Spanish flu

The 1918 flu pandemic (commonly referred to as the Spanish flu) was an influenza pandemic that spread to nearly every part of the world. It was caused by an unusually severe and deadly Influenza A virus strain of subtype H1N1. Historical and epidemiologic data are inadequate to identify the geographic origin of the virus. [ [http://www.cdc.gov/ncidod/EID/vol12no01/05-0979.htm 1918 Influenza Pandemic | CDC EID] ] Many of its victims were healthy young adults, in contrast to most influenza outbreaks which predominantly affect juvenile, elderly, or otherwise weakened patients.The Spanish flu lasted from March 1918 to June 1920, spreading even to the Arctic and remote Pacific islands. It is estimated that over 50 million people were killed worldwide, [ [http://www.ncbi.nlm.nih.gov/pubmed/11875246?dopt=Abstract www.ncbi.nlm.nih.gov. NCBI. PubMed. Johnson NP, Mueller J. "Updating the accounts: global mortality of the 1918-1920 "Spanish" influenza pandemic." (2002)] ] even more than the number killed in World War I. [cite book
last = Hakim
first = Joy
authorlink =
coauthors =
title = War, Peace, and all that Jazz
publisher = Oxford University Press
date = 1995
location = New York
pages = 21–24
url =
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isbn = ] This extraordinary death toll resulted from the extremely high illness rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms.

The disease was first observed at Fort Riley, Kansas, United States, on March 4, 1918, [ [http://www.avian-bird-flu.info/spanishfluepidemic1918.html Avian Bird Flu. "1918 Flu (Spanish flu epidemic)"] ] and Queens, New York, on March 11, 1918. In August 1918, a more virulent strain appeared simultaneously in Brest, France, in Freetown, Sierra Leone, and in the U.S. at Boston, Massachusetts. 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. [ [http://www.channel4.com/news/articles/world/spanish%20flu%20facts/111285 Channel 4 - News - Spanish flu facts] ] [See: unverifiable|date=November 2007 ]

Scientists have used tissue samples from frozen victims to reproduce the virus for study. Given the strain's extreme virulence there has been controversy regarding the wisdom of such research. Among the conclusions of this research is that the virus kills via a cytokine storm, which explains its unusually severe nature and the unusual age profile of its victims (the virus caused an overreaction of the body's immune system—the strong immune systems of young adults ravaged the body, while the weaker immune systems of children and middle-aged adults caused fewer deaths).

Mortality

The global mortality rate from the 1918/1919 pandemic is not known, but is estimated at 2.5 to 5% of the human population, with 20% or more of the world population suffering from the disease to some extent. Influenza may have killed as many as 25 million in its first 25 weeks (in contrast, AIDS killed 25 million in its first 25 years)Fact|date=October 2008. Older estimates say it killed 40–50 million peoplecite journal | last =Patterson | first = KD | coauthors = Pyle GF | title=The geography and mortality of the 1918 influenza pandemic | journal= Bull Hist Med. | year=1991 | month=Spring | volume=65 | issue=1 | pages = 4–21 | pmid = 2021692] while current estimates say 50 million to 100 million people worldwide were killed.cite book | editor=Knobler S, Mack A, Mahmoud A, Lemon S | title = The Threat of Pandemic Influenza: Are We Ready? Workshop Summary (2005) | chapter=1: The Story of Influenza | pages = 60–61 | chapterurl=http://darwin.nap.edu/books/0309095042/html/60.html | publisher=The National Academies Press | location=Washington, D.C.] This pandemic has been described as "the greatest medical holocaust in history" and may have killed more people than the Black Death.cite journal | last =Potter | first = CW| title=A History of Influenza | url= http://www.blackwell-synergy.com/doi/full/10.1046/j.1365-2672.2001.01492.x | journal= J Appl Microbiol. | year=2006 | month=Oct | volume=91 | issue= 4 | pages = 572–579 | pmid = 11576290 | doi =10.1046/j.1365-2672.2001.01492.x ]

An estimated 7 million died in India, about 2.78% of India's population at the time. In the Indian Army, almost 22% of troops who caught the disease died of it Fact|date=December 2007. In the U.S., about 28% of the population suffered, and 500,000 to 675,000 died. In Britain as many as 250,000 died; in France more than 400,000. In Canada approximately 50,000 died. Entire villages perished in Alaska and southern Africa. Ras Tafari (the future Haile Selassie) was one of the first Ethiopians who contracted influenza but survived, [Harold Marcus, "Haile Sellassie I: The formative years, 1892-1936" (Trenton: Red Sea Press, 1996), pp. 36f; Richard Pankhurst, "An Introduction to the Medical History of Ethiopia" (Trenton: Red Sea Press, 1990), pp. 48f] although many of his subjects did not; estimates for the fatalities in the capital city, Addis Ababa, range from 5,000 to 10,000, with some experts opining that the number was even higher, [Pankhurst, "Medical History", p. 63] while in British Somaliland one official on the ground estimated that 7% of the native population died from influenza. [Pankhurst, "Medical History", pp. 51f] In Australia an estimated 12,000 people died and in the Fiji Islands, 14% of the population died during only two weeks, and in Western Samoa 22%.

