1918 flu pandemic - wikipedia 1918 flu pandemic Soldiers from Fort Riley, Kansas, ill with Spanish influenza at a hospital ward at Camp Funston Influenza ( Flu ) Types Avian A / H5N1 subtype Canine Equine Swine A / H1N1 subtype Vaccines 2009 pandemic Pandemrix Fluzone Influvac Fluvax / Flucelvax / Fluad / Fluverin Live attenuated Optaflu Treatment Amantadine Laninamivir Oseltamivir Peramivir Rimantadine Umifenovir Vitamin D Zanamivir Pandemics 2009 swine 1968 -- 1969 Hong Kong 1957 Asian flu 1918 Outbreaks 2015 United States H5N2 outbreak 2008 West Bengal 2007 Bernard Matthews H5N1 2007 Australian equine 2006 H5N1 India 1976 swine flu See also Flu season Influenza evolution Influenza research Influenza - like illness Vaccine reformulations The 1918 flu pandemic ( January 1918 -- December 1920 ) was an unusually deadly influenza pandemic, the first of the two pandemics involving H1N1 influenza virus. It infected 500 million people around the world, including people on remote Pacific islands and in the Arctic, and resulted in the deaths of 50 to 100 million ( three to five percent of the world 's population ), making it one of the deadliest natural disasters in human history. Disease had already greatly limited life expectancy in the early 20th century. In the first year of the pandemic, life expectancy in the United States dropped by about 12 years. Most influenza outbreaks disproportionately kill juvenile, elderly, or already weakened patients ; in contrast, the 1918 pandemic predominantly killed previously healthy young adults. There are several possible explanations for the high mortality rate of the 1918 influenza pandemic. Some research suggests that the specific variant of the virus had an unusually aggressive nature. One group of researchers recovered the virus from the bodies of frozen victims, and found that transfection in animals caused a rapid progressive respiratory failure and death through a cytokine storm ( overreaction of the body 's immune system ). It was then postulated that the strong immune reactions of young adults ravaged the body, whereas the weaker immune systems of children and middle - aged adults resulted in fewer deaths among those groups. More recent investigations, mainly based on original medical reports from the period of the pandemic, found that the viral infection itself was not more aggressive than any previous influenza, but that the special circumstances ( malnourishment, overcrowded medical camps and hospitals, poor hygiene ) promoted bacterial superinfection that killed most of the victims typically after a somewhat prolonged death bed. Historical and epidemiological data are inadequate to identify the pandemic 's geographic origin. It was implicated in the outbreak of encephalitis lethargica in the 1920s. To maintain morale, wartime censors minimized early reports of illness and mortality in Germany, the United Kingdom, France, and the United States. Papers were free to report the epidemic 's effects in neutral Spain ( such as the grave illness of King Alfonso XIII ). This created a false impression of Spain as especially hard hit, thereby giving rise to the pandemic 's nickname, Spanish Flu. Contents 1 History 1.1 Hypotheses about source 1.2 Spread 2 Mortality 2.1 Around the globe 2.2 Patterns of fatality 2.3 Deadly second wave 2.4 Devastated communities 2.5 Less - affected areas 2.6 Aspirin poisoning 2.7 End of the pandemic 2.8 Long - term impact 3 Legacy 4 Spanish flu research 5 In popular culture 6 Gallery 7 See also 8 References 8.1 Notes 8.2 Bibliography 9 Further reading 10 External links History Hypotheses about source Historian Alfred W. Crosby recorded that the flu originated in the U.S. state of Kansas, and popular writer John Barry echoed Crosby in describing Haskell County, as the point of origin although already in late 1917 there had been a first wave in at least 14 US military camps. Investigative work in 1999 by a British team led by virologist John Oxford of St Bartholomew 's Hospital and the Royal London Hospital identified the major troop staging and hospital camp in Étaples, France, as being the center of the 1918 flu pandemic. In late 1917, military pathologists reported the onset of a new disease with high mortality that they later recognized as the flu. The overcrowded camp and hospital -- which treated thousands of victims of chemical attacks and other casualties of war -- was an ideal site for the spreading of a respiratory virus ; 100,000 soldiers were in transit every day. It also was home to a live piggery, and poultry was regularly brought in from surrounding villages. Oxford and his team postulated that a significant precursor virus, harbored in birds, mutated so it could migrate to pigs that were kept near the front. Earlier hypotheses of the epidemic 's origin have varied. Some hypothesized the flu originated in East Asia. Claude Hannoun, the leading expert on the 1918 flu for the Pasteur Institute, asserted the former virus was likely to have come from China, mutating in the United States near Boston and spreading to Brest, France, Europe 's battlefields, Europe, and the world using Allied soldiers and sailors as main spreaders. He considered several other hypotheses of origin, such as Spain, Kansas, and Brest, as being possible, but not likely. Political scientist Andrew Price - Smith published data from the Austrian archives suggesting the influenza had earlier origins, beginning in Austria in early 1917. In 2014, historian Mark Humphries of Canada 's Memorial University of Newfoundland stated that newly unearthed records confirmed that one of the side stories of the war, the mobilization of 96,000 Chinese laborers to work behind the British and French lines on World War I 's western front, might have been the source of the pandemic. In the report, Humphries found archival evidence that a respiratory illness that struck northern China in November 1917 was identified a year later by Chinese health officials as identical to the `` Spanish '' flu. A report published in 2016 in the Journal of the Chinese Medical Association found no evidence that the 1918 virus was imported to Europe via Chinese and Southeast Asian soldiers and workers. It found evidence that the virus had been circulating in the European armies for months and possibly years before the 1918 pandemic. Spread When an infected person sneezes or coughs, more than half a million virus particles can be spread to those close by. The close quarters and massive troop movements of World War I hastened the pandemic, and probably both increased transmission and augmented mutation ; the war may also have increased the lethality of the virus. Some speculate the soldiers ' immune systems were weakened by malnourishment, as well as the stresses of combat and chemical attacks, increasing their susceptibility. A large factor in the worldwide occurrence of this flu was increased travel. Modern transportation systems made it easier for soldiers, sailors, and civilian travelers to spread the disease. In the United States, the disease was first observed in Haskell County, Kansas, in January 1918, prompting local doctor Loring Miner to warn the U.S. Public Health Service 's academic journal. On 4 March 1918, company cook Albert Gitchell reported sick at Fort Riley, an American military facility that at the time was training American troops during World War I, making him the first recorded victim of the flu. Within days, 522 men at the camp had reported sick. By 11 March 1918, the virus had reached Queens, New York. Failure to take preventive measures in March / April was later criticised. In August 1918, a more virulent strain appeared simultaneously