AMERICAN EXPERINCE interviewed Dr. Shirley Fannin in 1997. Currently, Fannin is a pediatrician specializing in epidemiology and infectious diseases in Los Angeles.
A Time for Great Optimism
By 1918, we, for about 30 years, had been having success after success with conquering diseases, diseases that had caused one out of every four children to die before their second birthday in the mid-1800s. By 1918, it was very unusual for a child to die unless they were born with a severe illness and this came about because of pasteurization which was introduced between 1910 and 1914. Diseases such as yellow fever which used to sweep communities and kill off hundreds of people, they discovered its association with mosquitoes in 1900. By controlling mosquitoes, they virtually eliminated yellow fever as a serious disease of mankind. Since the 1700s, we had had a vaccine that was capable of preventing smallpox to a great degree, so, smallpox, which had been, in previous centuries, a scary, frightening disease of mankind, was under control, or we felt it was under control. So, from Pasteur’s time in 1875, when he taught us the connection between what we were seeing in the microscope and disease, from that, came knowledge just in huge amounts and everybody was feeling like we were well on our way to conquering infectious disease.
It was a time of great optimism in infectious disease control mainly because Pasteur had advanced knowledge to such a tremendous degree that we were following one success right after another success.
No Time to Sit Around
This wasn’t time to sit around and ponder and meet with your colleagues and discuss things and get some sense of shared information. This was happening too fast. Influenza has a short incubation period, meaning that you can be exposed today and dead tomorrow because an incubation period is one to three days and this appeared that some people even had a shorter incubation period. So, there wasn’t any time to do the usual, go through the usual thought processes or planning or support group development, all those things you do to solve mysteries or to make yourself think you’re solving mysteries. So, I just see it as very chaotic, because it was so rapid and so dramatic and the drama part is how some people, obviously, not everybody, but some people died very severe respiratory deaths because they had hemorrhagic pneumonias; and I’ve heard people say, “Oh, well, it was just bacterial pneumonias that complicated influenza” — no, it was not. And I have a feeling that the hemorrhagic pneumonia that was caused by this strain of influenza was probably one of its virulence factors and one of the things that made it so awful to deal with.
Enhancing the Spread
In 1918, whatever we were doing was doing not much more than enhancing the spread. Viruses are such tiny particles; they are spread very efficiently, so that, you know, for instance, if you’re in the front of a room full of people and you have influenza and you’re coughing, the virus spreads in the air and you probably are going to infect or have the potential for infecting up to 50% of that audience, just because there are so many millions of the viruses and because they spread out through the air very effectively, then all a person has to do is breathe in one of virions to get infected. Well, imagine barracks with hundreds of people breathing each other’s air back and forth and ventilation was not very well known or understood at the time. Just the rapidity of the spread – add that to the virus with an incubation period of one to three days at best, or at worst and maybe even shorter than that, with this virus. So you add that, the rapidity of spread, the efficiency of spread, the rapidity of onset of symptoms and then add to that virulence, where people literally got pneumonia within a day or two that wiped out their lungs so they couldn’t breathe anymore and you have a setting for a horrible, horrible dramatically horrible situation round every hospital, even every household.
We Are Not Safe
Unfortunately, we are not safe today. If you look at what was happening in 1918 and you look at all the information we’ve developed, our ability to isolate the influenza, to create influenza vaccine, we still only have a vaccine that is partially protective and its effect is only good for like five months. It’s not the world’s greatest vaccine, even knowing how to make it. We don’t have an effective treatment to cure, we have an antiviral agent that can be used and it modifies the infection, but it doesn’t cure it, and it doesn’t stop its spread. So we, even at this decades later, if we had the same thing that happened with influenza in 1918 happening again, we probably would have a devastating effect. We have more people, we have more crowded cities, we have more instant communication, we have airplane travel which will get people from one side of the globe to the other, so the worldwide spread would be more rapid. If it were as virulent as it was before, it would be an awful situation and the tools that we have are just one predictability we’re able to track viruses. If we’re lucky enough that the first virus is isolated on the other side of the globe six months before our season, we may have an opportunity to make some vaccine and save a few people that way, but it’s too little, too late, in general.
We need to understand that influenza virus is a virus that has a great potential for changing its biologic nature, for exchanging genetic material with a similar virus and coming up with a mutant strain. Now we know, by chance alone, mutations can go in different directions, but there is nothing that assures us that we cannot have a bad virus that has the potential to spread fast, as I’ve described, and we have no way to develop immunity except by having the disease. If it’s a virulent virus, you may not have a chance to develop immunity if it kills you first, obviously. It takes about two weeks after the infection to develop significant immunity. So, there’s no reassurance that this same thing cannot happen again. In fact, it appeared to us that the major changes in the virus occur approximately every ten to twelve years and then – boom, the last 20 years we haven’t had a major change in the influenza virus. So you just wait for – which year is it going to happen – and that major change, is it going to be a not so bad change or is it going to be a very bad change. We do not have the armamentarium to put us much farther ahead than they were in 1918 in dealing with this virus.