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. Indeed, 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 secondary infection caused by influenza, but the virus also killed people directly, causing massive hemorrhages and edema in the lung.cite journal | last = Taubenberger | first = J | coauthors = Reid A, Janczewski T, Fanning T | title = Integrating historical, clinical and molecular genetic data in order to explain the origin and virulence of the 1918 Spanish influenza virus | journal = Philos Trans R Soc Lond B Biol Sci | volume = 356 | issue = 1416 | pages = 1829–39 | year = 2001 | month=Dec 29 | pmid = 11779381 | url= http://www.journals.royalsoc.ac.uk/(3sud2455cjw1ut55yowx1d45)/app/home/contribution.asp?referrer=parent&backto=issue,3,22;journal,61,225;linkingpublicationresults,1:102022,1 | doi = 10.1098/rstb.2001.1020]

The unusually severe disease killed between 2 and 20% of those infected, as opposed to the more usual flu epidemic mortality rate of 0.1%. Another unusual feature of this pandemic was that it mostly killed young adults, with 99% of pandemic influenza deaths occurring in people under 65, and more than half in young adults 20 to 40 years old. [cite journal | last = Simonsen | first = L | coauthors = Clarke M, Schonberger L, Arden N, Cox N, Fukuda K | title = Pandemic versus epidemic influenza mortality: a pattern of changing age distribution | journal = J Infect Dis | volume = 178 | issue = 1 | pages = 53–60 | year = 1998 | month=Jul | pmid = 9652423] This is unusual since influenza is normally most deadly to the very young (under age 2) and the very old (over age 70), and may have been due to partial protection caused by exposure to a previous Russian flu pandemic of 1889. [O Hansen, 1923, "Undersøkelser om influenzaens opptræden specielt i Bergen 1918 - 1922" Skrifter utgit ved Klaus Hanssens Fond. Bergen: Medicinsk avdeling, Haukeland Sykehus, 1923: 3.]

History

While World War I did not cause the flu, the close troop quarters and massive troop movements hastened the pandemic. Researchers speculate that the soldiers' immune systems were weakened by the stresses of combat and chemical attacks, increasing their susceptibility to the disease.Fact|date=August 2008

A large factor of worldwide flu prevalence was increased travel. The modern transportation systems made it easier for soldiers, sailors, and travelers to spread the disease quickly and to communities worldwide.

Two poems, dedicated to the Spanish flu, were popular in those daysFact|date=August 2008:

"I had a little bird,
""Its name was Enza,
""I opened the window,
""And" in-flew-enza.
-American Skipping Rhyme circa 1918

"Obey the laws
""And wear the gauze.
""Protect your jaws
""From septic paws."

Patterns of fatality

The influenza strain was unusual in that this pandemic killed many young adults and otherwise healthy victims – typical influenzas kill mostly infants (aged 0-2 years), the elderly, and the immunocompromised. Another oddity was that this influenza outbreak was widespread in summer and fall (in the Northern Hemisphere). Typically, influenza is worse in the winter months.

People without symptoms could be stricken suddenly and within hours be too weak to walk; many died the next day. Symptoms included a blue tint to the face and coughing up blood caused by severe obstruction of the lungs. In some cases, the virus caused an uncontrollable hemorrhaging that filled the lungs, and patients drowned in their body fluids (pneumonia). In others, the flu caused frequent loss of bowel control and the victim would die from losing critical intestinal lining and blood loss.Fact|date=August 2008

In fast-progressing cases, mortality was primarily from pneumonia, by virus-induced consolidation. Slower-progressing cases featured secondary bacterial pneumonias, and there may have been neural involvement that led to mental disorders in a minority of cases. Some deaths resulted from malnourishment and even animal attacks in overwhelmed communities.Fact|date=August 2008

Devastated communities

While in most places less than one-third of the population was infected, only a small percentage of whom died, in a number of towns in several countries entire populations were wiped out.Fact|date=August 2008