in Brest, France ; in Freetown, Sierra Leone ; and in the U.S. in Boston, Massachusetts. The Spanish flu also spread through Ireland, carried there by returning Irish soldiers. The Allies of World War I came to call it the Spanish flu, primarily because the pandemic received greater press attention after it moved from France to Spain in November 1918. Spain was not involved in the war and had not imposed wartime censorship. Mortality Around the globe The difference between the influenza mortality age - distributions of the 1918 epidemic and normal epidemics -- deaths per 100,000 persons in each age group, United States, for the interpandemic years 1911 -- 1917 ( dashed line ) and the pandemic year 1918 ( solid line ) Three pandemic waves : weekly combined influenza and pneumonia mortality, United Kingdom, 1918 -- 1919 The global mortality rate from the 1918 / 1919 pandemic is not known, but an estimated 10 % to 20 % of those who were infected died. With about a third of the world population infected, this case - fatality ratio means 3 % to 6 % of the entire global population died. Influenza may have killed as many as 25 million people in its first 25 weeks. Older estimates say it killed 40 -- 50 million people, while current estimates say 50 -- 100 million people worldwide were killed. This pandemic has been described as `` the greatest medical holocaust in history '' and may have killed more people than the Black Death. It is said that this flu killed more people in 24 weeks than AIDS killed in 24 years, and more in a year than the Black Death killed in a century. However, a 2016 article in The Atlantic states that the Black Death, over the course of the decade of the 1340s, killed more than 10 % of the world population whereas the 1918 flu pandemic killed less than half this percentage. The disease killed in every corner of the globe. As many as 17 million died in India, about 5 % of the population. The death toll in India 's British - ruled districts alone was 13.88 million. In Japan, of the 23 million people who were affected, 390,000 died. In the Dutch East Indies ( now Indonesia ), 1.5 million were assumed to have died among 30 million inhabitants. In Tahiti 13 % of the population died during only a month. Similarly, in Samoa 22 % of the population of 38,000 died within two months. In Iran, the impact was enormous and according to an estimate, between 902,400 and 2,431,000 or 8.0 % and 21.7 % of the total population died. In the U.S., about 28 % of the population became infected, and 500,000 to 675,000 died. Native American tribes were particularly hard hit. In the Four Corners area alone, 3,293 deaths were registered among Native Americans. Entire village communities perished in Alaska. In Canada 50,000 died. In Brazil 300,000 died, including president Rodrigues Alves. In Britain, as many as 250,000 died ; in France, more than 400,000. In West Africa an influenza epidemic killed at least 100,000 people in Ghana. Tafari Makonnen ( the future Haile Selassie, Emperor of Ethiopia ) was one of the first Ethiopians who contracted influenza but survived, although many of his family 's subjects did not ; estimates for the fatalities in the capital city, Addis Ababa, range from 5,000 to 10,000, or higher. In British Somaliland one official estimated that 7 % of the native population died. This huge death toll was caused by an extremely high infection rate of up to 50 % and the extreme severity of the symptoms, suspected to be caused by cytokine storms. Symptoms in 1918 were so unusual that initially influenza was misdiagnosed as dengue, cholera, or typhoid. One observer wrote, `` One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred ''. The majority of deaths were from bacterial pneumonia, a common secondary infection associated with influenza, but the virus also killed people directly, by causing massive hemorrhages and edema in the lung. The unusually severe disease killed up to 20 % of those infected, as opposed to the usual flu epidemic mortality rate of 0.1 %. Patterns of fatality The pandemic mostly killed young adults. In 1918 -- 1919, 99 % of pandemic influenza deaths in the U.S. occurred in people under 65, and nearly half in young adults 20 to 40 years old. In 1920, the mortality rate among people under 65 had decreased sixfold to half the mortality rate of people over 65, but still 92 % of deaths occurred in people under 65. This is unusual, since influenza is normally most deadly to weak individuals, such as infants ( under age two ), the very old ( over age 70 ), and the immunocompromised. In 1918, older adults may have had partial protection caused by exposure to the 1889 -- 1890 flu pandemic, known as the Russian flu. According to historian John M. Barry, the most vulnerable of all -- `` those most likely, of the most likely '', to die -- were pregnant women. He reported that in thirteen studies of hospitalized women in the pandemic, the death rate ranged from 23 % to 71 %. Of the pregnant women who survived childbirth, over one - quarter ( 26 % ) lost the child. Another oddity was that the outbreak was widespread in the summer and autumn ( in the Northern Hemisphere ) ; influenza is usually worse in winter. Modern analysis has shown the virus to be particularly deadly because it triggers a cytokine storm, which ravages the stronger immune system of young adults. In fast - progressing cases, mortality was primarily from pneumonia, by virus - induced pulmonary consolidation. Slower - progressing cases featured secondary bacterial pneumonias, and there may have been neural involvement that led to mental disorders in some cases. Some deaths resulted from malnourishment. A study -- conducted by He et al. -- used a mechanistic modelling approach to study the three waves of the 1918 influenza pandemic. They tried to study the factors that underlie variability in temporal patterns, and the patterns of mortality and morbidity. Their analysis suggests that temporal variations in transmission rate provide the best explanation and the variation in transmission required to generate these three waves is within biologically plausible values. Another study by He et al. used a simple epidemic model, to incorporate three factors including school opening and closing, temperature changes over the course of the outbreak, and human behavioral changes in response to the outbreak to infer the cause of the three waves of the 1918 influenza pandemic. Their modelling results showed that all three factors are important but human behavioral responses showed the largest effects. Deadly second wave American Expeditionary Force victims of the flu pandemic at U.S. Army Camp Hospital no. 45 in Aix - les - Bains, France, in 1918 The second wave of the 1918 pandemic was much deadlier than the first. The first wave had resembled typical flu epidemics ; those most at risk were the sick and elderly, while younger, healthier people recovered easily. But in August, when the second wave began in France, Sierra Leone and the United States, the virus had mutated to a much deadlier form. As the American Experience Influenza 1918 episode says, October 1918 was the deadliest month of the whole pandemic. This increased severity has been attributed to the circumstances of the First World War. In civilian life, natural selection favors a mild strain. Those who get very ill stay home, and those mildly ill continue with their lives, preferentially spreading the mild strain. In the trenches, natural selection was reversed. Soldiers with a mild strain stayed where they were, while the severely ill were sent on crowded trains to crowded field hospitals, spreading the deadlier virus. The second