In A Pandemic, Early Intervention Can Save Lives

by Michael Cover

As we learn more about the evolving situation with regard the new strain of influenza circulating around the world, it is useful to look to our past experiences with pandemic influenza to learn and apply any lessons that can help mitigate morbidity and mortality.

Let’s call this a tale of two cities … in the 1918 Spanish Influenza epidemic, a minimum of 50 million people around the world died from the flu or from secondary infection. But not all localities experienced the same death rate, largely due to the public health guidance that was followed in that specific area. In the US, St. Louis and Philadelphia had vastly different outcomes, despite the fact that the same strain of influenza infected their communities.

In 1918, there were no influenza vaccines or antivirals and limited international travel. The public health responses were limited to 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.

By the time officials in Philadelphia determined they had a real public health threat, it was already too late. Influenza was rampaging through the city, in most part because city leaders had not followed public health guidance. They did not close schools and movie theaters in time. They succumbed to federal pressure to sell war bonds and allowed large public gatherings, including a citywide parade in support of war bond sales. The result was that in 16 weeks, more than 12,000 Philadelphians died, an excess death rate of 719 people for every 100,000 inhabitants.

The story in St. Louis was quite different. Two weeks before Philadelphia officials began to take action, physicians persuaded the city to require that flu patients register with the health department. Two days after the first cases of influenza, police helped enforce a shutdown of schools, churches and other gathering places. Public health guidance was issued on coughing, spitting, sneezing and other forms of transmission. The result? Excess deaths in St. Louis were 347 per 100,000 people, less than half the rate in Philadelphia. Early action saved thousands of lives.

In a 2007 statement, Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases noted the importance of early intervention. “A primary lesson of the 1918 influenza pandemic is that it is critical to intervene early,” he said. “While researchers are working very hard to develop pandemic influenza vaccines and increase the speed with which they can be made, nonpharmaceutical interventions may buy valuable time at the beginning of a pandemic while a targeted vaccine is being produced.”

We do not yet know how severe this influenza infection will become. But we live in a very different world than our grandparents and great grand parents did in 1918. We have the capacity for vaccine development and production. We have access to antivirals and medical care. We know more about how to fight viral infections and secondary bacterial infections. But the best way to fight influenza may be by sticking to the simple, time tested methods.

So what are they? Simple. Follow the public health guidance from the CDC and other health institutions. Heck, follow the advice your mom probably gave you: know proper cough and sneeze hygiene. Wash your hands often. If you’re sick, stay home. For more information, go to