Can history help us in the COVID-19 epidemic?

1918 flu epidemic: the Oakland Municipal Auditorium in use as a temporary hospital. Photo by Edward A. “Doc” Rogers. From the Joseph R. Knowland collection at the Oakland History Room, Oakland Public Library. Digital copy via http://content.cdlib.org/ark:/13030/kt3q2nc9rt/?&query=

In this time of great uncertainty around the impact that Coronavirus disease 2019 (COVID-19) will have on populations and health systems globally, can we look to history to help us in its management?

Many have already drawn comparisons between COVID-19 and the 1918 influenza pandemic, also known as ‘Spanish Flu’. The 1918 influenza pandemic which spanned a couple of years from 1918-1920 infected 27 per cent of the world’s populations, and killed between 17 and 50 million, making it one of the deadliest pandemics in modern history.

While it may have occurred over a century ago, in many ways the situation with COVID-19 is similar to that facing nations in 1918. With no specific treatment or vaccination available except best supportive care, governments are turning to epidemiologists to help stop the spread and mitigate the damage caused by the disease.

A widely circulated graphic from the paper, ‘Public health interventions and epidemic intensity during the 1918 influenza pandemic’ by Hatchett et al. shows how differing public health responses resulted in different death rates between two American cities: Philadelphia and St Louis.

1918 excess mortality in philadelphia and St Louis

Excess P&I mortality over 1913–1917 baseline in Philadelphia and St. Louis, September 8–December 28, 1918. Source: Hatchett et al. https://doi.org/10.1073/pnas.0610941104

While authorities in Philadelphia became aware of the disease on 17 September 1918, they downplayed its significance and still allowed large social gatherings to take place including, a city-wide parade. They only implemented measures such as school closures and a ban on public gatherings on 3 October.

By contrast St Louis reported its first cases of the disease on 5 October and authorities mobilised containment measures rapidly on 7 October. The difference in the responses between both cities appear to have borne out in the excess pneumonia and influenza death rates seen in both cities.

Philadelphia experienced a peak weekly pneumonia and influenza excess death rate of 257 per 100,000 whereas St Louis experienced a rate of 31 per 100,000.

The above example appears to demonstrate the impact of early interventions such as social distancing to help contain the spread of the disease. If anything is to be learned from history a rapid implementation of such measures may be required to contain the spread of COVID-19.

For further reading on the impact of ‘Spanish Flu’, please refer to this post by Jane Orr.

 

Words by Flora Malein

 

Sources used:

Taubenberger JK, Morens DM (2006). “1918 Influenza: the mother of all pandemics”. Emerging Infectious Diseases. 12 (1): 15–22. doi:10.3201/eid1201.050979. PMC 3291398. PMID 16494711.

Spreeuwenberg; et al. (2018). “Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic”. American Journal of Epidemiology. 187 (12): 2561–2567. doi:10.1093/aje/kwy191. PMID 30202996

Richard J. Hatchett et al. (2007) Public health interventions and epidemic intensity during the 1918 influenza pandemic. PNAS May 1, 2007 104 (18) 7582-7587; first published April 6, 2007 https://doi.org/10.1073/pnas.0610941104

Tuberculosis, Philately and the history of the ‘Christmas seal’

Paris: Comité National de Défense contre la Tuberculose; Quimper: Comité d’Hygiène Sociale du Finistère, [between 1930 and 1939?]. Image Credit: Wellcome Collection, CC BY.

Christmas has long been recognised as a time of charity and fundraising. Perhaps familiar to some is the ‘Christmas seal’ – a label placed on post over the Christmas period – to raise awareness and funds for charitable organisations.

Christmas seals fall into a category known as ‘cinderella stamps’: items that resemble stamps but cannot be used in payment for postage

While the Christmas seal concept has been adopted to raise funds for many different types of charitable organisations, they have most closely been allied to raising awareness of tuberculosis. According to a New York Times article, the concept originated in Denmark in 1904, when a Danish postal worker called Einar Holbøll came up with the idea to sell the penny seals to raise money for children with tuberculosis.

Other countries quickly followed suit with fundraising seals being produced to support tuberculosis causes in Sweden, Iceland and Argentina.

At the time, tuberculosis was still one of the major causes of death globally. And despite the discovery of the M. tuberculosis bacillus by Robert Koch in 1882, no effective treatment had been found. Organised national efforts to combat the disease were looking for means to raise awareness and financial support for the disease. These campaigns can be seen as some of the very first public health initiatives, in which the financial contributions of ordinary people were used to fund treatment of a disease.

Picture credit: W. Dibb Private Collection.

The first American Christmas seals were produced in 1907 by a Red Cross volunteer called Emily Bissell, who adopted the idea to help raise money for a tuberculosis sanatorium in Delaware that was under the threat of closure if a sum of $300 was not raised.