wave began and the flu quickly spread around the world again. Consequently, during modern pandemics health officials pay attention when the virus reaches places with social upheaval ( looking for deadlier strains of the virus ). The fact that most of those who recovered from first - wave infections were now immune showed that it must have been the same strain of flu. This was most dramatically illustrated in Copenhagen, which escaped with a combined mortality rate of just 0.29 % ( 0.02 % in the first wave and 0.27 % in the second wave ) because of exposure to the less - lethal first wave. On the rest of the population it was far more deadly now ; the most vulnerable people were those like the soldiers in the trenches -- young previously healthy adults. Devastated communities A chart of deaths in major cities, showing a peak in October and November 1918 Even in areas where mortality was low, so many were incapacitated that much of everyday life was hampered. Some communities closed all stores or required customers to leave orders outside. There were reports that health - care workers could not tend the sick nor the gravediggers bury the dead because they too were ill. Mass graves were dug by steam shovel and bodies buried without coffins in many places. Several Pacific island territories were particularly hard - hit. The pandemic reached them from New Zealand, which was too slow to implement measures to prevent ships carrying the flu from leaving its ports. From New Zealand, the flu reached Tonga ( killing 8 % of the population ), Nauru ( 16 % ) and Fiji ( 5 %, 9,000 people ). Worst affected was German Samoa, today the independent state of Samoa, which had been occupied by New Zealand in 1914. 90 % of the population was infected ; 30 % of adult men, 22 % of adult women and 10 % of children died. By contrast, the flu was kept away from American Samoa when Governor John Martin Poyer imposed a blockade. In New Zealand itself, 8,573 deaths were attributed to the 1918 pandemic influenza, resulting in a total population fatality rate of 0.74 %. In Ireland, the Spanish Flu accounted for 10 % of the total deaths in 1918. Data analysis revealed 6,520 recorded deaths in Savannah - Chatham County, Georgia ( population = 83,252 ) for the three - year period from January 1, 1917, to December 31, 1919. Of these deaths, influenza was specifically listed as the cause of death in 316 cases, representing 4.85 percent of all causes of death for the total time period. Less - affected areas In Japan, 257,363 deaths were attributed to influenza by July 1919, giving an estimated 0.425 % mortality rate, much lower than nearly all other Asian countries for which data are available. The Japanese government severely restricted maritime travel to and from the home islands when the pandemic struck. In the Pacific, American Samoa and the French colony of New Caledonia also succeeded in preventing even a single death from influenza through effective quarantines. In Australia, nearly 12,000 perished. By the end of the pandemic, the isolated island of Marajó, in Brazil 's Amazon River Delta had not reported an outbreak. Saint Helena also reported no deaths. Aspirin poisoning In a 2009 paper published in the journal Clinical Infectious Diseases, Karen Starko proposed that aspirin poisoning contributed substantially to the fatalities. She based this on the reported symptoms in those dying from the flu, as reported in the post mortem reports still available, and also the timing of the big `` death spike '' in October 1918 which happened right after the Surgeon General of the United States Army, and the Journal of the American Medical Association both recommended very large doses of 8 to 31 grams of aspirin per day. These levels will produce hyperventilation in 33 % of patients, as well as lung edema in 3 % of patients. Starko also points out that many early deaths showed `` wet, '' sometimes hemorrhagic lungs, whereas late deaths showed bacterial pneumonia. She suggests that the wave of aspirin poisonings was due to a `` perfect storm '' of events : Bayer 's patent on aspirin expired, so that many companies rushed in to make a profit and greatly increased the supply ; this coincided with the flu pandemic ; and the symptoms of aspirin poisoning were not known at the time. As an explanation for the universally high mortality rate, this hypothesis was questioned in a letter to the journal published in April 2010 by Andrew Noymer and Daisy Carreon of the University of California, Irvine, and Niall Johnson of the Australian Commission on Safety and Quality in Health Care. They questioned this universal applicability given the high mortality rate in countries such as India, where there was little or no access to aspirin at the time compared to the rate where aspirin was plentiful. They concluded that `` the salicylate ( aspirin ) poisoning hypothesis ( was ) difficult to sustain as the primary explanation for the unusual virulence of the 1918 -- 1919 influenza pandemic ''. In response, Starko pointed to anecdotal evidence of aspirin use in India and argued that even if aspirin over-prescription had not contributed to the high Indian mortality rate, it could still have been a factor for other high rates in areas where other exacerbating factors present in India played less of a role. End of the pandemic After the lethal second wave struck in late 1918, new cases dropped abruptly -- almost to nothing after the peak in the second wave. In Philadelphia, for example, 4,597 people died in the week ending 16 October, but by 11 November, influenza had almost disappeared from the city. One explanation for the rapid decline of the lethality of the disease is that doctors got better at preventing and treating the pneumonia that developed after the victims had contracted the virus, although John Barry stated in his book that researchers have found no evidence to support this. Another theory holds that the 1918 virus mutated extremely rapidly to a less lethal strain. This is a common occurrence with influenza viruses : there is a tendency for pathogenic viruses to become less lethal with time, as the hosts of more dangerous strains tend to die out ( see also `` Deadly Second Wave '', above ). Long - Term impact A 2006 study in the Journal of Political Economy found that `` cohorts in utero during the pandemic displayed reduced educational attainment, increased rates of physical disability, lower income, lower socioeconomic status, and higher transfer payments compared with other birth cohorts. '' Legacy See also : List of 1918 flu pandemic cases American Red Cross nurses tend to flu patients in temporary wards set up inside Oakland Municipal Auditorium, 1918. Academic Andrew Price - Smith has made the argument that the virus helped tip the balance of power in the later days of the war towards the Allied cause. He provides data that the viral waves hit the Central Powers before they hit the Allied powers, and that both morbidity and mortality in Germany and Austria were considerably higher than in Britain and France. In the United States, Britain and other countries, despite the relatively high morbidity and mortality rates that resulted from the epidemic in 1918 -- 1919, the Spanish flu began to fade from public awareness over the decades until the arrival of news about bird flu and other pandemics in the 1990s and 2000s. This has led some historians to label the Spanish flu a `` forgotten pandemic ''. Various theories of why the Spanish flu was `` forgotten '' include the rapid pace of the pandemic, which killed most of its victims in the United States, for example, within a period of less than nine months, resulting