sures for disease control during the past
50 years, and ethical limitations of using
population-wide nonpharmaceutical in-
terventions in the absence of a serious
These findings contrast with the con-
ventional wisdom that the 1918 pan-
demic rapidly spread through each
community killing everyone in its path.
Although these urban communities had
neither effective vaccines nor antivi-
rals, cities that were able to organize and
execute a suite of classic public health
interventions before the pandemic
swept fully through the city appeared
to have an associated mitigated epi-
demic experience. Our study suggests
that nonpharmaceutical interventions
can play a critical role in mitigating the
consequences of future severe influ-
enza pandemics (category 4 and 5) and
should be considered for inclusion in
contemporary planning efforts as com-
panion measures to developing effec-
tive vaccines and medications for pro-
phylaxis and treatment. The history of
US epidemics also cautions that the
public’s acceptance of these health mea-
sures is enhanced when guided by ethi-
cal and humane principles.
Author Contributions: Drs Markel and Cetron had full
access to all of the data in the study and take respon-
sibility for the integrity of the data and the accuracy
of the data analysis.
Study concept and design: Markel, Lipman, Navarro,
Acquisition of data: Markel, Navarro, Sloan, Michalsen,
Analysis and interpretation of data: Markel, Lipman,
Navarro, Sloan, Michalsen, Stern, Cetron.
Drafting of the manuscript: Markel, Lipman, Navarro,
Sloan, Michalsen, Stern, Cetron.
Critical revision of the manuscript for important in-
tellectual content: Markel, Lipman, Navarro, Stern,
Statistical analysis: Markel, Lipman, Cetron.
Obtained funding: Markel, Cetron.
Administrative, technical, or material support: Markel,
Navarro, Sloan, Michalsen, Cetron.
Study supervision: Markel, Cetron.
Financial Disclosures: None reported.
Funding/Support: This study was funded by a con-
tract from the US Centers for Disease Control and Pre-
vention (Sol No. 2006-N-08562, Non-Pharmaceuti-
cal Interventions Study/contract 200-2006-16894).
Role of the Sponsor: The US Centers for Disease Con-
trol and Prevention provided funding as part of pan-
demic preparedness research. Drs Cetron and Lip-
man from the Division of Global Migration and
Quarantine at the Centers for Disease Control and Pre-
vention participated as full scientific collaborators in
Acknowledgment: Matthew Cartter, MD, MPH,
Cleto DiGiovanni Jr, Jeffrey Duchin, MD, Bruce Gel-
lin, MD, Richard Goodman, MD, JD, Daniel Jerni-
gan, MD, MPH, Lisa Koonin, MN, MPH, Anthony
Marfin, MD, Martin Meltzer, PhD, William Thomp-
son, PhD, David Shay, MD, and Mary Wilson, MD,
provided constructive review of this manuscript. No
one metioned in this section was compensated for
1. Murray CJL, Lopez AD, Chin B, Feehan D, Hill KH.
Estimation of potential global pandemic influenza mor-
tality on the basis of vital registry data from the 1918-20
pandemic: a quantitative analysis. Lancet.2006;
2. Crosby A. America’s Forgotten Pandemic: The In-
fluenza of 1918. New York, NY: Cambridge Univer-
sity Press; 2003.
3. Jordan EO. Epidemic Influenza: A Survey. Chi-
cago, IL: American Medical Association; 1927.
4. Byerly CR. Fever of War: The Influenza Epidemic
in the US Army During World War I. New York, NY:
New York University; 2005.
5. Markel H. When Germs Travel: Six Major Epidem-
ics That Invaded America Since 1900 and the Fears
They Unleashed. New York, NY: Pantheon; 2004.
6. Rosen G. AHistoryofPublicHealth.Baltimore, MD:
Johns Hopkins University Press; 1993.
7. Bell DM; World Health Organization Writing Group.
Nonpharmaceutical interventions for pandemic influ-
enza, international measures. Emerg Infect Dis.2006;
8. Bell DM; World Health Organization Writing Group.
Nonpharmaceutical interventions for pandemic influ-
enza, national and community measures. Emerg
9. Inglesby TV, Nuzzo JB, O’Toole T, Henderson
DA. Disease mitigation measures in the control of
pandemic influenza. Biosecur Bioterror.2006;
10. Aledort JE, Bozzette S, Lurie N, Ricci K, Adamson
D, Stern S. Working Paper Non-Pharmacological Pub-
lic Health Interventions for Pandemic Influenza: Pro-
ceedings of an Expert Panel Meeting—Final Draft.
Washington, DC: RAND Health Center for Domestic
and International Health Security; 2006.
