feature
Coffin Supply is Exhausted
Undertakers Must Wait Turn for Caskets to Bury “Flu” Victims
Headline, The Courier-Journal, Louisville
October 23, 1918
“I thought I was going to die.
I remember lying here in the front
room and watching hearse after
hearse pass by my window outside.”
So Barbara Burkett-Halapin, PhD,
remembers her grandmother
telling her as she recounted her
illness with the influenza virus that
ravaged the world in 1918-19.
Burkett-Halapin’s grandmother, whose
experience is captured in the US Centers
for Disease Control and Prevention’s
(CDC’s) Pandemic Influenza Storybook,
was lucky. She survived the virus at
age 20 in small-town Shenandoah, VA.
But an estimated 675,000 Americans—
and 50 million to 100 million people
worldwide—succumbed to the first
pandemic influenza of the 20th
Century, 100 years ago this year.
The toll of that pandemic—described
as the “greatest medical holocaust in
history”—was so great that it eclipsed
the loss of 18 million lives in World War I
and actually decreased the population of
the US. Because the “grippe,” as influenza
was also known, disproportionately killed
those in the prime of life, it shortened
US life expectancy by 12 years.
After the virus slowed in 1919, this
particular lineage disappeared into
the pig population—a known virus
reservoir, considered a “universal
mixing bowl” where avian, swine and
human flu viruses reshuffle their
genomes. Then, nearly a century after
its deadly debut, a descendent of the
1918 virus re-emerged to prompt the
first pandemic of the 21st Century—the
2009 influenza A(H1N1) pandemic. But
this time the virus was substantially
changed. And so was the world.
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100 Years of Detective Work
In 1918, no one even knew for sure
that influenza was a viral disease; the
potentially grave respiratory illness was
widely believed to be bacterial, perhaps
caused by a species of Bacillus. But then,
the field of public health laboratory
practice was still in its infancy.
In 1930, scientists isolated influenza
virus for the very first time, from a
specimen taken from a pig. This classical
swine flu strain was later dubbed
influenza A(H1N1), with the “H” and
the “N” referring to hemagglutinin
and neuraminidase, two glycoproteins
that sit on the surface of the virus and
play a major role in its transmission
and pathogenicity. (Hemagglutinin,
additionally, is the major antigenic target
that triggers the host’s immune response.)
In 1933, the first human influenza virus
was isolated. With laboratory case
confirmation now possible, the public
health community made rapid gains.
A second influenza genus, influenza
B, was identified in 1940. Not long
thereafter, the first vaccines appeared.
Today, the world enjoys a robust,
laboratory-based Global Influenza
Surveillance and Response System
(GISRS), coordinated by the World
Health Organization (WHO), which
was itself established in 1948.
Yet, the threat of another 1918-
type pandemic persists.
“I wouldn’t call it likely, but I wouldn’t
be at all surprised if it happened,”
said Pete Shult, PhD, who heads the
Communicable Disease Division of
the Wisconsin State Laboratory of
Hygiene. “We have it in the back of our
mind that it could happen at any time.
That’s a prudent way to look at it.”
APHL.org
Said Daniel Jernigan, MD, MPH, director
of CDC’s Influenza Division, “Influen za is
as much of a foe now as it was [in 1918].
We can treat it better, we can prevent
it better, we can detect it a lot better.
But the potential for a severe pandemic
now is just as great as it was then.”
The most worrisome emerging influenza
today is the A(H7N9) virus, first detected
in China in 2013. H7N9 is the only virus
rated as having a “moderate-high” risk
for emergence and impact based on the
criteria considered in CDC’s Influenza
Risk Assessment Tool, including (1) viral
properties (e.g., antiviral susceptibility),
(2) population attributes (e.g., existing
immunity) and (3) viral ecology
(e.g., infection rates in animals).
To fully appreciate the risk, it helps to
recall the impact of past pandemics.
The 2009 A(H1N1) virus infected 24%
of the world population and had a case
fatality rate about 0.02%—a relatively mild
outcome compared with its 1918 ancestor,
which infected a third of the global
population and killed over 2.5% of those
stricken. In contrast, influenza A(H7N9)
has a mortality rate approaching 40%.
Although human H7N9 cases have
been mostly associated with exposure
to infected poultry, the number and
geographic distribution of cases
expanded significantly between the first
four Chinese outbreaks—involving 798
human infections during March 2013
to September 30, 2016—and the fifth
outbreak—involving 759 human infections
during October 1, 2016 to August 7, 2017.
Should the virus acquire greater facility
for human-to-human transmission,
GISRS will face its biggest test yet.
Winter 2018 LAB MATTERS
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