in limited media coverage. The general population was familiar with patterns of pandemic disease in the late 19th and early 20th centuries : typhoid, yellow fever, diphtheria, and cholera all occurred near the same time. These outbreaks probably lessened the significance of the influenza pandemic for the public. In some areas, the flu was not reported on, the only mention being that of advertisements for medicines claiming to cure it. In addition, the outbreak coincided with the deaths and media focus on the First World War. Another explanation involves the age group affected by the disease. The majority of fatalities, from both the war and the epidemic, were among young adults. The deaths caused by the flu may have been overlooked due to the large numbers of deaths of young men in the war or as a result of injuries. When people read the obituaries, they saw the war or postwar deaths and the deaths from the influenza side by side. Particularly in Europe, where the war 's toll was extremely high, the flu may not have had a great, separate, psychological impact, or may have seemed a mere extension of the war 's tragedies. The duration of the pandemic and the war could have also played a role. The disease would usually only affect a certain area for a month before leaving, while the war, which most had initially expected to end quickly, had lasted for four years by the time the pandemic struck. This left little time for the disease to have a significant impact on the economy. Regarding global economic effects, many businesses in the entertainment and service industries suffered losses in revenue, while the health care industry reported profit gains. February 1918 drawing by Marguerite Martyn of a visiting nurse in St. Louis, Missouri, with medicine and babies Historian Nancy Bristow has argued that the pandemic, when combined with the increasing number of women attending college, contributed to the success of women in the field of nursing. This was due in part to the failure of medical doctors, who were predominantly men, to contain and prevent the illness. Nursing staff, who were predominantly women, felt more inclined to celebrate the success of their patient care and less inclined to identify the spread of the disease with their own work. In Spain, sources from the period explicitly linked the Spanish flu to the cultural figure of Don Juan. The nickname for the flu, the `` Naples Soldier '', was adopted from Federico Romero and Guillermo Fernández Shaw 's operetta, The Song of Forgetting ( La canción del olvido ), the protagonist of which is a stock Don Juan type. Federico Romero, one of the librettists, quipped that the play 's most popular musical number, Naples Soldier, was as catchy as the flu. Davis has argued the Spanish flu -- Don Juan connection served a cognitive function, allowing Spaniards to make sense of their epidemic experience by interpreting it through a familiar template, namely the Don Juan story. Spanish flu Research Main article : Spanish flu research An electron micrograph showing recreated 1918 influenza virions Centers for Disease Control and Prevention as Dr. Terrence Tumpey examines a reconstructed version of the 1918 flu. The origin of the Spanish flu pandemic, and the relationship between the near - simultaneous outbreaks in humans and swine, have been controversial. One hypothesis is that the virus strain originated at Fort Riley, Kansas, in viruses in poultry and swine which the fort bred for food ; the soldiers were then sent from Fort Riley around the world, where they spread the disease. Similarities between a reconstruction of the virus and avian viruses, combined with the human pandemic preceding the first reports of influenza in swine, led researchers to conclude the influenza virus jumped directly from birds to humans, and swine caught the disease from humans. Others have disagreed, and more recent research has suggested the strain may have originated in a nonhuman, mammalian species. An estimated date for its appearance in mammalian hosts has been put at the period 1882 -- 1913. This ancestor virus diverged about 1913 -- 1915 into two clades ( or biological groups ), which gave rise to the classical swine and human H1N1 influenza lineages. The last common ancestor of human strains dates to between February 1917 and April 1918. Because pigs are more readily infected with avian influenza viruses than are humans, they were suggested as the original recipients of the virus, passing the virus to humans sometime between 1913 and 1918. An effort to recreate the 1918 flu strain ( a subtype of avian strain H1N1 ) was a collaboration among the Armed Forces Institute of Pathology, the USDA ARS Southeast Poultry Research Laboratory and Mount Sinai School of Medicine in New York City. The effort resulted in the announcement ( on 5 October 2005 ) that the group had successfully determined the virus 's genetic sequence, using historic tissue samples recovered by pathologist Johan Hultin from a female flu victim buried in the Alaskan permafrost and samples preserved from American soldiers. On 18 January 2007, Kobasa et al. ( 2007 ) reported that monkeys ( Macaca fascicularis ) infected with the recreated flu strain exhibited classic symptoms of the 1918 pandemic, and died from a cytokine storm -- an overreaction of the immune system. This may explain why the 1918 flu had its surprising effect on younger, healthier people, as a person with a stronger immune system would potentially have a stronger overreaction. On 16 September 2008, the body of British politician and diplomat Sir Mark Sykes was exhumed to study the RNA of the flu virus in efforts to understand the genetic structure of modern H5N1 bird flu. Sykes had been buried in 1919 in a lead coffin which scientists hoped had helped preserve the virus. The coffin was found to be split because of the weight of soil over it, and the cadaver was badly decomposed. Nonetheless, samples of lung and brain tissue were taken through the split, with the coffin remaining in situ in the grave during this process. In December 2008, research by Yoshihiro Kawaoka of the University of Wisconsin linked the presence of three specific genes ( termed PA, PB1, and PB2 ) and a nucleoprotein derived from 1918 flu samples to the ability of the flu virus to invade the lungs and cause pneumonia. The combination triggered similar symptoms in animal testing. In June 2010, a team at the Mount Sinai School of Medicine reported the 2009 flu pandemic vaccine provided some cross-protection against the 1918 flu pandemic strain. One of the few things known for certain about the influenza in 1918 and for some years after was that it was, out of the laboratory, exclusively a disease of human beings. In 2013, the AIR Worldwide Research and Modeling Group `` characterized the historic 1918 pandemic and estimated the effects of a similar pandemic occurring today using the AIR Pandemic Flu Model ''. In the model, `` a modern day `` Spanish flu '' event would result in additional life insurance losses of between USD 15.3 -- 27.8 billion in the United States alone '' with 188,000 -- 337,000 deaths in the United States. In popular culture The 1995 film Outbreak, the 2011 film Contagion and the 2013 film World War Z make reference to the pandemic. Twentieth - century fiction includes at least three novels with the flu pandemic as a major theme : Katherine Anne Porter 's Pale Horse, Pale Rider, Thomas Mullen 's The Last Town on Earth, and Thomas Wolfe 's Look Homeward, Angel. In the one - act play 1918 by Horton Foote ( part of his Orphans ' Home Cycle ( 1979 ) ), the presence and threat of the flu ( and the tragedy it ultimately