TIME health

What Made the Spanish Flu so Deadly?

Red Cross 1918
APIC / Getty Images Red Cross volunteers fighting against the spanish flu epidemic in United States in 1918

Mar. 11, 1918: A soldier in Fort Riley, Kans., reports to the infirmary with what will become known as Spanish flu

Nearly a century after it made its grisly debut, the mysteries surrounding Spanish flu continue to plague epidemiologists. In 2005, as Slate has reported, scientists succeeded in sequencing the virus’ RNA — eight years after exhuming a flu victim’s frozen corpse from an Alaskan grave to obtain a sample. But they still don’t know exactly where the virus came from or how it achieved such staggering lethality, killing more than half a million Americans and an estimated 50 million people worldwide in a single year.

Some researchers believe the story began on the morning of this day, Mar. 11, 1918, when a soldier in Fort Riley, Kans., went to the camp infirmary with a fever. According to the PBS documentary Influenza 1918, more than 100 soldiers had reported to the infirmary by noon. Within a week, that number had quintupled. Several dozen soldiers died there that spring, before the contagion seemed the ebb; the official cause was pneumonia.

As soldiers fanned out to fight World War I, however, the virus made its way around the globe, from European battlefields to remote areas of Russia and Greenland, spawning two more pandemic waves that were even deadlier than the first. (It became known as Spanish flu only because the Spanish news media was the first to widely report the epidemic, which had been hushed by wartime censors elsewhere in Europe.)

What made this flu different from all other flus was a dramatically higher fatality rate, plus the fact that while ordinary flus claimed casualties among the very young and the very old, this virus was especially deadly to young adults between the ages of 20 and 40. And their deaths weren’t pretty. As Slate tells it, “Many sufferers came down with severe nosebleeds — some spewed blood out of their nostrils with such force that nurses had to duck to avoid the flow. Those unable to recover eventually drowned in their own bodily fluids.”

Why Spanish flu was so fatal, especially to people in the prime of their lives, is what scientists are striving to understand, as TIME reported in the wake of Hong Kong’s 1997 avian flu outbreak. It was during that outbreak that a pathologist named Johan Hultin collected an intact, long-frozen sample of the Spanish flu virus from a mass grave in a tiny Alaska town called Brevig Mission, where 85 percent of the population had been felled by the flu in a single week. Research on that sample has shown that one way Spanish flu worked was by overstimulating the immune system and turning it against its owner — so having a strong immune system to begin with may have been a disadvantage.

But there is more to it than that, other scientists say. And understanding the full story of Spanish flu could help develop vaccines to protect us from the next flu epidemic — an epidemic that is inevitable, as Hultin told TIME in 1998. In the meantime, there’s only one surefire method of surviving pandemic flu, according to Hultin: Isolate yourself in a mountain hideaway until the outbreak subsides. TIME explains: “It was a tactic… successfully used in 1918 by a village just 30 miles from Brevig. Its elders, after learning of the advancing plague, stationed armed guards at the village perimeter with orders to shoot anyone who tried to enter. The village survived unscathed.”

Read original coverage of the Hong Kong outbreak, here in the TIME archives: The Flu Hunters

Read next: Why the Government Has Legal Authority to Quarantine

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TIME public health

You Get the Flu Way Less Than You Think

Instead of twice each winter, you might actually get the flu twice every 10 years

If it seems like you’re constantly getting the flu, you might be blaming the wrong bugs. A new study published in PLOS Biology suggests that after age 30, people generally only get the flu about twice a decade.

Researchers from Imperial College London looked at a single blood sample from 151 people in southern China and examined their flu antibody levels to the current strain of flu, as well as several historical strains prevalent over the last 40 years. They then estimated how many times people were infected and what happened to their antibodies at different points in their lives.

Young people got the flu more often, about once every other year. That might be because young people socialize more, the authors write. But once they hit age 30, rates flattened out; adults got the flu about twice every 10 years.

“A lot of people say once or twice a year they’ve got the flu, and that’s very unlikely to be true,” says Dr. Steven Riley, senior author of the study and reader at the Medical Research Council Centre for Outbreak Analysis and Modelling at Imperial College London. Sometimes flu can be mild—you may not even know you have it, but your sky-high antibody levels indicate otherwise, Riley says.

Though Riley is cautious to overinterpret the findings, the data was able to estimate infection rates across many years, which may one day prove valuable in vaccine applications, he says. “You could certainly think that down the road, this type of analysis would lead to a more sophisticated vaccine protocol—possibly the frequency with which you vaccinate and the doses with which you vaccinate could be optimized,” he says. “We can’t say what those optimal regimes would be based on this paper, but these nicely reproducible patterns suggest that that’s a good avenue to look for in the future.”

TIME Morning Must Reads

Morning Must Reads: January 16

Capitol
Mark Wilson—Getty Images The early morning sun rises behind the US Capitol Building in Washington, DC.

Europe On High Alert

Authorities launched a wave of counter-terrorism raids across Europe overnight and into Friday morning, resulting in two deaths and 23 arrests, as the continent steps up security measures in the wake of last week’s attack on the satirical newspaper Charlie Hebdo

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Google Decides Glass Half Empty

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Birdman and The Grand Budapest Hotel (pictured) led the way in nominations for the 87th Academy Awards with nine nods each, while Selma received only two.

Muhammad Ali Back in Hospital for ‘Follow-up Care’

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Nebraska Bill Would Abolish Closing Time for Bars

A Nebraska state senator introduced legislation Thursday that would allow bars in the state to stay open all night, if they wished. State and local laws generally require the Cornhusker state’s bars to stop serving alcohol at 1 a.m. or 2 a.m.

Flu Shot a Flub, CDC Says

People who got a flu shot this winter are only 23% less likely to get the flu than someone who didn’t get the vaccine, the CDC said in a new report. Since the health institute started tracking flu vaccine effectiveness in 2004, the rates have ranged from 10% to 60%

Oklahoma Resumes Executions After Nearly 9-Month Delay

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Republicans Want to Give President Obama More Power

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His other stories can be found here.

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TIME Infectious Disease

The Flu Shot Isn’t Working Well This Winter

TIME.com stock photos Health Syringe Needle
Elizabeth Renstrom for TIME

People who got the vaccine aren't as shielded as they sometimes are

People who got a flu shot this winter are only 23% less likely to get the flu than someone who didn’t get the vaccine, the Centers for Disease Control and Prevention (CDC) said in a new report Thursday.

This flu season, H3N2 flu viruses have been the most predominant, but the CDC reports that about 70% of them have genetically changed so that they are not as responsive to the flu vaccine as they were in the past. This is likely why the vaccine appears to be less effective, a measure the CDC calculates by looking at the number of medical visits related to the flu.

Since the flu vaccine is developed based on early predictions of what flu viruses will be most common during a certain season, it’s always possible that the estimates will be off and the vaccine won’t protect against the most common flu viruses circulating. Since the CDC started tracking flu vaccine effectiveness in 2004, the rates have ranged from 10% to 60%.

When the flu vaccine is less effective, people need to be more cautious and stringent about other ways to prevent contagion, like washing hands and treating the flu with medication if it is contracted. “Physicians should be aware that all hospitalized patients and all outpatients at high risk for serious complications should be treated as soon as possible with one of three available influenza antiviral medications if influenza is suspected,” Joe Bresee, an official in the CDC’s Influenza Division, in a statement.

The report shows that the vaccine is the effective among kids ages 6 to 17. The CDC said it’s classifying this flu season as moderately severe, and that it is similar to the 2012-2013 season.

TIME

Morning Must Reads: January 9

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Mark Wilson—Getty Images The early morning sun rises behind the US Capitol Building in Washington, DC.

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See If You’re Likely to Get the Flu

It’s not enough to know if your state is a flu hot zone. Now you can find out if the street you live on is teeming with flu cases, with these apps and websites

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HBO announced Thursday that the fifth season of Game of Thrones will premiere on Sunday, April 12 at 9 p.m. E.T. Veep and Silicon Valley will both return that day as well, providing some much-needed comic relief after the bloody show

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TIME flu

Here’s Where to Find Out If You’re Likely to Get the Flu

It’s not enough to know if your state is a flu hot zone. Now you can find out if the street you live on is teeming with flu cases

With this year’s flu season nearing epidemic levels — it’s widespread in 43 states, according to the Centers for Disease Control and Prevention (CDC) — prevention (and preparation) is certainly your best medicine.

Fortunately, there is no shortage of apps and websites that can help. Flu tracking is a popular subject, and ever since Google Flu Trends launched in 2008, it seems everyone wants to know how prevalent flu is — not just in their state and in their city, but in their neighborhood and even their office building. (Facebook can even help you figure out which of your friends might have given you the flu but tracking members’ posts about the illness and its symptoms.)

And while none are perfect, there are a few good ones.

The CDC’s FluView:

It gathers data from clinics, urgent care centers, doctor’s offices and hospitals and reports the number of people coming in with flu-like symptoms — fever, cough, sore throats, muscle aches — and people who test positive for the bug. It offers a good snapshot but it has some shortcomings. Because it logs symptoms in addition to diagnosed cases, there’s a chance that some of the fever and respiratory problems could be something else entirely. It also doesn’t record the countless people who likely just decide to weather out their illness at home with over-the-counter remedies or some chicken soup. There’s also a lag in the reporting, which means FluView can’t provide a real-time look at what the virus is doing at a given time.

The CDC has an epidemiologist studying alternative ways of collecting flu information, including crowdsourcing, to see if the CDC can provide more real time data. “There is potential there,” says Lynnette Brammer, an epidemiologist in the influenza division at CDC. “But with any data set you’ve got to know how to appropriately interpret that data and when you might be over reaching.”

MORE: Why Some Experts Want Mandatory Flu Shots For School Kids

Flu Near You:

This app is more granular, portraying in real time the actual level of flu activity in a given area. It can pinpoint your location down to the street and give you a low-moderate-high reading on flu activity. It’s based on self reports from people who register on the app and voluntarily provide information on their sniffle status on a weekly basis. Blue dots indicate people who are still symptom-free, while yellow dots indicate people who might have some of the symptoms of flu — including fever, coughs, or sore throats — and red dots represent people who meet the CDC criteria for influenza-like illness: fever over 100F and a cough or sore throat that’s not caused by any other known infection.

Self-reporting may not provide an entirely accurate picture either, however. To address such confounding factors, Flu Near Your deletes the first two reports by newcomers, to reduce the possibility that new users are just playing around with the app, but there’s still no way to verify the symptoms that people log in. But so far, Mark Smolinski, director of global health for Skoll Foundation Global Health Threats, which created the app, is confident that the reports are valid, since they track pretty well with the CDC data.

Alexis de Belloy, who pores over the Flu Near You data, says that registration for the app is up 40% compared to last year, and the proportion of them who actively respond to the weekly surveys is also up; the more participants, the stronger and more reliable the signal generated by the users.

The Flu Forecaster:

Jeffrey Shaman, professor of at the Mailman School of Public Health at Columbia University, decided to combine a bit of both the CDC and real-time strategies into his flu forecaster, which he launched last year. You can select your city and receive a chart of when flu is likely to peak where you live. It’s based on the same predictive modeling that weather forecasters use — combining information from past flu seasons and current trends to make educated guesses about the ebb and flow of cases in the future. “There are problems with all data, so I don’t think any data should be used in isolation,” he says. “We should consider them all until we have that gold standard.”

And it’s not just an academic exercise. Smolinski points out that critical public health information can be gleaned from flu tracking and forecasting, such as how effective a particular flu season’s vaccine is. By comparing rates of illness among people who have been vaccinated and those who haven’t, doctors can get a good sense of whether the shot is a good match for circulating flu strains or not. It can also help doctors, hospitals and pharmacies to make informed decisions about stocking flu remedies like Tamiflu so everyone who needs them will have access to them.

In Australia, crowd-based online surveillance is becoming the country’s go-to resource on flu tracking. Their system, FluTracking.net, asks participants about whether they have had a fever or cough every week during the flu season; since the program began in 2006, more than 16,000 people now complete the survey regularly. In Europe, 10 countries participate in Influenzanet, an online flu tracking system that also relies on volunteers to report on their symptoms weekly.

“It’s what’s coming down the pike, and what’s going to be in our future,” says Shaman of the real time information from the public. “We already get pollution levels and the pollen count. Why not have a real time flu forecast?”

TIME Healthcare

Why Some Experts Want Mandatory Flu Shots For School Kids

Flu Outbreak Continues In Bay Area
Justin Sullivan—Getty Images A syringe filled with influenza vaccination is seen at a Walgreens Pharmacy on January 14, 2014 in Concord, California.

'This is just part of being a good citizen and not hurting your neighbor'

How do you prevent elderly people from dying from the flu? Immunize preschoolers, infectious disease experts say.

A new policy mandating that preschool children receive flu vaccination went into effect in New York City earlier this month with exactly that goal in mind.

Young children respond particularly well to the flu vaccine, and giving it to preschoolers creates a ripple effect that diminishes the flu in the population as a whole. Even though preschoolers are just a fraction of the population, immunizing a critical percentage of the population from the flu could significantly diminish the chance of a widespread outbreak, a phenomenon known as herd immunity.

“This is just part of being a good citizen and not hurting your neighbor,” says Jon C. Tilburt, a medical professor at the Mayo Clinic. “It’s good for your neighbor’s kids and it’s good for grandma.”

Jane Zucker, an assistant commissioner at New York City’s Department of Health, says herd immunity “absolutely” shaped her department’s new policy, which mirrors similar rules that have been followed in Connecticut and New Jersey followed for years.

“There’s a good evidence base about the importance of vaccinating young children on community transmission, and [herd immunity] was really a strong influence on the decision to move forward,” she says.

Mandatory vaccination is nothing new in the United States. School children across the country have been required receive immunization for diseases like measles and mumps for years. But mandatory influenza vaccination hasn’t caught on as fast, even though vaccination for young children is strongly recommended by the Centers for Disease Control and Prevention.

The constantly evolving nature of the flu and its less-than-perfect effectiveness are among the reasons why the requirement hasn’t taken root, says University of California San Francisco medical professor Barbara Koenig. The warnings of dangerous side effects propagated by the attention-grabbing anti-vaccination movement do nothing to further the cause of mandatory vaccines.

MORE: Why the Anti-Vaccine Crowd Won’t Fade Away

Health officials have begun to latch onto the idea, says Zucker. She says she’s been in touch with policy makers from other jurisdictions who say they are considering a similar measure, and the National Foundation for Infectious Diseases sponsored a webinar on the topic last year, Zucker says.

Health experts say there is little risk of side effects, and they stress that in New York parents can obtain a religious or medical exemption. But parents should want to protect their own children with immunization, experts say. In Connecticut, the number of hospitalizations in the impacted age group fell by 12% following the implementation of a mandatory vaccination.

“There needs to be some individual direct benefit to the individual,” says Richard Malley, a doctor at Boston Children’s Hospital. “What we have here are vaccines that are recommended for children. They are disease sparing and, in some cases, they are life saving. They have a phenomenal effect on individual.”

TIME Health Care

The Flu Is Now Widespread in 43 States

A Walgreens employee holds a flu shot clinic on Dec. 19, 2014 in Oakland, California.
Justin Sullivan—Getty Images A Walgreens employee holds a flu shot clinic on Dec. 19, 2014 in Oakland, California.

CDC still says people should get a flu vaccine to guard against infection

The annual influenza outbreak has reached widespread levels in 43 states – up from 36 states a week ago.

New figures from the Centers for Disease Control and Prevention show that six more children have died from flu, including three kids in Tennessee, making for 21 pediatric deaths this flu season.

Flu activity typically waxes and wanes during the coldest months. While the nation reached an epidemic level of flu last week, the portion of weekly flu-and pneumonia-related deaths – 6.8 percent of all deaths – dipped below the epidemic threshold for the first week of January.

Flu generally hits hardest in the very young and the…

Read the rest of the story from our partners at NBC News

TIME Infectious Disease

How To Prevent The Flu This Winter

Getting a flu shot tops the list

Flu season may begin as early as October, but it really heats up in December. To stay healthy and enjoy the holidays, follow these basic flu prevention tips.

Get a flu shot

You should have done this months ago, but it’s not too late. This year’s flu shot may not have been the most effective, but the vaccine is the best protection against the disease, which, it bears reminding, is not just a couple of days feeling woozy—some people have to miss work (and play) for weeks when the virus hits. Look for a place that’s still offering the shot and get vaccinated.

Wash Your Hands

The guidelines are pretty simple. Put soap on your hands and wash them with hot water for 20 seconds. Still, more than 95% of people don’t meet this standard, according to a 2013 study. The Centers for Disease Control and Prevention recommends that you wash your hands frequently, including but not limited to when you eat, sneeze, touch garbage and use the restroom.

Avoid Sick People

This one is obvious. Leave the area if you see someone who looks feverish and is sneezing or coughing. Stay home if you have flu symptoms yourself.

Go to the Gym

Exercise boosts your immune system and makes you less likely to catch the flu. Exercising at least 2 and a half hours a week reduces the likelihood that you’ll catch a flu-like ailment by about 10%, according to a study from the London School of Hygiene and Tropical Medicine.

Get Sleep

Your immune system will function best when you’re well rested. Adults typically need 6 to 8 hours each night. If you’re getting less than 6, you may want to rethink your habits.

TIME Research

Here’s How Hugs Can Prevent the Flu

Getty Images

Hug-deprived people may get more severe colds

Want to stay well this flu season? New research suggests you can inoculate yourself with a hug—sort of.

For a study published Thursday in the journal Psychological Science, researchers from Carnegie Mellon University had an inkling that hugs—as an indicator of social support but also because it involves touch—might pack a flu-fighting punch. Studies have shown that strong social ties can protect against stress, anxiety and depression, and the researchers wanted to see if they can be a buffer for a purely physiological diseases, too. The researchers discovered that it did.

For two weeks, researchers from Carnegie Mellon University called up 400 people daily and assessed their levels of social support. They asked them if they’d been hugged that day, and if they were experiencing any conflicts or tension with people. The researchers then gave them nasal drops brimming with either the cold or flu virus, quarantined them for about a week in a hotel, and monitored their symptoms. (Everyone who participated in the study was compensated for their time, says study co-author Sheldon Cohen, professor of psychology at Carnegie Mellon.)

Even though everyone was exposed to infection-causing drops, 78% who developed an infection and 31% actually got sick—meaning they had physical symptoms of illness. For the unfortunate third whose hugs weren’t enough to prevent physical symptoms of being sick, they at least got some big benefit: those who got regularly hugged and those who felt they had more social support had less severe symptoms than the hug-deprived.

“There’s a lot of evidence out there suggesting that touch might be really effective at protecting people from stressors,” says Cohen, and this study adds to that very hug-friendly body of work. “It’s a communication to people that you care about them, and that you have a close intimate relationship with them.”

And as for the ideal “dose” of hugs? Cohen says: “It looks like one hug a day might be enough.”

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