolation was slowly implemented at both Fort Snelling and the Dunwoody Naval Detachment (military installations in Minneapolis). On September xxx, the first twenty-four hours of isolation, cases numbered in the hundreds.3
Influenza cases were not limited to enlisted men for long. In Minneapolis, the number of civilian cases outstripped the number of armed services cases for the first time on October 9, less than 2 weeks after the offset case was identified in the state (700 noncombatant cases; 675 cases at Fort Snelling).4 Influenza had become a reportable condition in Minnesota on October 8 in response to the growing epidemic.v
MEDICAL RESOURCES
Two major issues contributed to the gravity of the pandemic: the war effort and limited scientific knowledge. World State of war I was non only plush, it required much of the medical community to exist stationed overseas. In 1918, lilliputian was known about influenza. While this lack of knowledge did non negatively impact infection control deportment, effective treatment and prevention methods were not fully utilized.
When influenza first appeared in Minnesota on September 27, the state was sick equipped for a health crisis.2 Although World War I was coming to an end, more than four million Americans were mobilized and the nation'south resources were directed to supporting the war effort. An editorial in the Minneapolis Tribune daily paper described the lack of physicians and nurses: "The medical fraternity is severely taxed already. So many physicians and surgeons have gone to Europe or to training that those at home take more than they can attend to comfortably and to good reward."6
The number of influenza patients that needed the attention of physicians and nurses overwhelmed St. Paul and Minneapolis clinicians. The war'southward considerable drain on the medical profession was compounded past other factors that hindered nurse and physician mobilization. Methods to keep them good for you while caring for influenza patients were ineffective. Many health-care providers savage ill, and some died. At 1 point, Minneapolis'due south City Hospital reported that "nearly half of the nursing staff has been ill with influenza in the last three weeks."7 This bleak situation discouraged some clinicians from providing their services. Dr. H.Grand. Bracken, Secretary of the Minnesota State Board of Health, reported to Dr. Rupert Blue, U.S. Surgeon General, on his campaign to recruit physicians for the flu effort: "A number who we accept called for have made excuses and have not come at all."8 Other physicians who were recruited by Dr. Bracken simply did not show up.9
Dr. Bracken attempted to secure senior medical students for influenza work. Dr. Bracken worked not only with the U.S. Surgeon General just also with the Surgeon General of the Army, the Committee on Teaching and Special Training, and the Dean of the University of Minnesota Medical School for three weeks and still was unable to obtain senior medical students for help, because each party insisted that someone else had to authorize it. In the stop, Bracken failed to receive any medical students.10
Not surprisingly, Minneapolis and St. Paul hospitals proved to be inadequate to handle the big number of patients. Minneapolis's City Hospital and St. Paul'south St. John's Hospital were solely devoted to treating influenza patients. Non-influenza patients were transferred to other area hospitals. This inadequacy was non entirely due to the lack of beds and supplies; at that place simply were not enough salubrious nurses. At City Hospital, Superintendent Dr. Harry Britton reported that the "hospital was caring for near 150 cases, and had almost seventy on the waiting list. It had beds available for that waiting number, but not nurses."11
In St. Paul, a arrangement was fix upwardly between St. John's Hospital and other hospitals to insure an adequate number of nurses to care for flu patients, but unfortunately this system failed. Dr. F.C. Plondke, St. John'south Hospital's Medical Director, complained that the other hospitals were abandoning their promises to assign assist from their nursing staff. "The other hospitals had refused to furnish a unmarried nurse to assistance the fifteen who are caring for ninety patients at St. John'southward from their individual nursing staffs."12
In 1918, medical science maintained that flu was bacterial in origin. Physicians at Fort Snelling claimed that the "bacillus influenza of Pfeiffer," which is today known as Haemophilus influenzae, was the cause of Spanish Influenza.i , 13 Nevertheless, despite this lack of understanding nigh viruses, advice to curb infection was relatively accurate. The Minnesota State Board of Health recommended the use of handkerchiefs to comprehend sneezes and coughs, plenty of fresh air, avoidance of the ill and of crowds, and to contact a physician if ill.14
COMMUNITY DISEASE CONTAINMENT
As influenza was beginning to take hold in the civilian population, in that location was disagreement between the Minneapolis and St. Paul health commissioners, Dr. Guilford and Dr. Simon, respectively. Their approaches varied; Dr. Guilford tended to be broadly proactive to prevent cases, whereas Dr. Simon tended toward initiating activities in response to private cases. Dr. Guilford believed that closing public places was the best course of action and that isolation of private cases was useless.15 Dr. Simon asserted that isolation of flu cases would be more constructive in preventing the spread of illness.14
The St. Paul Health Department and the Minnesota State Board of Health met Dr. Guilford's strong advocacy with opposition. Dr. Bracken, siding with St. Paul, questioned, "If y'all begin to close, where are you going to stop? When are y'all going to reopen, and what do you accomplish past opening"?11
Debate between the two cities on the merits of closing schools acquired further strain. Dr. Simon held that St. Paul's school nurses were the best defense against the spread of the illness, and that endmost schools would permit cases to go undetected as the children would not be under whatever medical supervision. Dr. Guilford disagreed, pointing out that 30 schoolhouse nurses would not be able to adequately care for the 50,000 pupils in the Minneapolis public school system during a pandemic.16 Minneapolis closed the schools on ii separate occasions (October 12 to November 17, and December 10 to Dec 29, 1918).
