Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic | Geriatrics | JAMA | JAMA Network
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Murray CJL, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis.  Lancet. 2006;368(9554):2211-221817189032Google ScholarCrossref
Crosby A. America's Forgotten Pandemic: The Influenza of 1918. New York, NY: Cambridge University Press; 2003
Jordan EO. Epidemic Influenza: A Survey. Chicago, IL: American Medical Association; 1927
Byerly CR. Fever of War: The Influenza Epidemic in the US Army During World War I. New York, NY: New York University; 2005
Markel H. When Germs Travel: Six Major Epidemics That Invaded America Since 1900 and the Fears They Unleashed. New York, NY: Pantheon; 2004
Rosen G. A History of Public Health. Baltimore, MD: Johns Hopkins University Press; 1993
Bell DM.World Health Organization Writing Group.  Nonpharmaceutical interventions for pandemic influenza, international measures.  Emerg Infect Dis. 2006;12(1):81-8716494722Google ScholarCrossref
Bell DM.World Health Organization Writing Group.  Nonpharmaceutical interventions for pandemic influenza, national and community measures.  Emerg Infect Dis. 2006;12(1):88-9416494723Google Scholar
Inglesby TV, Nuzzo JB, O’Toole T, Henderson DA. Disease mitigation measures in the control of pandemic influenza.  Biosecur Bioterror. 2006;4(4):366-37517238820Google ScholarCrossref
Aledort JE, Bozzette S, Lurie N, Ricci K, Adamson D, Stern S. Working Paper Non-Pharmacological Public Health Interventions for Pandemic Influenza: Proceedings of an Expert Panel Meeting—Final DraftWashington, DC: RAND Health Center for Domestic and International Health Security; 2006
Ferguson NM, Cummings DAT, Fraser C, Cajka JC, Cooley PC, Burke DS. Strategies for mitigating an influenza pandemic.  Nature. 2006;442(7101):448-45216642006Google ScholarCrossref
Ferguson NM, Cummings DAT, Cauchemez S.  et al.  Strategies for containing an emerging influenza pandemic in Southeast Asia.  Nature. 2005;437(7056):209-21416079797Google ScholarCrossref
Longini IM Jr, Nizam A, Xu S.  et al.  Containing pandemic influenza at the source.  Science. 2005;309(5737):1083-108716079251Google ScholarCrossref
Germann TC, Kadau C, Longini IM Jr, Macken CA. Mitigation strategies for pandemic influenza in the United States.  Proc Natl Acad Sci U S A. 2006;103(15):5935-594016585506Google ScholarCrossref
Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social distancing design for pandemic influenza.  Emerg Infect Dis. 2006;12(11):1671-168117283616Google ScholarCrossref
US Centers for Disease Control and Prevention.  Interim Pre-Pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States: Early, Targeted, Layered Use of Nonpharmaceutical Interventions. Atlanta, GA: Centers for Disease Control and Prevention; 2007
US Bureau of the Census.  Weekly Health Index [October 6, 1917 to June 26, 1920]. Located at: New York Public Library, New York, NY
Collins SD, Frost WH, Gover M, Sydenstricker E. Mortality from influenza and pneumonia in 50 large cities in the United States, 1910-1929.  Public Health Rep. 1930;45:2277-2329Google ScholarCrossref
Ministry of Health.  Reports on Public Health and Medical Subjects No. 4: Report on the Pandemic of Influenza, 1918-19. London, England: His Majesty's Stationery Office; 1920
McLaughlin AJ. The Shattuck lecture: epidemiology and etiology of influenza.  Boston Med Surg J. 1920;183:1-23Google ScholarCrossref
Sydenstricker E. Variations in case fatality during the influenza epidemic of 1918.  Public Health Rep. 1921;36:2201-2211Google ScholarCrossref
Sydenstricker E. Preliminary statistics of the influenza epidemic.  Public Health Rep. 1918;33:2305-2321Google ScholarCrossref
Frost WH. The epidemiology of influenza.  Public Health Rep. 1919;34:1823-1837Google ScholarCrossref
Eichel OR. A Special Report on the Mortality From Influenza in New York State During the Epidemic of 1918-19. New York: New York State Department of Health; 1923
Klotz O. The pathology of epidemic influenza. In:Studies in Epidemic Influenza. Pittsburgh, PA: University of Pittsburgh School of Medicine; 1919:207
Mills CE, Robins JM, Lipsitch M. Transmissibility of 1918 pandemic influenza.  Nature. 2004;432(7019):904-90615602562Google ScholarCrossref
Lyon MW. Gross pathology of epidemic influenza at Walter Reed General Hospital.  JAMA. 1919;72(13):924-929Google ScholarCrossref
Vaughan WT. American Journal of Hygiene, Monograph Series. Influenza: an epidemiologic study. In: Baltimore, MD: American Journal of Hygiene ; 1921
Morens DM, Fauci AS. The 1918 influenza pandemic: insights for the 21st century.  J Infect Dis. 2007;195(7):1018-102817330793Google ScholarCrossref
Reid AH, Janczewski TA, Lourens RM.  et al.  1918 influenza pandemic caused by highly conserved viruses with two receptor-binding variants.  Emerg Infect Dis. 2003;9(10):124914609459Google ScholarCrossref
Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics.  Emerg Infect Dis. 2006;12(1):15-2216494711Google ScholarCrossref
Taubenberger JK, Reid AH, Krafft AE, Bijwaard KE, Fanning TG. Initial genetic characterization of the 1918 Spanish influenza virus.  Science. 1997;275(5307):1793-17969065404Google ScholarCrossref
Taubenberger JK, Reid AH, Lourens RM, Wang R, Jin G, Fanning TG. Characterization of the 1918 influenza virus polymerase genes.  Nature. 2005;437(7060):889-89316208372Google ScholarCrossref
Department of Health of the City of New York.  Minutes of the Department of Health meetings from August 10 thru December 31, 1918. 1918;Book No. 31. Located at: Municipal Archives of New York, New York, NY
Markel H. Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892. Baltimore, MD: Johns Hopkins University Press; 1999
Hill AB. The environment and disease: association or causation?  Proc R Soc Med. 1965;58:295-30014283879Google Scholar
Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic.  Proc Natl Acad Sci U S A. 2007;104(18):7582-758717416679Google ScholarCrossref
Bootsma MCJ, Ferguson NM. The effect of public health measures on the 1918 influenza pandemic in US cities.  Proc Natl Acad Sci U S A. 2007;104(18):7588-759317416677Google ScholarCrossref
Berman Institute of Bioethics; Johns Hopkins University.  Bellagio meeting on social justice and influenza. Accessibility verified July 9, 2007
Gostin L. Public health strategies for pandemic influenza.  JAMA. 2006;295(14):1700-170416609092Google ScholarCrossref
Institute of Medicine; Board on Global Health, Forum on Microbial Threats.  Ethical and Legal Considerations in Mitigating a Pandemic Disease Event: Workshop Summary. Washington, DC: National Academies Press; 2007
Original Contribution
August 8, 2007

Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic

Author Affiliations

Author Affiliations: Center for the History of Medicine, University of Michigan Medical School, Ann Arbor (Drs Markel, Navarro, and Stern, and Ms Sloan and Mr Michalsen); and Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Lipman and Cetron).

JAMA. 2007;298(6):644-654. doi:10.1001/jama.298.6.644

Context A critical question in pandemic influenza planning is the role nonpharmaceutical interventions might play in delaying the temporal effects of a pandemic, reducing the overall and peak attack rate, and reducing the number of cumulative deaths. Such measures could potentially provide valuable time for pandemic-strain vaccine and antiviral medication production and distribution. Optimally, appropriate implementation of nonpharmaceutical interventions would decrease the burden on health care services and critical infrastructure.

Objectives To examine the implementation of nonpharmaceutical interventions for epidemic mitigation in 43 cities in the continental United States from September 8, 1918, through February 22, 1919, and to determine whether city-to-city variation in mortality was associated with the timing, duration, and combination of nonpharmaceutical interventions; altered population susceptibility associated with prior pandemic waves; age and sex distribution; and population size and density.

Design and Setting Historical archival research, and statistical and epidemiological analyses. Nonpharmaceutical interventions were grouped into 3 major categories: school closure; cancellation of public gatherings; and isolation and quarantine.

Main Outcome Measures Weekly excess death rate (EDR); time from the activation of nonpharmaceutical interventions to the first peak EDR; the first peak weekly EDR; and cumulative EDR during the entire 24-week study period.

Results There were 115 340 excess pneumonia and influenza deaths (EDR, 500/100 000 population) in the 43 cities during the 24 weeks analyzed. Every city adopted at least 1 of the 3 major categories of nonpharmaceutical interventions. School closure and public gathering bans activated concurrently represented the most common combination implemented in 34 cities (79%); this combination had a median duration of 4 weeks (range, 1-10 weeks) and was significantly associated with reductions in weekly EDR. The cities that implemented nonpharmaceutical interventions earlier had greater delays in reaching peak mortality (Spearman r = −0.74, P < .001), lower peak mortality rates (Spearman r = 0.31, P = .02), and lower total mortality (Spearman r = 0.37, P = .008). There was a statistically significant association between increased duration of nonpharmaceutical interventions and a reduced total mortality burden (Spearman r = −0.39, P = .005).

Conclusions These findings demonstrate a strong association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States. In planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment.