Influenza, One Century Later

Illustrated by Avni Joshi

Imagine it is the autumn of 1918 and World War I is raging on in Europe. As a latecomer to the war, the U.S. is fighting in the trenches alongside the Allies, and daily news trickles back to the mainland bringing pictures of the war and the faces of the fallen. However, bullets are not the deadliest killer at large. The culprit, rather than picking off the old or the very young, seems to target previously healthy people between 20-40 years old. It kills more American soldiers than combat itself, but it makes no headlines. Even after the fighting is over, it rages on. President Woodrow Wilson collapses at the Versailles Peace Conference and though he survives it, hundreds of thousands of Americans did not [2]. This tidal wave of death was the Spanish flu, and it would revolutionize public health policy and influence modern responses to epidemics.


Between 1918 and 1919, an H1N1 influenza pandemic swept across the globe, its sheer scale dwarfing even the great human drama playing out in Europe. It was called the Spanish flu not because it originated in Spain, but rather because Spain was a neutral country in the conflict and reported on the mortality and spread of the disease accurately. Other countries including the U.S. suppressed reports in order to keep up wartime morale. Its impact was worsened due to troop movements, malnutrition, wartime refugees crowding cities and shortages of doctors, nurses and medicine [2]. One-third of the entire world population was infected. Bodies piled up, cities prohibited large public gatherings and corpses were buried in crates because there were not enough coffins. More Americans died of the Spanish flu than the combined number of all U.S. soldiers killed in World War I, World War II, the Korean War and the Vietnam War. It was so severe that the average life expectancy in the United States dropped by twelve years [2]. Modern estimates put the death toll from the 1918-1919 outbreak of the Spanish flu between 80 to 100 million people worldwide–  roughly 5 times the number of people killed in World War I.


A full century later, flu season is in full swing again, but the Spanish flu is largely forgotten. However, it has left a lot of unanswered questions even a hundred years later. Scientists still do not know the flu’s original host species, nor why it caused so many deaths among the young and healthy rather than the elderly [6]. A loss of life on that scale is almost unimaginable in the current day, but descendants of the 1918 Spanish flu strain continue to claim lives. The modern world is more interconnected than ever, and influenza strains of animal origin are becoming a threat due to higher rates of animal transportation. The H1N1 swine flu in 2009 and the H5N1 avian flu are recent examples [6]. The annual flu season also continues to pose a threat. Last year, 48 million Americans were infected and the death toll from influenza in the U.S. was 80,000, which was the highest it has been in over a decade. Of those, 183 were children, most of whom did not receive the vaccine [3]. In fact, only 37% of Americans received the vaccine last year, a drop from previous years [1].


While there is no reliable method to predict the severity of future outbreaks, the CDC recommends all people aged 6 months and above to get vaccinated, with special emphasis on children under 5, and those with respiratory illnesses, such as asthma or other health problems [1, 2]. “When children go and get the vaccine, they actually end up protecting the more vulnerable people around them, particularly older folks,” said Michael Worobey, the head of the department of ecology and evolutionary biology at the University of Arizona, who works on the evolution of the 1918 influenza virus [4]. “The beautiful thing is that even if the vaccine doesn’t work perfectly in an older person, if the people around that older person including grandkids are vaccinated, that has an impact.” This phenomenon is known as “herd immunity,” when immune individuals protect those vulnerable to a disease simply by not transmitting it. The influenza vaccine is also reformulated every year to protect against the strains most likely to be active that season. The accuracy of the prediction and protection are better during some years than others. Although getting the vaccine is not absolute protection against infection, it will nevertheless lower its severity and significantly reduce one’s risk of death [1].


Flu response today has also undoubtedly progressed leaps and bounds since 1918. While the best way to fend off infection is still to get vaccinated, new treatment and prevention methods are on the horizon. An example includes a high potency vaccine for older people as the regular vaccine tends to be less effective for them [3]. There is an increasing push for a universal flu vaccine that would be effective against many different strains and not require an annual shot, but federal funding has fallen far short of the required resources for such an endeavor [4]. In terms of treatment, the FDA has recently approved baloxavir marboxil under the brand name Xofluza as the first new flu drug in 20 years [5]. Despite this development, the problem of drug resistance has largely been unaddressed with respect to the flu. Unlike diseases like HIV and tuberculosis, influenza is treated not with a cocktail of different drugs, but usually with only one, the most common being Tamiflu [5]. Scientific advances continue to better influenza response, but there are still plenty of issues to be tackled such as the pushback against vaccination and general perception about the risk the flu poses to vulnerable populations.

Edited by: Jessica Yu 

Illustrated by: Avni Joshi

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