Politics, Pushback, and Pandemics: Challenges to Public Health Orders in the 1918 Influenza Pandemic.

During the first wave of the COVID-19 pandemic in the United States, many state governors faced an increasing number of acts of defiance as well as political and legal challenges to their public health emergency orders. Less well studied are the similar acts of protest that occurred during the 1918-1919 influenza pandemic, when residents, business owners, clergy, and even local politicians grew increasingly restless by the ongoing public health measures, defied public health edicts, and agitated to have them rescinded. We explore several of the themes that emerged during the late fall of 1918 and conclude that, although the nation seems to be following the same path as it did in 1918, the motivations for pushback to the 2020 pandemic are decidedly more political than they were a century ago.

A Tale of Many Cities: A Contemporary Historical Study of the Implementation of School Closures during the 2009 pA(H1N1) Influenza Pandemic.

Applying qualitative historical methods, we examined the consideration and implementation of school closures as a nonpharmaceutical intervention (NPI) in thirty US cities during the spring 2009 wave of the pA(H1N1) influenza pandemic. We gathered and performed close textual readings of official federal, state, and municipal government documents; media coverage; and academic publications. Lastly, we conducted oral history interviews with public health and education officials in our selected cities. We found that several local health departments pursued school closure plans independent of CDC guidance, that uncertainty of action and the rapidly evolving understanding of pA(H1N1) contributed to tension and pushback from the public, that the media and public perception played a significant role in the response to school closure decisions, and that there were some notable instances of interdepartmental communication breakdown. We conclude that health departments should continue to develop and fine-tune their action plans while also working to develop better communication methods with the public, and work more closely with education officials to better understand the complexities involved in closing schools. Lastly, state and local governments should work to resolve lingering issues of legal authority for school closures in times of public health crises.

Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research.

In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)-strategies other than vaccines and antiviral medications-to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the acceptability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research.

Nonpharmaceutical interventions implemented by US cities during the 1918-1919 influenza pandemic.

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.

Nonpharmaceutical influenza mitigation strategies, US communities, 1918-1920 pandemic.

We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.