11. Ferguson NM, Cummings DAT, Fraser C, Cajka
JC, Cooley PC, Burke DS. Strategies for mitigating an
influenza pandemic. Nature.2006;442(7101):448-452.
12. Ferguson NM, Cummings DAT, Cauchemez S,
et al. Strategies for containing an emerging influenza
pandemic in Southeast Asia. Nature.2005;
13. Longini IM Jr, Nizam A, Xu S, et al. Containing
pandemic influenza at the source. Science.2005;
14. Germann TC, Kadau C, Longini IM Jr, Macken
CA. Mitigation strategies for pandemic influenza in the
United States. Proc Natl Acad SciUSA.2006;
15. Glass RJ, Glass LM, Beyeler WE, Min HJ. Tar-
geted social distancing design for pandemic influenza.
Emerg Infect Dis.2006;12(11):1671-1681.
16. US Centers for Disease Control and Prevention.
Interim Pre-Pandemic Planning Guidance: Commu-
nity Strategy for Pandemic Influenza Mitigation in the
United States: Early, Targeted, Layered Use of Non-
pharmaceutical Interventions. Atlanta, GA: Centers for
Disease Control and Prevention; 2007.
17. US Bureau of the Census. Weekly Health Index
[October 6, 1917 to June 26, 1920]. Located at: New
York Public Library, New York, NY.
18. 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
19. 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.
20. McLaughlin AJ. The Shattuck lecture: epidemi-
ology and etiology of influenza. Boston Med Surg J.
21. Sydenstricker E. Variations in case fatality during
the influenza epidemic of 1918. Public Health Rep.
22. Sydenstricker E. Preliminary statistics of the in-
fluenza epidemic. Public Health Rep.1918;33:2305-
23. Frost WH. The epidemiology of influenza. Pub-
lic Health Rep.1919;34:1823-1837.
24. Eichel OR. ASpecialReportontheMortalityFrom
Influenza in New York State During the Epidemic of
1918-19. New York: New York State Department of
25. Klotz O. The pathology of epidemic influenza. In:
Studies in Epidemic Influenza. Pittsburgh, PA: Uni-
versity of Pittsburgh School of Medicine; 1919:207.
26. Mills CE, Robins JM, Lipsitch M. Transmissibility
of 1918 pandemic influenza. Nature.2004;432
27. Lyon MW. Gross pathology of epidemic influ-
enza at Walter Reed General Hospital. JAMA.1919;
28. Vaughan WT. American Journal of Hygiene,
Monograph Series. Influenza: an epidemiologic study.
In: Baltimore, MD: American Journal of Hygiene; 1921.
29. Morens DM, Fauci AS. The 1918 influenza pan-
demic: insights for the 21st century. JInfectDis.2007;
30. Reid AH, Janczewski TA, Lourens RM, et al. 1918
influenza pandemic caused by highly conserved vi-
ruses with two receptor-binding variants. Emerg In-
31. Taubenberger JK, Morens DM. 1918 influenza:
the mother of all pandemics. Emerg Infect Dis.2006;
32. Taubenberger JK, Reid AH, Krafft AE, Bijwaard
KE, Fanning TG. Initial genetic characterization of the
1918 Spanish influenza virus. Science.1997;275
33. Taubenberger JK, Reid AH, Lourens RM, Wang
R, Jin G, Fanning TG. Characterization of the 1918
influenza virus polymerase genes. Nature.2005;
34. 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
35. Markel H. Quarantine! East European Jewish Im-
migrants and the New York City Epidemics of 1892.
Baltimore, MD: Johns Hopkins University Press;
36. Hill AB. The environment and disease: associa-
tion or causation? Proc R Soc Med.1965;58:295-300.
37. 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;
38. Bootsma MCJ, Ferguson NM. The effect of pub-
lic health measures on the 1918 influenza pandemic
in US cities. Proc Natl Acad Sci U S A.2007;104
39. Berman Institute of Bioethics; Johns Hopkins
University. Bellagio meeting on social justice
and influenza. http://www.johnshopkinsmedicine
.org/bioethics/bellagio. Accessibility verified July 9,
40. Gostin L. Public health strategies for pandemic
41. Institute of Medicine; Board on Global Health, Fo-
rum on Microbial Threats. Ethical and Legal Consid-
erations in Mitigating a Pandemic Disease Event:
Workshop Summary. Washington, DC: National Acad-
emies Press; 2007.
INTERVENTIONS DURING 1918-1919 INFLUENZA PANDEMIC
654 JAMA, August 8, 2007—Vol 298, No. 6 (Reprinted) ©2007 American Medical Association. All rights reserved.
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