Although she could not get permission to have the U.S. national postal service to print and distribute the seals, as they had in Denmark, she was allowed to privately sell the seals in the post office lobbies. The seals were such a success they raised over ten times the amount needed and became an annual tradition that raised major funds for The National Tuberculosis Association (now known as the ‘American Lung Association’). The American Lung Association continues to sell their Christmas Seals™. Selling tuberculosis Christmas seals has also funded major disease prevention programmes in countries, such as Canada, through chest X-ray screening or tuberculin tests.

The Cross of Lorraine

National Tuberculosis Association, 1940. Image Credit: Wellcome Collection, CC BY.

Many examples of the Christmas seals created to raise funds for tuberculosis charities contain the symbol of the double-barred cross. Symbolically known as the ‘Cross of Lorraine’, it was adopted as the symbol of the fight against tuberculosis at the International Conference on tuberculosis held in Berlin, 1902.

A French doctor – Gilbert Sersiron – proposed the emblem which had been the banner of Godfrey of Bouillon, one of the leaders of the first Crusades who successfully laid siege to Jerusalem and became it first ruler. In adopting this Crusader symbol, the cross became a symbol of the new, organised anti-tuberculosis ‘crusade’.

 

Flora Malein

 

 

 

 

 

You can read more about postal items and infectious disease in a previous post, here

Sources used:

The New York Times: https://www.nytimes.com/1989/12/24/style/pastimes-stamps.html

The American Lung Association: https://www.lung.org/get-involved/ways-to-give/christmas-seals/history.html

The Canadian Lung Association: https://web.archive.org/web/20111115234620/http://lung.ca/involved-impliquez/christmas-noel/history-histoire/index_e.php

TB Alert: https://web.archive.org/web/20090302074617/http://www.tbalert.org/about/cross.php

John, Simon (2017). Godfrey of Bouillon: Duke of Lower Lotharingia, Ruler of Latin Jerusalem, c.1060-1100. Taylor & Francis. ISBN 978-1-317-126300.

https://wellcomecollection.org/works/msbjucxs

https://wellcomecollection.org/works/hdh9a7xw

The “Spanish” Influenza Pandemic of 1918-19

In this centenary year there have been several new books, articles and television programmes about the pandemic which killed between 50 and 100 million people worldwide.  Much of this writing, however, has been very America-centric, and has ignored the influenza that had been spreading in Europe from the autumn of 1916.  Although this version of influenza had a low penetrance, it had a high mortality due to the fact that 25% suffered what we now know to be a cytokine storm, so 20% died a very unpleasant death.  At the time it was not known what was happening – was it an infection, or some new poison gas produced by the other side?  Amongst the British it almost exclusively affected soldiers, but when they discovered that German and Austrian soldiers and civilians were badly affected, the conspiratory theory was discarded.  In UK there was a small outbreak in Aldershot, but it did not spread.  The bacteriologists could find no common organism and labelled it “purulent bronchitis”.  It was not until the 1918 pandemic, when it was noted that survivors of purulent bronchitis were immune to the influenza, that they realised they were looking at the same disease.  Sadly, no tissues or samples remain of this early manifestation.

By definition “Spanish” Flu started in the USA in March 1918.  This behaved in quite the opposite way to the purulent bronchitis.  The mortality of the first wave (March-early September) was no higher than normal influenza epidemics, but it was extremely infectious.  In the worst week, in July 1918, 46,275 British soldiers in France reported sick – they nearly overwhelmed the medical system.  It was during this time that the infection got its misnomer.  The warring nations did not wish to give any information to the enemy that might suggest that they had an increased rate of sickness, but Spain, which was neutral, had no such compunction.  This meant that our press was able to report an epidemic in Spain, and the name stuck.  The incorrect fact that it had started in Spain was believed to such a degree that when exploring the National Archives in Malta I came across the draft of a telegram from the Governor to the British Ambassador in Madrid demanding medical information.  This was sent in cypher.

National Archives of Malta, CSG 01 – 1033/1918

In September 1918 it appears that the two expressions of the influenza met and mutated in Étaples near Boulogne and created the  deadly 2nd wave which caused a huge death rate as it still had the high penetrance of the American 1st wave, but about 10% suffered the haemorrhagic cytokine storms.  The figures are frightening.  17 million died in India alone, Samoa lost 20% of its population.  In London 13,000 died of influenza (in 1912 the influenza deaths has been 535).

It must have been a horrendous time to be a doctor, struggling to understand why so many previously healthy young people were dying, and struggling to find places to nurse them.  Many factory buildings had to be converted into makeshift hospitals.  Let us all pray that we are able to contain the next severe pandemic.

Jane Orr