Despite Dr. Simon's confidence that the endmost of public places would be ineffective, on November vi St. Paul authorities officials overruled him and enacted a closing order for the whole city, including schools, theaters, churches, and dance halls. The St. Paul Citizens' Committee—consisting of fifteen physicians, church leaders, and community members who were appointed by Dr. Simon—which was concerned by the record of 218 new cases on November five, as well as 36 deaths between November 4 and November 5, 1918, recommended this policy change (Figure i).17 The number of new cases began to decline ten days later, with only 24 new cases, and the side by side twenty-four hour period, Dr. Simon reopened St. Paul businesses and churches.
Influenza cases in St. Paul as recorded by the St. Paul Wellness Department in the St. Paul Daily News, 1918–1919
aCases were not uniformly reported on Sundays, so Monday's data may be inflated.
Minneapolis and St. Paul both attempted to combat influenza by limiting crowding in places with restricted admission to fresh air. Both cities enacted streetcar regulations aimed to go along the air in the streetcars fresh by mandating open windows and limiting the number of passengers to 84 (streetcars had a seating chapters of 46).5 , 17 , 18 Considering the measure limiting the number of auto passengers, implemented on October 26 in St. Paul, was accounted successful, Minneapolis enacted a similar regulation on October xxx.17 As an experiment, Dr. Bracken also proposed that St. Paul regulate the business hours of stores and theaters to go along streetcar congestion to a minimum. Again, Minneapolis followed St. Paul's example on October sixteen, 1918, past regulating the hours of retail stores, office buildings, and wholesale stores.xix
There were several complaints that the mandate in Minneapolis to go on iii streetcar windows open at all times caused people to get sick due to winter colds. A compromise was reached by Dr. Guilford allowing streetcars with heating and ventilation systems to close their windows in one case the temperature dropped to 32 degrees Fahrenheit.twenty
St. Paul as well targeted elevators every bit places where influenza could easily be transmitted due to the tight quarters and limited fresh air. Buildings with fewer than six stories were no longer permitted to use their elevators.21
Public response to customs containment disease
The measures used to contain influenza greatly affected the day-to-24-hour interval lives of citizens. While some accepted the changes imposed on them, others protested regulations that they considered unfair. Some chosen for more stringent methods, while others blatantly broke the new rules that were intended to protect them.
The closing of public places in Minneapolis was appear in advance, so people rushed to consummate those activities that would presently be banned, resulting in the very same crowded weather the ban sought to foreclose. "Downtown theaters were packed last night with patrons who took reward of their last chance to encounter a performance until the ban is lifted."22 While some St. Paul citizens were relieved that Dr. Simon initially pledged to go on public places open, others felt this was wrong. "Fearfulness of influenza contamination in crowded places has reduced the patronage of St. Paul motion film theaters past nearly one-half, according to reports to Dr. H.M. Bracken."23
Many sporting organizations responded negatively to closing orders. For example, in November 1918, the bowlers of St. Paul drew up a petition that requested permission to begin bowling again.24 Minneapolis football game teams chose to ignore the ban and attempted to play confronting each other in forepart of large crowds. Police were called in to disperse the crowds and halt the games.25 Minneapolis teams found a way to play despite the closing order. Because Minneapolis loftier schoolhouse football game games were banned, exercise games were scheduled with St. Paul teams.26 Several establishments serving alcohol and nutrient deliberately broke the closing order to continue their regular business. "One saloon was discovered with the back door route open up."27
The elevator regulations in St. Paul were peculiarly unpopular. "Some of the downtown hotels objected to stopping their elevators, saying that they would lose guests. This acquired a change in the ruling to permit hotel elevators and those in apartment houses to operate."28 Many insisted it was unhealthy for the sick to be forced to climb stairs in their impaired country, while others felt concerned that people would be shut off from fresh air if they were not allowed to use their elevators. Consequently, the city compromised and all elevators were dorsum in employ starting November 9, 1918, although only one person per v square feet was permitted.29
The Hennepin County School Lath (where Minneapolis is located) was exceptionally defiant to the closing order. The schoolhouse board was concerned for the health of the students as well every bit the "12,000 dollars a day" that the closing orders cost considering teachers connected to be paid, and actress school days would have to be added to the schoolhouse twelvemonth.30 Against the explicit orders of Dr. Guilford, and the pleading of several Parent-Teacher Clan officers, the schoolhouse board reopened schools on Oct 21, only to be shut down on the aforementioned day under threat of constabulary activity.31
In St. Paul, all flu cases were supposed to be reported to a medico, who in turn was required to isolate the instance in his or her ain home and notify the health department. Several problems sprung up with these requirements that hampered surveillance, the care of patients, and protecting people from getting sick. For one, both physicians and patients were often hesitant to bring attention to cases. "Physicians are non reporting their cases to preclude homes from being quarantined."21 (Annotation: At the time of the 1918 influenza pandemic, the separation of the sick from the full general population, what is now referred to as isolation, was termed "quarantine.") The sick also sought to evade isolation in their homes by not seeking medical attending, or only seeking medical attending when they became gravely sick. "Hundreds of persons in the metropolis do not phone call for medical assistance until the 2nd, third, or fourth day and in many cases pneumonia already has adult when medical attending is get-go given."29 Staffing shortages fabricated isolation even less desirable. Because there were a express number of inspectors to release houses from isolation, houses were not released promptly from isolation.32
Starting on Nov 15, St. Paul telephone operators went on strike. Co-ordinate to the Pioneer Press daily paper, "Less than one 3rd the new cases [are] beingness reported to the wellness department," every bit a effect of the phone strike.33 This strike not only affected the reporting of cases, but also isolation, as well as their release from such a measure.
After all of the difficulties involved in establishing isolation for each case, some flagrantly disobeyed the isolation orders birthday. "Disregard of the city quarantine yesterday caused the arrest of 1 man who insisted on taking his child from the urban center hospital before the patient was ready to be discharged. The mother and father and the child afterward were found mingling with other persons in the neighborhood."29
INFECTION Control AND VACCINATION
In add-on to endmost public places and isolating cases in their homes, both Minneapolis and St. Paul wellness departments took other steps to keep people from getting infected. The use of gauze masks, more stringent sanitation laws, and vaccination campaigns were deployed in this endeavor.
