Authors:
JS Oxford, A Sefton, R Jackson, W Innes, RS Daniels, NPAS Johnson
Summary
The 1918 influenza pandemic caused 40 million deaths, and so dwarfed in mortality and morbidity the preceding pandemic of 1889 and the 1957 and 1968 pandemics. In retrospect, much can be learnt about the source, the possible subterranean spread of virus, and the genetic basis of virulence. The World Health Organization has urged every nation to prepare a pandemic plan for the first global outbreak of the 21st century. We present an appraisal of epidemiological and mortality evidence of early outbreaks of respiratory disease in France and the UK in the years 1915 to 1917. Certain of these earlier focal outbreaks—called epidemic bronchitis rather than influenza— occurred during the winter months when influenza was known to be in circulation, and presented with a particular heliotrope cyanosis that was so prominent in the clinical diagnosis in the world pandemic outbreak of 1918–1919 (the Great Pandemic). The outbreaks in army camps at Etaples in France and Aldershot in the UK in 1916–1917 caused very high mortality in 25–35 year olds. Increased deaths from bronchopneumonia and influenza were also recorded in England. We deduce that early focal outbreaks of influenza-like disease occurred in Europe and on the balance of probability the Great Pandemic was not initiated in Spain in 1918 but in another European country in the winter of 1916 or 1917. We suggest that the pandemic had its origins on the Western Front, and that World War I was a contributor.
In anticipation of the first influenza pandemic of the 21st century WHO has published a template pandemic plan,1 as have many national authorities.2 A recent analysis has emphasised the changing modern factors that could increase the rate of spread of a new pandemic virus,3 such as air travel, global tourism, and population expansion. By contrast, we have the effectiveness of the new anti-neuraminidase drugs, both of which can be used prophylactically,4, 5 and also the greatly increased capacity to produce influenza vaccine, which globally exceeds 200 million doses per year. Nevertheless, in a worst-case scenario predictions of morbidity and mortality in a new pandemic still approach those recorded in 1918.3 Planning would be easier if the origin of a new pandemic virus and any warning time ahead of the main wave could be identified. Our review sheds some light on both questions, the possible non-Asian origin of a new pandemic virus and the lead-time to an outbreak, which could be as long as 18 months. At the same time our review emphasises the need for extensive and accurate surveillance in all areas of the world.
The initial basis of our review was the implication of the short period from late September to November 1918 that saw the death of the US Army private, Private Vaughan, in South Carolina6 and of “Lucy” at Brevig Mission, Alaska;7 and of six Norwegian coal miners in Spitsbergen8 of “Spanish” influenza. Reports of influenza deaths in Norway, Sweden, Finland, Canada, Spain, Britain, France, Germany, Senegal, Tanzania, Nigeria, China, Zimbabwe, South Africa, India, and Indonesia were also recorded in this short time frame.9, 10 Although quarantine prevented widespread outbreaks in Australia until 1919, influenza deaths occurred in medical nursing staff of the Sydney quarantine unit as early as October 1918. The very wide geographic spread of these deaths in such a short period, in the absence of air travel at that time, suggested to us that the disease had spread around the globe before this time and that earlier “seeding” had taken place.
we therefore investigated explosive outbreaks of respiratory disease that affected young people in the winter periods of 1916 to 1918, and focused on those with high mortality and with heliotrope cyanosis. All these features characterised the 1918–1919 influenza pandemic. The term influenza was not widely used until after the Great Pandemic and therefore we searched for other descriptions such as epidemic catarrh, epidemic bronchitis, or 3–day fever.