causes ) is a major element of the plot. The play was made into a film of the same title, released in 1985, which was subsequently edited for broadcast by PBS as the last part of the miniseries `` The Story of A Marriage ''. Gallery Two American Red Cross nurses demonstrating treatment practices during the influenza pandemic of 1918. Albertan farmers wearing masks to protect themselves from the flu. Policemen wearing masks provided by the American Red Cross in Seattle, 1918 A street car conductor in Seattle in 1918 refusing to allow passengers aboard who are not wearing masks Red Cross workers remove a flu victim in St. Louis, Missouri ( 1918 ) Influenza ward at Walter Reed Hospital during the Spanish flu pandemic of 1918 -- 1919 Burying flu victims, North River, Canada ( 1918 ) 1919 Tokyo, Japan Japanese poster in 1919 Demonstration at the Red Cross Emergency Ambulance Station in Washington, D.C., during the influenza pandemic of 1918 Cavalry memorial on the hill Lueg, memory of the Bernese cavalrymen victims of the 1918 flu pandemic ; Emmental, Bern, Switzerland The Spanish flu as the Naples Soldier ( Spain, 1918 ) Spanish biologists and the flu microbe ( Spain, 1918 ) See also Medicine portal Viruses portal Death portal References Notes Jump up ^ `` La Grippe Espagnole de 1918 '' ( in French ). Institut Pasteur. Archived from the original ( Powerpoint ) on 17 November 2015. ^ Jump up to : Taubenberger & Morens 2006. Jump up ^ `` Historical Estimates of World Population ''. Retrieved 29 March 2013. ^ Jump up to : Patterson & Pyle 1991. ^ Jump up to : Billings 1997. Jump up ^ Johnson & Mueller 2002. Jump up ^ `` The Nation 's Health ''. www.flu.gov. U.S. Department of Health & Human Services. Archived from the original on 2016 - 10 - 26. Retrieved 2016 - 03 - 31. Jump up ^ `` Life Expectancy ''. Our World in Data. Archived from the original on 31 March 2016. Retrieved 31 March 2016. Jump up ^ `` Life expectancy in the USA, 1900 -- 98 ''. demog.berkeley.edu. Archived from the original on 2003 - 06 - 08. Retrieved 2016 - 03 - 31. Jump up ^ `` The Influenza Epidemic of 1918 ''. Archives.gov. National Archives and Records Administration. Retrieved March 31, 2016. ^ Jump up to : Barry 2004. Jump up ^ MacCallum, W.G. ( 1919 ). `` Pathology of the pneumonia following influenza ''. JAMA : The Journal of the American Medical Association. 72 ( 10 ) : 720 -- 723. doi : 10.1001 / jama. 1919.02610100028012. Jump up ^ Hirsch, Edwin F. ; McKinney, Marion ( 1919 ). `` An epidemic of pneumococcus broncho - pneumonia ''. Journal of Infectious Diseases. 24 ( 6 ) : 594 -- 617. doi : 10.1093 / infdis / 24.6. 594. Jump up ^ Brundage, John F. ; Shanks, G. Dennis ( 2007 ). `` What Really Happened during the 1918 Influenza Pandemic ? The Importance of Bacterial Secondary Infections ''. Journal of Infectious Diseases. 196 ( 11 ) : 1717 -- 1718. doi : 10.1086 / 522355. Jump up ^ Morens, David M ; Fauci, Anthony S. ( 2007 ). `` The 1918 influenza pandemic : insights for the 21st century ''. Journal of Infectious Diseases. 195 ( 7 ) : 1018 -- 1028. doi : 10.1086 / 511989. Jump up ^ Vilensky, Foley & Gilman 2007. Jump up ^ Valentine 2006. Jump up ^ Anderson, Susan ( 29 August 2006 ). `` Analysis of Spanish flu cases in 1918 -- 1920 suggests transfusions might help in bird flu pandemic ''. American College of Physicians. Retrieved 2 October 2011. Jump up ^ Porras - Gallo & Davis 2014. Jump up ^ Barry 2004, p. 171. Jump up ^ Galvin 2007. ^ Jump up to : Crosby 2003. ^ Jump up to : Barry 2004b. Jump up ^ `` How the US Army infected the World with Spanish Flu ''. Limpia por dentro. Retrieved 7 December 2017. Jump up ^ `` EU Research Profile on Dr. John Oxford ''. Archived from the original on 12 May 2009. Retrieved 9 May 2009. Jump up ^ Connor, Steve, `` Flu epidemic traced to Great War transit camp '', The Guardian ( UK ), Saturday, 8 January 2000. Accessed 2009 - 05 - 09. Archived 11 May 2009. Jump up ^ Oxford, J.S. ; Lambkin, R. ; Sefton, A. ; Daniels, R. ; Elliot, A. ; Brown, R. ; Gill, D. ( 2005 ). `` A hypothesis : the conjunction of soldiers, gas, pigs, ducks, geese and horses in Northern France during the Great War provided the conditions for the emergence of the `` Spanish '' influenza pandemic of 1918 -- 1919 ``. Vaccine. 23 ( 7 ) : 940 -- 945. doi : 10.1016 / j. vaccine. 2004.06. 035. Jump up ^ 1918 killer flu secrets revealed. BBC News. 5 February 2004. Jump up ^ Hannoun, Claude, `` La Grippe '', Ed Techniques EMC ( Encyclopédie Médico - Chirurgicale ), Maladies infectieuses, 8 - 069 - A-10, 1993. Documents de la Conférence de l'Institut Pasteur : La Grippe Espagnole de 1918. ^ Jump up to : Price - Smith 2008. Jump up ^ Humphries 2014. Jump up ^ Vergano, Dan ( January 24, 2014 ). `` 1918 Flu Pandemic That Killed 50 Million Originated in China, Historians Say ''. National Geographic. Retrieved November 4, 2016. Jump up ^ Shanks, G. Dennis ( 2016 ). `` No evidence of 1918 influenza pandemic origin in Chinese laborers / soldiers in France ''. Journal of the Chinese Medical Association. 79 ( 1 ) : 46 -- 8. doi : 10.1016 / j. jcma. 2015.08. 009. PMID 26542935. Jump up ^ Sherman, Irwin W. ( 2007 ). Twelve diseases that changed our world. Washington, DC : ASM Press. p. 161. ISBN 978 - 1 - 55581 - 466 - 3. Jump up ^ Ewald 1994. Jump up ^ Film : We Heard the Bells : The Influenza of 1918 ( 2010 ). U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services. 2010. Retrieved 20 February 2012. Jump up ^ Barry, John M ( 20 January 2004 ). `` The site of origin of the 1918 influenza pandemic and its public health implications ''. Journal of Translational Medicine. 2 : 3. doi : 10.1186 / 1479 - 5876 - 2 - 3. PMC 340389. PMID 14733617. Jump up ^ Bynum, Bill ( March 14, 2009 ). `` Stories of an influenza pandemic '' ( PDF ). The Lancet. 373 : 885 -- 886. doi : 10.1016 / s0140 - 6736 ( 09 ) 60530 - 4. Jump up ^ Avian Bird Flu. 1918 Flu ( Spanish flu epidemic ). Jump up ^ Spanish flu strikes during World War I, Timelines of great Epidemics, xtimeline.com Archived 14 January 2010 at the Wayback Machine. Jump up ^ Channel 4 -- News -- Spanish flu facts. Jump up ^ Taubenberger & Morens 2006, pp. 15 -- 22. Jump up ^ CDC 2009. ^ Jump up to : Knobler 2005. Jump up ^ Potter 2006. Jump up ^ Human Extinction Is n't That Unlikely, The Atlantic, Robinson Meyer, April 29, 2016. Jump up ^ Flu experts warn of need for pandemic plans British Medical Journal. Jump up ^ Chandra, Kuljanin & Wray 2012. Jump up ^ `` Spanish Influenza in Japanese Armed Forces, 1918 -- 1920 ''. Centers for Disease Control and Prevention ( CDC ). Jump up ^ Historical research report from University of Indonesia, School of History, as reported in Emmy Fitri. Looking Through Indonesia 's History For Answers to Swine Flu Archived 2 November 2009 at the Wayback Machine... The Jakarta Globe. 28 October 2009 edition. Jump up ^ Kohn 2007. Jump up ^ Afkhami 2003 ; Afkhami 2012. Jump up ^ The Great Pandemic : The United States in 1918 -- 1919, U.S. Department of Health & Human Services. Jump up ^ `` Flu Epidemic Hit Utah Hard in 1918, 1919 ''. 28 March 1995. Retrieved 7 July 2012. Jump up ^ `` The Great Pandemic of 1918 : State by State ''. Archived from the original on 6 May 2009. Retrieved 4 May 2009. Jump up ^ `` A deadly virus rages throughout Canada at the end of the First World War ''. CBC History. Jump up ^ `` A gripe espanhola no Brasil -- Elísio Augusto de Medeiros e Silva, empresário, escritor e membro da AEILIJ '' ( in Portuguese ). Jornal de Hoje. Retrieved 22 January 2014. Jump up ^ The `` bird flu '' that killed 40 million. BBC News. 19 October 2005. Jump up ^ Hays 1998. Jump up ^ Harold Marcus, Haile Sellassie I : The formative years, 1892 -- 1936 ( Trenton : Red Sea Press, 1996 ), pp. 36f Jump up ^ Pankhurst 1991, pp. 48f. Jump up ^ Pankhurst 1991, p. 63. Jump up ^ Pankhurst 1991, pp. 51ff. Jump up ^ `` Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic ''. National Institutes of Health. ^ Jump up to : Taubenberger et al. 2001, pp. 1829 -- 1839. ^ Jump up to : Simonsen et al. 1998. Jump up ^ Hanssen, Olav. Undersøkelser over influenzaens optræden specielt i Bergen 1918 -- 1922. Bg. 1923. 