Directions for wearing the masks were issued to the public. "The outside of a face up mask is marked with a black thread woven into it. E'er wear this side away from the confront. Article of clothing the mask to comprehend the nose and the oral fissure, tying 2 tapes around the caput above the ears. Tie the other tapes rather tightly effectually the neck. Never clothing the mask of another person. When the mask is removed … information technology should be advisedly folded with the inside folded in, immediately boiled and disinfected. When the mask is removed by ane seeking to protect himself from the influenza it should be folded with the within folded out and boiled ten minutes. Persons considerably exposed to the disease should boil their masks at least once a mean solar day."21 However, there was inconsistent communication on the use of gauze masks. Dr. Bracken, of the Country Lath of Wellness, advocated the wearing of masks, though he did not wear one himself, proverb, "I personally adopt to take my chances."34
Medical students working in clinics in each district of St. Paul distributed gauze masks.12 But the Citizens' Committee rejected an ordinance requiring the wearing of masks at all times, fifty-fifty though, "All physicians were united in the opinion that the gauze covering should be worn in hospitals or in the presence of hundred-to-one cases."35 Despite the lack of official orders requiring the wearing of masks and Dr. Bracken'south unclear bulletin, many people sought out masks for themselves. The Northern Partitioning of the American Red Cross manufactured tens of thousands of masks. Minneapolis ordered 15,000 masks from the Carmine Cantankerous on October 1, 1918.36 These masks were used by nurses in schools and hospitals, doctors, hospital visitors, and those suspected of being infected with flu.37
As the number of cases increased in St. Paul, employers sought means to keep their workers salubrious and productive. Several companies requested masks to distribute to their workers. Despite the thousands of masks provided by the Red Cross, however more were needed to fulfill the demand. The Citizens' Committee suggested that companies inquire their female employees to fabricate masks for all their employees.21 St. Paul introduced new sanitation laws that chosen for the sterilization of dishes and cups in restaurants and confined, and the banning of roller towels and common drinking cups in public restrooms.38
At least two different vaccines were administered in Minneapolis-St. Paul, neither of them effective as neither actually independent flu virus. 1 made by bacteriologists at the University of Minnesota was purported to prevent pneumonia.39 The Mayo Clinic in Rochester, Minnesota, fabricated another vaccine that was intended to prevent both pneumonia and flu.40 This latter vaccination was composed of Streptococcus pneumoniae types I, Two, and III, Southward. pneumoniae group IV, hemolytic streptococci, Staphylococcus aureus, and "flu bacillus."41
Armed services personnel too equally civilians were inoculated first every bit early every bit October 4, 1918.37 Both urban center wellness departments purchased vaccine and distributed it to physicians at no charge to encourage widespread use. In Minneapolis, people desiring the vaccine "thronged" the offices of doctors hoping to be vaccinated, and in St. Paul information technology was reported that "thousands of persons accept been inoculated."39 , 42 Some physicians took advantage of their access to vaccine and the public's fear of influenza. Co-ordinate to St. Paul's Citizens' Committee, it was discovered that "a few physicians were charging a fat fee for inoculations."29 This was particularly disturbing as the vaccinations were supplied to the physicians for free.
COMMUNICATIONS
Postal workers, Boy Scouts, and teachers were enlisted to provide educational materials to the public and to teach health precautions. Mail carriers distributed educational materials on their routes. Male child Scouts distributed posters to stores, offices, and factories in downtown Minneapolis.22 Minneapolis teachers who were put out of work by the closing of schools were asked to volunteer for a wellness education entrada. The main goals of the campaign were to go rid of shared drinking cups, which were the precursor of the water fountain, as well every bit the roller towels, which were used to dry easily after washing.43 St. Paul teachers were sent "to define the plight of families worst affected by the epidemic."28 This was accomplished through a sail of homes where the teachers learned if anyone was sick, needed to encounter a doc, or needed food.27 St. Paul fix up a public kitchen, a children's home, and an emergency hospital for these cases.21
Limitations
Although the two cities chose different methods of disease containment, determining which method was more successful is challenging. Information on cases in both cities depended on ill individuals seeking the attention of physicians, who were in curt supply. The physicians were then required to study the number of new cases each day to their city health department. The city so reported the total number of cases to the newspapers, which published the number of new cases and deaths each day. This chain of information left much room for error and possible falsification.
Because St. Paul chose to utilize isolation and Minneapolis did not, case reporting varied profoundly between the ii cities. Individuals with influenza who had their condition reported in St. Paul had to endure isolation until they were released with a dr.'s blessing. This may have discouraged people from seeking the attention of physicians, and thus existence reported—an undesired consequence of enforced isolation (Table). Considering those with influenza were not isolated in Minneapolis, more than people might have felt comfy seeking medical attention. This could explain why St. Paul had such a high example fatality charge per unit compared with Minneapolis (Tabular array, Figures 2 and 3).
Influenza case rates per 100,000, Minneapolis and St. Paul, 1918–1919
aCases were not uniformly reported on Sundays, and then Monday's data may be inflated.
Daily death rates per 100,000, Minneapolis and St. Paul, 1918–1919
aCases were non uniformly reported on Sundays, so Mon's data may be inflated.
