A year of terror and a century of reflection: perspectives on the great influenza pandemic of 1918-1919

Abstract

Background: In the spring of 1918, the "War to End All Wars", which would ultimately claim more than 37 million lives, had entered into its final year and would change the global political and economic landscape forever. At the same time, a new global threat was emerging and would become one of the most devastating global health crises in recorded history.

Main text: The 1918 H1N1 pandemic virus spread across Europe, North America, and Asia over a 12-month period resulting in an estimated 500 million infections and 50-100 million deaths worldwide, of which ~ 50% of these occurred within the fall of 1918 (Emerg Infect Dis 12:15-22, 2006, Bull Hist Med 76:105-115, 2002). However, the molecular factors that contributed to the emergence of, and subsequent public health catastrophe associated with, the 1918 pandemic virus remained largely unknown until 2005, when the characterization of the reconstructed pandemic virus was announced heralding a new era of advanced molecular investigations (Science 310:77-80, 2005). In the century following the emergence of the 1918 pandemic virus we have landed on the Moon, developed the electronic computer (and a global internet), and have eradicated smallpox. In contrast, we have a largely remedial knowledge and understanding of one of the greatest scourges in recorded history.

Conclusion: Here, we reflect on the 1918 influenza pandemic, including its emergence and subsequent rapid global spread. In addition, we discuss the pathophysiology associated with the 1918 virus and its predilection for the young and healthy, the rise of influenza therapeutic research following the pandemic, and, finally, our level of preparedness for future pandemics.

Keywords: 1918 Spanish flu; Influenza; Pandemic; Pneumonia; Preparedness; Therapeutics.

Fig. 1

Timeline of Influenza Pandemics from 1918 Onwards. Four pandemics have occurred over the last century (1918, 1957, 1968 and 2009). Circulation of H1N1 was reinitiated in 1977 and has therefore been added to this timeline. Grey arrows designate the circulating or co-circulating strains during the interpandemic periods

Fig. 2

The First and Second Waves of the 1918–1919 Pandemic. First outbreaks and foci of second waves of the pandemic are labeled as red and purple circles, respectively. The lines of spread of the first and second waves of the pandemic are labeled as purple dashed lines and red solid lines, respectively. Map images were derived and/or modified from Servier Medical Arts under a Creative Commons Attribution 3.0 Unported License. Adapted from Nicholson et al. [80]

Fig. 3

Association of Age with Influenza Mortality Prior to and During the 1918–1919 pandemic. Influenza- and pneumonia-specific mortality in the United States is plotted for 1911–1917 (blue line) and for 1918 (red line) [81, 82]. Means with standard deviations are presented for the pre-pandemic mortality curve. Adapted from Taubenberger and Morens [4]