66 s. ill. ( Haukeland sykehus. Med. avd. Arb. 2 ) ( Klaus Hanssens fond. Skr. 3 ) Jump up ^ Payne, Matthew S. ; Bayatibojakhi, Sara ( 2014 ). `` Exploring Preterm Birth as a Polymicrobial Disease : An Overview of the Uterine Microbiome ''. Frontiers in Immunology. 5 : 595. doi : 10.3389 / fimmu. 2014.00595. ISSN 1664 - 3224. PMC 4245917. PMID 25505898. Jump up ^ Barry 2004, p. 239. Jump up ^ Key Facts about Swine Influenza ( 1 ) accessed 22 : 45 GMT - 6 30 April 2009. Archived 4 May 2009. Jump up ^ He et al. 2011. Jump up ^ He et al. 2013. Jump up ^ UK Parliament -- http://www.parliament.the-stationery-office.com/pa/ld200506/ldselect/ldsctech/88/88.pdf. Accessed 2009 - 05 - 06. Archived 8 May 2009. Jump up ^ Gladwell 1997, p. 55. Jump up ^ Gladwell 1997, p. 63. Jump up ^ Fogarty International Center. `` Summer Flu Outbreak of 1918 May Have Provided Partial Protection Against Lethal Fall Pandemic ''. Fic.nih.gov. Retrieved 2012 - 05 - 19. Jump up ^ Gladwell 1997, p. 56. Jump up ^ Fortune article `` Viruses of Mass Destruction '' written 1 November 2004. accessed 01 : 12 GMT + 1 30 April 2009 ^ Jump up to : Denoon 2004. Jump up ^ Rice 2005, p. 221. Jump up ^ Plaspohl, Sata S. ; Dixon, Betty T. ; Owen, Nyssa ( 2016 ). `` '' The Effect of the 1918 Spanish Influenza Pandemic on Mortality Rates in Savannah, Georgia ``. Georgia Historical Quarterly. 100 ( 3 ) : 332. Retrieved 14 February 2018. Jump up ^ `` Influenza of 1918 ( Spanish Flu ) and the US Navy ''. history.navy.mil. Archived from the original on 11 January 2015. Retrieved 14 May 2009. Jump up ^ World Health Organization Writing Group ( 2006 ). `` Nonpharmaceutical interventions for pandemic influenza, international measures '' ( PDF ). Centers for Disease Control and Prevention ( CDC ) Emerging Infectious Diseases ( EID ) Journal. 12 ( 1 ) : 189. Jump up ^ Anne Grant, History House, Portland. Influenza Pandemic 1919. Portland Victoria Jump up ^ Ryan, Jeffrey, ed. Pandemic influenza : emergency planning and community preparedness. Boca Raton : CRC Press, 2009. P. 24 Jump up ^ `` Colonial Annual Report '', 1919 ^ Jump up to : Starko 2009. ^ Jump up to : Noymer, Carreon & Johnson 2010. Jump up ^ Starko 2010. Jump up ^ Almond, Douglas ( 2006 - 08 - 01 ). `` Is the 1918 Influenza Pandemic Over ? Long ‐ Term Effects of In Utero Influenza Exposure in the Post ‐ 1940 U.S. Population ''. Journal of Political Economy. 114 ( 4 ) : 672 -- 712. doi : 10.1086 / 507154. ISSN 0022 - 3808. Jump up ^ Honigsbaum 2008. Jump up ^ Morrissey 1986. Jump up ^ Benedict & Braithwaite 2000, p. 38. Jump up ^ Crosby 2003, pp. 320 -- 322. Jump up ^ Garrett 2007. Jump up ^ Lindley, Robin, The Forgotten American Pandemic : Historian Dr. Nancy K. Bristow on the Influenza Epidemic of 1918 Jump up ^ Davis 2013, pp. 103 -- 136. Jump up ^ `` Open Collections Program : Contagion, Spanish Influenza in North America, 1918 -- 191 ''. Retrieved 22 November 2016. Jump up ^ Sometimes a virus contains both avian - adapted genes and human - adapted genes. Both the H2N2 and H3N2 pandemic strains contained avian flu virus RNA segments. `` While the pandemic human influenza viruses of 1957 ( H2N2 ) and 1968 ( H3N2 ) clearly arose through reassortment between human and avian viruses, the influenza virus causing the ' Spanish flu ' in 1918 appears to be entirely derived from an avian source ( Belshe 2005 ). '' ( from Chapter Two : Avian Influenza by Timm C. Harder and Ortrud Werner, a free on - line book called Influenza Report 2006 ) Jump up ^ Taubenberger et al. 2005. Jump up ^ Antonovics, Hood & Baker 2006. Jump up ^ Vana & Westover 2008. Jump up ^ dos Reis, Hay & Goldstein 2009. Jump up ^ Center for Disease Control : Researchers Reconstruct 1918 Pandemic Influenza Virus ; Effort Designed to Advance Preparedness Retrieved on 2 September 2009 Jump up ^ Kobasa & et al. 2007. Jump up ^ USA Today : Research on monkeys finds resurrected 1918 flu killed by turning the body against itself Retrieved on 14 August 2008. Jump up ^ BBC News : Body exhumed in fight against flu Retrieved on 16 September 2008. Jump up ^ BBC Four documentary. In Search of Spanish Flu Jump up ^ Fox 2008. Jump up ^ Fox 2010. Jump up ^ Crosby 1976, p. 295. Jump up ^ Madhav 2013. Jump up ^ `` Outbreak -- Daily Script '' ( PDF ). p. 94. Jump up ^ `` World War Z Quotes -- ' Every human being we save is one less zombie to fight. ' ''. Retrieved 22 November 2016. Bibliography Antonovics, J. ; Hood, M.E. ; Baker, C.H. ( 2006 ). `` Molecular virology : was the 1918 flu avian in origin ? ''. Nature. 440 ( 7088 ) : E9, E10. Bibcode : 2006Natur. 440E... 9A. doi : 10.1038 / nature04824. PMID 16641950. Afkhami, Amir ( 2003 ). `` Compromised Constitutions : The Iranian Experience with the 1918 Influenza Pandemic ''. Bulletin of the History of Medicine. The Johns Hopkins University Press. 77 ( 2 ) : 367 -- 392. doi : 10.1353 / bhm. 2003.0049. -- Open access material by the Psychiatry and Behavioral Sciences at Health Sciences Research Commons. Afkhami, Amir ( 29 March 2012 ) ( 15 December 2004 ). `` Influenza ''. In Yarshater, Ehsan. Encyclopædia Iranica. Fasc. 2. XIII ( Online ed. ). New York City : Bibliotheca Persica Press. pp. 140 -- 143. Barry, John M. ( 2004 ). The Great Influenza : The Epic Story of the Greatest Plague in History. Viking Penguin. ISBN 978 - 0 - 670 - 89473 - 4. Barry, John M. ( 2004b ). `` The site of origin of the 1918 influenza pandemic and its public health implications ''. Journal of Translational Medicine. 2 ( 3 ) : 3. doi : 10.1186 / 1479 - 5876 - 2 - 3. PMC 340389. PMID 14733617. Archived from the original on 4 May 2009. Benedict, Michael Les ; Braithwaite, Max ( 2000 ). `` The Year of the Killer Flu ''. In the Face of Disaster : True Stories of Canadian Heroes from the Archives of Maclean 's. New York, N.Y : Viking. p. 38. ISBN 978 - 0 - 670 - 88883 - 2. Billings, Molly ( 1997 ). `` The 1918 Influenza Pandemic ''. Virology at Stanford University. Archived from the original on 4 May 2009. Retrieved 1 May 2009. Bristow, Nancy K. American Pandemic : The Lost Worlds of the 1918 Influenza Epidemic ( OUP, 2012 ) `` 1918 Influenza : the Mother of All Pandemics ''. Archived from the original on 1 October 2009. Retrieved 2 September 2009. Chandra, S. ; Kuljanin, G. ; Wray, J. ( 2012 ). `` Mortality From the Influenza Pandemic of 1918 -- 1919 : The Case of India ''. Demography. 49 ( 3 ) : 857 -- 865. doi : 10.1007 / s13524 - 012 - 0116 - x. PMID 22661303. Collier, Richard ( 1974 ). The Plague of the Spanish Lady -- The Influenza Pandemic of 1918 -- 19. Atheneum. ISBN 978 - 0 - 689 - 10592 - 0. Crosby, Alfred W. ( 1976 ). Epidemic and Peace, 1918. Westport, Ct : Greenwood Press. ISBN 978 - 0 - 8371 - 8376 - 3. Crosby, Alfred W. ( 2003 ). America 's Forgotten Pandemic : The Influenza of 1918 ( 2nd ed. ). Cambridge University Press. ISBN 978 - 0 - 521 - 54175 - 6. Davis, Ryan A. ( 2013 ). The Spanish Flu : Narrative and Cultural Identity in Spain, 1918. Palgrave Macmillan. ISBN 978 - 1 - 137 - 33921 - 8. Denoon, Donald ( 2004 ). `` New Economic Orders : Land, Labour and Dependency ''. In Denoon, Donald. The Cambridge History of the Pacific Islanders. CUP. p. 247. ISBN 978 - 0 - 521 - 00354 - 4. dos Reis, M. ; Hay, A.J. ; Goldstein, R.A. ( 2009 ), `` Using Non-Homogeneous Models of Nucleotide Substitution to Identify Host Shift Events : Application to the Origin of the 1918 ' Spanish ' Influenza Pandemic Virus '', Journal of Molecular Evolution, 69 ( 4 ) : 333 -- 345, Bibcode : 2009JMolE... 