Analysis of 43 US cities during 1918-1919 Spanish flu pandemic uncovers strong link between social restrictions and lower death rates

ANN ARBOR, Mich. — Although physicians have imposed quarantine orders since at least 1374, when the Port of Venice officially isolated foreigners and shippers for 40 days to keep out infectious scourges, there has been no definitive evidence that public health measures like quarantining the sick and isolating people after exposure to ill people would save lives during an influenza pandemic.

Until now.

In a study published in the Aug. 8 Journal of the American Medical Association, a team of University of Michigan medical historians and epidemiologists from the federal Centers for Disease Control and Prevention say that social restrictions allowed 43 U.S. cities to save thousands of lives during the Spanish influenza pandemic of 1918-1919.

Although these urban communities had neither effective vaccines nor antiviral medicines, they were able to organize and execute a suite of classic public health measures – called non-pharmaceutical interventions or NPIs – before the pandemic gained full force.

The new study finds that cities whose NPIs were sustained and layered with multiple tactics had the best outcomes. In addition to quarantine and isolation, the NPIs examined in this study were school closures and cancellation of public gatherings.

"Public health is everyone's responsibility. In a world faced by the threat of newly emerging and re-emerging infectious diseases, it is critical to determine if costly and potentially socially harsh NPI measures can save lives and reduce the numbers of those infected," says lead author Howard Markel, M.D., Ph.D., the George E. Wantz Distinguished Professor of the History of Medicine, professor of pediatrics and communicable diseases, and director of the U-M Center for the History of Medicine. "Now we know the answer is 'yes.' "

Markel adds that in today's world, implementing these measures in a layered, sustained fashion would also provide a cushion of time for the development and distribution of effective vaccines and antivirals, while reducing the crush on essential infrastructure.

"By better understanding what worked in the past, we can better prepare for the future," says senior author Martin Cetron, M.D., director of the CDC's Division of Global Migration and Quarantine. "Communities that were most successful during
the 1918 pandemic quickly enacted a variety of measures. Those planning for the next pandemic need to carefully consider how to best use these strategies to protect people and decrease the potential impact of the next pandemic in their communities."

The 43 cities in the study were scattered from coast to coast and represented a combined population of approximately 23 million. In an exhaustive review of 1,144 primary and secondary sources that included U.S. census data, municipal records, newspapers and handbills covering a 24-week period – Sept. 8, 1918 through Feb. 22, 1919 – the researchers identified which NPIs were used in each city and when officials turned them on and off.

Using both actual death rates from pneumonia and influenza, and baseline rates for what would have been normal without a pandemic, the researchers found there were 115,340 excess pneumonia and influenza deaths attributable to the pandemic in these cities during the period studied. In comparing the death rates to when NPIs were turned on and off, they found that NPIs did mitigate the death rate, with a statistically significant association between increased duration of NPIs and reduced mortality.

Further, they discovered that city-to-city variation in mortality was associated with the timing, duration and combination of NPIs. St. Louis, Missouri, for example, closed schools and cancelled public gatherings relatively early in the pandemic and sustained these measures for about 10 weeks. The analysis shows that St. Louis had one of the largest drops in mortality while the NPIs were in force.

As a whole, the study's findings contrast markedly with the conventional wisdom that the Spanish Flu ravaged the United States and elsewhere, with little that could be done to stop its deadly toll.

Markel predicts that NPI measures will be socially painful in the next pandemic, but that the public's acceptance of NPIs is essential.


"We need to have informed concern about what to do in a pandemic – and why," concludes Markel.

Citation: JAMA, Nonpharmaceutical Interventions Implemented by US Cities During the 1918 -1919 Influenza Pandemic, Aug. 8, 2007, p. 644-654, Vol. 298, No. 6.

Other collaborators on the research were Alexandra Minna Stern, Ph.D., associate director, Center for the History of Medicine; J. Alexander Navarro, Ph.D., senior researcher, Center for the History of Medicine; Joseph R. Michalsen, research associate, Center for the History of Medicine; Alexandra Sloan, research associate, Center for the History of Medicine; and Harvey B. Lipman, Ph.D., (insert title), Centers for Disease Control and Prevention.

This work was funded by the Centers for Disease Control and Prevention and conducted by the University of Michigan Center for the History of Medicine and the CDC Division of Global Migration and Quarantine.

The complete bibliography of the 1,144 primary and secondary sources is available as an online supplement at www.cdc.gov/ncidod/dq/index.htm. The supplement provides access to data specific to each of the 43 cities.

The Center for the History of Medicine also has a Web-based source of materials that cover the 1918-919 influenza pandemic, which can be viewed at www.med.umich.edu/medschool/chm/influenza/.

More information about community strategies for pandemic influenza is available at www.pandemicflu.gov/plan/community/commitigation.html.

Originally from EurekAlert! - Breaking News on August 6, 2007, 9:00pm


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    Employment: 2008 - present, website developer and writer. 2015 - present, insurance broker. Education: Arizona State University, Bachelor of Science in Political Science. City University of Seattle, graduate studies in Public Administration. Volunteerism: 2007 - present, president of the Real Liberal Christian Church and Christian Commons Project.
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    • Real Liberal Christian Church comment:

      Quarantines must be humane. People who are sick must be treated with kindness, mercy, and compassion. The way the Maricopa County sheriff's department in Arizona, USA, treated a young man with tuberculosis was very inhumane.

      Back in the first week of April, 2007, we reported the following:

      Robert Daniels has an as-yet incurable strain of tuberculosis. Under a court order, Maricopa County, Arizona has been holding him in a medical-isolation prison cell since July 2006 even though he was never charged with a crime, never tried, and not convicted.

      Now, what makes this story awful is that Robert has no hot water, no mirror, no phone, no TV, no radio, no computer, no ability to turn out the lights at night, no normal-sized windows on the outside world, and is not allowed outside visitors. He's been completely cut off from the world outside. He is being treated exactly as a convicted-criminal inmate by the county Sheriff's Department.

      This is disgusting. The Sheriff's Department knows Robert is not a criminal, yet they are treating him in this manner. That treatment is criminal. Those at the top are responsible and should be held to account.

      Just when Robert needs the most compassionate concern and care, he is treated as a criminal fit for punishment. What kind of world are we living in? Whom are we choosing to follow as our leaders?

      Robert Daniels says he understands fully that county health authorities are concerned not to allow his TB to spread to any other people. He is not unwilling to cooperate in taking all reasonable steps to accomplish that. He is willing to use a mask and to do other things to avoid spreading the strain. The county locked him up for not following doctor's orders to wear a mask in public. However, Robert says he didn't understand since when he was in Russia where they knew he had the disease they had not required him to wear a mask. He seems to be suggesting that he took the doctor's orders as overkill and just a suggestion. Did they do a good job of explaining the mandatory aspect? Did they warn him that he could face immediate lock-up if he didn't adhere to the rules?

      It must be pointed out that TB is not highly contagious even in the strain Robert has. People with weakened immune systems though are susceptible.

      At the very least, any involuntary-quarantine facility ought to be as comfortable and interactive as possible.

      The very kind of unmerciful treatment Robert has been receiving is exactly the reason that this strain of TB even exists.