Tabular array
Minneapolis and St. Paul influenza cases and deaths, September 30, 1918, to Jan 6, 1919
CONCLUSION
Several factors impede directly comparisons of the two cities' approaches. The cities border each other and residents travel back and along. Although the containment philosophies differed greatly, in reality St. Paul government officials overruled public health, and schools and public gathering places were closed in both cities for varying lengths of time. Although the furnishings of isolation vs. closure of public places cannot be specifically determined, other lessons can be learned from what happened in 1918. Many steps could have been taken to prevent illness and relieve lives. Prior planning, clear orders, as well as consequent and transparent advice and information to the public may have fabricated a significant difference in the number of cases and deaths due to influenza in 1918.
At that place was a paucity of planning for a wellness emergency when influenza beginning appeared. While the actions that the two city wellness departments took to stem the spread of influenza align closely with current pandemic plans, wellness officials had the disadvantage of trying to conceive and realize plans during a wellness crunch. Many current recommendations were implemented, including the use of masks, the use of vaccines (albeit ineffective ones), increasing the stringency of sanitation measures, limiting crowding in public places, and trying to coordinate hospitals, nurses, physicians, and medical students to maximize resources. Equally part of maximizing homo resources during an influenza pandemic, information technology is imperative that the safety of wellness-care workers is insured. The number of nurses and physicians who fell ill and even died as a effect of assisting in the fight against the pandemic scared other nurses and physicians away.
Had these ideas been generated prior to such a big emergency, several bug could have been averted. The debates and disagreements between unlike public officials and wellness agencies, as with the Hennepin County School Board and the Minneapolis Wellness Department or between the Minneapolis Health Department and the St. Paul Health Section, could have been discussed in advance. Supplies could accept been stockpiled, business leaders and community members could have provided input on controversial affliction containment policies, and medical students could accept been put to work in hospitals and communities that lacked physicians. Unfortunately, these disputes arose and continued throughout the pandemic.
Articulate authority and management by public health officials were generally lacking at the federal and state levels. It was almost as if the fear of using their authority led Surgeon General Blue and Dr. Bracken to fail to take decisive action. Surgeon General Blueish suggested to Dr. Bracken, and all other state health officials, "the advisability [of] discontinuing all public meetings, closing all schools and places of public amusement on appearance of local outbreaks."44 Because this was simply a proffer, and local outbreaks were not divers objectively, Blue's urgent telegram had no upshot.
On the country level, Dr. Bracken acknowledged that the St. Paul Health Department "followed his advice" to not close public places, and went on to say that St. Paul, "has the ability to do the opposite whatsoever time it wants to."11 This argument forced local health departments to define their own rules while attempting to decipher conflicting messages from the land and federal level.
Because clear orders were not being given to public health officials, the public in turn was not receiving transparent and consistent advice and information. Should the public article of clothing masks? Why was information technology allowable to exist next to someone in a streetcar and non in an lift? Why were church services airtight while Ruby-red Cross workers gathered in crowded conditions in those very aforementioned churches? Was influenza a life-threatening condition, or was panic the nigh dangerous chemical element of the influenza pandemic? In Minneapolis and St. Paul. in that location was no unmarried message on any of these issues. In many cases, the public had to decide for itself. In which case, the effect of the messages that were communicated only served to contradict each other.
In reviewing this history, some lessons stand out. Recent analyses of nonpharmaceutical interventions during 1918 indicate cities in which multiple interventions were implemented early in the pandemic fared meliorate.45 Of primary importance is developing a programme ahead of time that incorporates all levels of government health infrastructure and describes articulate lines of responsibilities and roles. Plans for surge capacity and community containment must be discussed with stakeholders and consensus must be accomplished.
Further, general approaches should be put forth for public annotate and approval. The public health benefit of isolation should be weighed against the possibility that some people would be discouraged from seeking care. Clear explanations of the reason for isolation, generous employer support, and providing food, medicine, and social service to those in isolation may mitigate fears and increase cooperation. The public must as well be educated nigh the reasoning behind other health measures (i.due east., closures), should those methods be implemented.
Approaches and plans should be based on scientific data whenever possible, and include input from ethicists. Unlike in 1918, a pandemic flu vaccine volition probable be available today, albeit four to vi months afterwards the pandemic starts. But like to 1918, the challenge volition be designing an orderly and ethical distribution of a scarce commodity. Further, experts in take a chance communication should assist in developing letters that are scientifically accurate, understandable, clear, and useful. Finally, we need to take careful note of local and national lessons from the by so nosotros do not repeat them.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1997248/
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