69... 333D, doi : 10.1007 / s00239 - 009 - 9282 - x, PMC 2772961, PMID 19787384 Ewald, Paul W. ( 1994 ). Evolution of infectious disease. OUP. ISBN 978 - 0 - 19 - 506058 - 4. Fox, Maggie ( 29 December 2008 ). `` Researchers unlock secrets of 1918 flu pandemic ''. Reuters. Retrieved 2 September 2009. Fox, Maggie ( 16 June 2010 ). `` Swine flu shot protects against 1918 flu : study ''. Reuters. Galvin, John ( 31 July 2007 ). `` Spanish Flu Pandemic : 1918 ''. Popular Mechanics. Retrieved 2 October 2011. Garrett, T.A. ( 2007 ). Economic Effects of the 1918 Influenza Pandemic : Implications for a Modern - day Pandemic ( PDF ). Gladwell, Malcolm ( 29 September 1997 ). `` The Dead Zone ''. New Yorker. Hays, J.N. ( 1998 ). The Burdens of Disease : Epidemics and Human Response in Western History. p. 274. ISBN 978 - 0 - 8135 - 2528 - 0. He, Dai Hai ; Dushoff, Jonathan ; Day, Troy ; Ma, Junling ; Earn, David J.D. ( 2011 ). `` Mechanistic modelling of the three waves of the 1918 influenza pandemic ''. Theoretical Ecology. 4 ( 2 ) : 283 -- 288. doi : 10.1007 / s12080 - 011 - 0123 - 3. ISSN 1874 - 1738. He, Dai Hai ; Dushoff, Jonathan ; Day, Troy ; Ma, Junling ; Earn, David J.D. ( 2013 ). `` Inferring the causes of the three waves of the 1918 influenza pandemic in England and Wales ''. Proceedings of the Royal Society of London B : Biological Sciences. 280 ( 1766 ) : 20131345. doi : 10.1098 / rspb. 2013.1345. ISSN 0962 - 8452. PMC 3730600. PMID 23843396. Honigsbaum, Mark ( 2008 ). Living with Enza : The Forgotten Story of Britain and the Great Flu Pandemic of 1918. Palgrave Macmillan. ISBN 978 - 0 - 230 - 21774 - 4. Humphries, Mark Osborne ( 2014 ). `` Paths of Infection : The First World War and the Origins of the 1918 Influenza Pandemic '' ( PDF ). War in History. 21 ( 1 ) : 55 -- 81. doi : 10.1177 / 0968344513504525. Johnson, Niall P. ; Mueller, J. ( 2002 ). `` Updating the accounts : global mortality of the 1918 -- 1920 `` Spanish '' influenza pandemic ``. Bull Hist Med. 76 ( 1 ) : 105 -- 115. doi : 10.1353 / bhm. 2002.0022. PMID 11875246. Knobler, S. ; Mack, A. ; Mahmoud, A. ; et al. ( eds. ). `` 1 : The Story of Influenza ''. The Threat of Pandemic Influenza : Are We Ready ? Workshop Summary ( 2005 ). Washington, D.C. : The National Academies Press. pp. 60 -- 61. Kobasa, Darwyn ; Jones, Steven M. ; Shinya, Kyoko ; Kash, John C. ; Copps, John ; Ebihara, Hideki ; Hatta, Yasuko ; Kim, Jin Hyun ; Halfmann, Peter ; Hatta, Masato ; Feldmann, Friederike ; Alimonti, Judie B. ; Fernando, Lisa ; Li, Yan ; Katze, Michael G. ; Feldmann, Heinz ; Kawaoka, Yoshihiro ( 2007 ). `` Aberrant innate immune response in lethal infection of macaques with the 1918 influenza virus ''. Nature. 445 ( 7125 ) : 319 -- 323. Bibcode : 2007Natur. 445... 319K. doi : 10.1038 / nature05495. PMID 17230189. Kohn, George C. ( 2007 ). Encyclopedia of plague and pestilence : from ancient times to the present ( 3rd ed. ). Infobase Publishing. p. 363. ISBN 978 - 0 - 8160 - 6935 - 4. Madhav, Nita ( 21 February 2013 ). Markey, Molly J., ed. `` Modeling a Modern - Day Spanish Flu Pandemic ''. AIR 's Research and Modeling Group. Retrieved 5 August 2014. Morrisey, Carla R. ( 1986 ). `` The Influenza Epidemic of 1918 ''. Navy Medicine. 77 ( 3 ) : 11 -- 17. Noymer, Andrew ; Carreon, Daisy ; Johnson, Niall ( 2010 ). `` Questioning the salicylates and influenza pandemic mortality hypothesis in 1918 -- 1919 ''. Clinical Infectious Diseases. 50 ( 8 ) : 1203. doi : 10.1086 / 651472. PMID 20233050. Pankhurst, Richard ( 1991 ). An Introduction to the Medical History of Ethiopia. Trenton : Red Sea Press. ISBN 978 - 0 - 932415 - 45 - 5. Patterson, K.D. ; Pyle, G.F. ( 1991 ). `` The geography and mortality of the 1918 influenza pandemic ''. Bull Hist Med. 65 ( 1 ) : 4 -- 21. PMID 2021692. Phillips, Howard ( 2010 ). `` The re-appearing shadow of 1918 : trends in the historiography of the 1918 -- 19 influenza pandemic ''. Can Bull Med Hist. 21 ( 1 ) : 121 -- 134. PMID 15202430. Porras - Gallo, Maria ; Davis, Ryan A., eds. ( 2014 ). `` The Spanish Influenza Pandemic of 1918 -- 1919 : Perspectives from the Iberian Peninsula and the Americas ''. Rochester Studies in Medical History. 30. University of Rochester Press. ISBN 978 - 1 - 58046 - 496 - 3. Potter, C.W. ( October 2006 ). `` A History of Influenza ''. J Appl Microbiol. 91 ( 4 ) : 572 -- 579. doi : 10.1046 / j. 1365 - 2672.2001. 01492. x. PMID 11576290. Price - Smith, Andrew T. ( 2008 ). Contagion and Chaos. Cambridge, MA : MIT Press. ISBN 978 - 0 - 262 - 66203 - 1. Rice, Geoffrey W. ( 2005 ). Black November ; the 1918 Influenza Pandemic in New Zealand ( 2nd ed. ). University of Canterbury Press. ISBN 978 - 1 - 877257 - 35 - 3. Simonsen, L. ; Clarke, M. ; Schonberger, L. ; Arden, N. ; Cox, N. ; Fukuda, K. ( 1998 ). `` Pandemic versus Epidemic Influenza Mortality : A Pattern of Changing Age Distribution ''. The Journal of Infectious Diseases. 178 ( 1 ) : 53 -- 60. doi : 10.1086 / 515616. JSTOR 30114117. PMID 9652423. Starko, Karen M. ( 2009 ). `` Salicylates and Pandemic Influenza Mortality, 1918 -- 1919, Pharmacology, Pathology, and Historic Evidence ''. Clinical Infectious Diseases. 49 ( 9 ) : 1405 -- 1410. doi : 10.1086 / 606060. PMID 19788357. ( summary by Infectious Diseases Society of America and ScienceDaily, October 3, 2009 ) Starko, Karen M. ( 2010 ). `` Reply to Noymer et al ''. Clinical Infectious Diseases. 50 ( 8 ) : 1203 -- 1204. doi : 10.1086 / 651473. Taubenberger, J. ; Reid, A. ; Janczewski, T. ; Fanning, T. ( 2001 ). `` Integrating historical, clinical and molecular genetic data in order to explain the origin and virulence of the 1918 Spanish influenza virus ''. Philos Trans R Soc Lond B Biol Sci. 356 ( 1416 ) : 1829 -- 1839. doi : 10.1098 / rstb. 2001.1020. PMC 1088558. PMID 11779381. Taubenberger, J. ; Reid, A. ; Lourens, R.M. ; Wang, R. ; Jin, G. ; Fanning, T.G. ( 2005 ). `` Characterization of the 1918 influenza virus polymerase genes ''. Nature. 437 ( 7060 ) : 889 -- 893. Bibcode : 2005Natur. 437... 889T. doi : 10.1038 / nature04230. PMID 16208372. Taubenberger, Jeffery K. ; Morens, David M. ( 2006 ). `` 1918 Influenza : the mother of all pandemics ''. Emerging Infectious Diseases. Centers for Disease Control and Prevention. 12 ( 1 ) : 15 -- 22. doi : 10.3201 / eid1201. 050979. PMC 3291398. PMID 16494711. Archived from the original on 1 October 2009. Retrieved 28 September 2009. Valentine, Vikki ( 20 February 2006 ). `` Origins of the 1918 Pandemic : The Case for France ''. NPR. Retrieved 2 October 2011. Vana, G. ; Westover, K.M. ( 2008 ). `` Origin of the 1918 Spanish influenza virus : a comparative genomic analysis ''. Molecular Phylogenetics and Evolution. 47 ( 3 ) : 1100 -- 1110. doi : 10.1016 / j. ympev. 2008.02. 003. PMID 18353690. Vilensky, J.A. ; Foley, P. ; Gilman, S. ( 2007 ). `` Children and encephalitis lethargica : a historical ''. Pediatr Neurol. 37 ( 2 ) : 79 -- 84. doi : 10.1016 / j. pediatrneurol. 2007.04. 012. PMID 17675021. Further reading Beiner, Guy ( 2006 ). `` Out in the Cold and Back : New - Found Interest in the Great Flu ''. Cultural and Social History. 3 ( 4 ) : 496 -- 505. Duncan, Kirsty ( 2003 ). Hunting the 1918 flu : one scientist 's search for a killer virus ( illustrated ed. ). University of Toronto Press. ISBN 978 - 0 - 8020 - 8748 - 5. Humphries, Mark Osborne. The Last Plague : Spanish Influenza and the Politics of Public Health in Canada ( University of Toronto Press ; 29013 ) examines the public - policy impact of the 1918 epidemic, which killed 50,000 Canadians. Johnson, Niall ( 2006 ). Britain and the 1918 -- 19 Influenza Pandemic : A Dark Epilogue. London and New York : Routledge. ISBN 0 - 415 - 36560 - 0. Johnson, Niall ( 2003 ). `` Measuring a pandemic : Mortality, demography and geography ''. Popolazione e Storia : 31 -- 52. Johnson, Niall ( 2003 ). `` Scottish ' flu -- The Scottish mortality experience of the `` Spanish flu ''. Scottish Historical Review. 83 ( 2 ) : 216 -- 226. doi : 10.3366 / shr. 2004.83. 2.216. Kolata, Gina ( 1999 ). Flu : The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It. New York : Farrar, Straus and Giroux. ISBN 0 - 374 - 15706 - 5. Little, Jean ( 2007 ). If I Die Before I Wake : The Flu Epidemic Diary of Fiona Macgregor, Toronto, Ontario, 1918. Dear Canada. Markham, Ont. : Scholastic Canada. ISBN 978 - 0 - 439 - 98837 - 7. Noymer, Andrew ; Michel Garenne ( 2000 ). `` The 1918 Influenza Epidemic 's Effects on Sex Differentials in Mortality in the United States ''. Population and Development Review. 26 ( 3 ) : 565 -- 581. doi : 10.1111 / j. 1728 - 4457.2000. 00565. x. PMC 2740912. PMID 19530360. Oxford JS, Sefton A, Jackson R, Innes W, Daniels RS, Johnson NP ( 2002 ). `` World War I may have allowed the emergence of `` Spanish '' influenza ``. The Lancet Infectious Diseases. 2 ( 2 ) : 111 -- 4. doi : 10.1016 / S1473 - 3099 ( 02 ) 00185 - 8. PMID 11901642. Oxford JS, Sefton A, Jackson R, Johnson NP, Daniels RS ( 1999 ). `` Who 's that lady ? ''. Nat. Med. 5 ( 12 ) : 1351 -- 2. doi : 10.1038 / 70913. PMID 10581070. Pettit, Dorothy ; Janice Bailie ( 2008 ). A Cruel Wind : Pandemic Flu in America, 1918 -- 1920. Murfreesboro, TN : Timberlane Books. ISBN 978 - 0 - 9715428 - 2 - 2. Phillips, Howard ; Killingray, David, eds. ( 2003 ). The Spanish Flu Pandemic of 1918 : New Perspectives. London and New York : Routledge. Rice, Geoffrey W. ; Edwina Palmer ( 1993 ). `` Pandemic Influenza in Japan, 1918 -- 1919 : Mortality Patterns and Official Responses ''. Journal of Japanese Studies. 19 ( 2 ) : 389 -- 420. doi : 10.2307 / 132645. JSTOR 132645. Tumpey TM, García - Sastre A, Mikulasova A, et al. ( 2002 ). `` Existing antivirals are effective against influenza viruses with genes from the 1918 pandemic virus ''. Proc. Natl. Acad. Sci. U.S.A. 99 ( 21 ) : 13849 -- 54. Bibcode : 2002PNAS... 9913849T. doi : 10.1073 / pnas. 212519699. PMC 129786. PMID 12368467. External links Wikimedia Commons has media related to Spanish flu. We Heard the Bells : The Influenza of 1918 on YouTube Nature `` Web Focus '' on 1918 flu, including new research Influenza Pandemic on stanford.edu The Great Pandemic : The U.S. in 1918 -- 1919. US Dept. of HHS The American Influenza Epidemic of 1918 -- 1919 : A Digital Encyclopedia Largest digital collection of newspapers, archival manuscripts and interpretive essays exploring the impact of the epidemic on 50 U.S. cities ( Univ. of Michigan ). Little evidence for New York City quarantine in 1918 pandemic. 27 Nov 2007 ( CIDRAP News ) Flu by Eileen A. Lynch. The devastating effect of the Spanish flu in the city of Philadelphia, PA, USA Dialog : An Interview with Dr. Jeffery Taubenberger on Reconstructing the Spanish Flu The Deadly Virus -- The Influenza Epidemic of 1918 US National Archives and Records Administration -- pictures and records of the time The 1918 Influenza Pandemic in New Zealand -- includes recorded recollections of people who lived through it Influenza 1918 `` American Experience '' PBS. An Avian Connection as a Catalyst to the 1918 -- 1919 Influenza Pandemic Fluwiki.com Annotated links to articles, books and scientific research on the 1918 influenza pandemic Alaska Science Forum -- Permafrost Preserves Clues to Deadly 1918 Flu Pathology of Influenza in France, 1920 Report Yesterday 's News blog 1918 newspaper account on impact of flu on Minneapolis `` Study uncovers a lethal secret of 1918 influenza virus '' University of Wisconsin -- Madison, 17 January 2007 Spanish Influenza in North America, 1918 -- 1919 1918 Influenza Virus and memory B - cells -- Exposure to virus generates lifelong immune response. Influenza Research Database -- Database of influenza genomic sequences and related information. Spanish Flu with rare pictures from Otis Historical Archives `` No Ordinary Flu '' a comic book of the 1918 flu pandemic published by Seattle & King County Public Health `` Closing in on a Killer : Scientists Unlock Clues to the Spanish Influenza Virus '' An online exhibit from the National Museum of Health and Medicine. Sources for the study of the 1918 influenza pandemic in Sheffield, UK Produced by Sheffield City Council 's Libraries and Archives Booknotes interview with Gina Kolata on Flu : The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It, 27 February 2000. Influenza General topics Research Vaccine Treatment Genome sequencing Reassortment Superinfection Flu season Viruses Orthomyxoviridae Influenza A Influenza B Influenza C Influenza A virus subtypes H1N1 H1N2 H2N2 H2N3 H3N1 H3N2 H3N8 H5N1 H5N2 H5N3 H5N6 H5N8 H5N9 H6N1 H7N1 H7N2 H7N3 H7N4 H7N7 H7N9 H9N2 H10N7 H1N1 Pandemics 1918 ( `` Spanish flu '' ) 2009 ( `` swine flu '' ) Science 2009 A / H1N1 H5N1 Outbreaks Croatia ( 2005 ) India ( 2006 ) UK ( 2007 ) West Bengal ( 2008 ) Science Genetic structure Transmission and infection Global spread Vaccine clinical trials Human mortality Social impact Pandemic preparation Treatments Antiviral drugs Adamantane derivatives Amantadine Rimantadine Neuraminidase inhibitor Oseltamivir Laninamivir Peramivir Zanamivir Peramivir ( experimental ) Umifenovir Vaccines Live attenuated influenza vaccine Fluzone Pandemrix Pandemics and epidemics Pandemics `` Russian flu '' ( 1889 -- 1890 ) `` Spanish flu '' ( 1918 ) `` Asian flu '' `` Hong Kong flu '' ( 1968 ) `` Swine flu '' ( 2009 ) Epidemics `` Russian flu '' ( 1977 -- 1978 ) `` Fujian flu '' ( H3N2 ) Central Luzon H5N6 ( 2017 ) Non-human Mammals Canine Feline Equine 2007 Australian outbreak Swine Non-mammals Avian Fujian ( H5N1 ) Complications Acute bronchitis Bronchiolitis Croup Otitis media Pharyngitis Pneumonia Sinusitis Strep throat Related topics Influenza - like illness 2017 -- 18 United States flu season GND : 4278432 - 3 SUDOC : 035290692 BNF : cb131794532 ( data ) Retrieved from `` https://en.wikipedia.org/w/index.php?title=1918_flu_pandemic&oldid=831546475 '' Categories : 1918 flu pandemic Global health Hidden categories : CS1 French - language sources ( fr ) Webarchive template wayback links CS1 Portuguese - language sources ( pt ) Wikipedia indefinitely semi-protected pages Use dmy dates from January 2013 Good articles All articles with unsourced statements Articles with unsourced statements from February 2018 Wikipedia articles with GND identifiers Wikipedia articles with BNF identifiers Talk View source Contents About Wikipedia Alemannisch Asturianu Azərbaycanca Беларуская Беларуская ( тарашкевіца ) ‎ Български Bosanski Català Čeština Cymraeg Dansk Deutsch Eesti Ελληνικά Español Esperanto Euskara فارسی Français Frysk Gaeilge Galego ગુજરાતી 한국어 Հայերեն Hrvatski Bahasa Indonesia Íslenska Italiano עברית Latina Latviešu Lietuvių Lingála Magyar Bahasa Melayu မြန်မာဘာသာ Nederlands 日本 語 Norsk Norsk nynorsk ਪੰਜਾਬੀ Polski Português Română Русский Simple English Slovenščina Српски / srpski Srpskohrvatski / српскохрватски Suomi Svenska தமிழ் ไทย Tsetsêhestâhese Türkçe Українська Tiếng Việt 粵語 中文 52 more Edit links This page was last edited on 21 March 2018, at 03 : 56. 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Question: where did the influenza epidemic first occur in 1918
Answer: Haskell County, Kansas