Even in areas where mortality was low, those incapacitated by the illness were often so numerous as to bring much of everyday life to a stop. Some communities closed all stores or required customers not to enter the store but place their orders outside the store for filling. There were many reports of places with no health care workers to tend the sick because of their own ill health and no able-bodied grave diggers to bury the dead. Mass graves were dug by steam shovel and bodies buried without coffins in many places.Fact|date=August 2008

Unaffected locales

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. The only sizeable inhabited place with no documented outbreak of the flu in 1918–1919 was the island of Marajó at the mouth of the Amazon River in BrazilFact|date=September 2007

. In the Pacific, American Samoa [http://www.history.navy.mil/library/online/influenza_main.htm Influenza of 1918 (Spanish Flu) and the US Navy] ] and the French colony of New Caledoniacite journal
author=World Health Organization Writing Group | title=Nonpharmaceutical interventions for pandemic influenza, international measures | journal=Centers for Disease Control and Prevention (CDC) Emerging Infectious Diseases (EID) Journal | year=2006 | pages=189 | volume=12 | issue=1 |url=http://www.cdc.gov/ncidod/EID/vol12no01/05-1370.htm ] also succeeded in preventing even a single death from influenza through effective quarantines. In Australia, only 12,000 perished compared to higher rates in other countriesFact|date=August 2008.

Government Response

The Great Influenza was the source of much fear in citizens around the world. Further inflaming that fear was the fact that governments and health officials were downplaying the influenza. While the panic from WWI was dwindling, governments attempted to keep morale up by spreading lies and dismissing the influenza. On Sept. 11, 1918, Washington officials reported that the Spanish Influenza had arrived in the city. The following day, roughly thirteen million men across the country lined up to register for the war draft, providing the influenza with an efficient way to spread. However, the influenza had little impact upon institutions and organizations. While medical scientists did rapidly attempt to discover a cure or vaccine, there were virtually no changes in the government or corporations. Additionally, the political and military events were fairly unaffected due to the impartiality of the disease, affecting either side likewise. [Graham, Rod. "Author Brings "The Great Influenza" to the School.." John Hopkins Bloomberg School of Public Health. 4 Mar 2005. John Hopkins Bloomberg School of Public Health. 6 Jun 2008 http://www.jhsph.edu/publichealthnews/articles/2005/great_influenza.html]

Cultural Impact

In the United States, despite the relatively high morbidity and mortality rates that resulted from the epidemic in 1918-1919, the Spanish flu remained a relatively obscure event until the rise in public awareness of bird flu and other pandemics in the 1990s and 2000s. This has led some historians to label the Spanish flu a “forgotten pandemic.” [Crosby, Alfred. "America's Forgotten Pandemic". New York: Cambridge University Press, 2003.] Indeed, one of the only major works of American literature written after 1918 that deals directly with the Spanish flu is Katherine Anne Porter’s "Pale Horse, Pale Rider". More recently (2006), author Thomas Mullen wrote a novel called "The Last Town on Earth", about the impact of the Spanish flu on a fictional mill town in Washington and author Myra Goldberg wrote a novel called "Wickett's Remedy" that is set in Boston during the pandemic.

Several theories have been offered as to why the Spanish flu may have been “forgotten” by historians and the public over so many years, including the rapid pace of the pandemic (it killed most of its victims in the United States in a period of less than nine months), Americans' familiarity with pandemic disease in the late 19th and early 20th centuries, and the distraction of the First World War. [Crosby, "America's Forgotten Pandemic", pp. 320–322.] Another explanation is shown when observing the age group affected by the disease. The majority of fatalities, in both World War One and by the Spanish Flu, were young adults. The deaths caused by the flu were overlooked due to the deaths from the war. When people would read the obituaries they would see the deaths from war and the deaths from the influenza side by side. Seeing the figures right next to each other lessened the impact the influenza had on individual people. [Simonsen, L; Clarke M, Schonberger L, Arden N, Cox N, Fukuda K (Jul 1998). "Pandemic versus epidemic influenza mortality: a pattern of changing age distribution."] The fact that the disease would usually only affect a certain area for a month before leaving, left little time for the disease to have a significant impact on the economy. During this time period pandemic out breaks were not uncommon, the terror of typhoid, yellow fever, diphtheria, and cholera all occurred near the same time period. These outbreaks lessened the impact the Influenza pandemic had on Americans. [Morrisey, Carla R. "The Influenza Epidemic of 1918." Navy Medicine 77, no. 3 (May-June 1986): 11-17.]

Spanish flu research

One theory is that the virus strain originated at Fort Riley, Kansas, by two genetic mechanisms – genetic drift and antigenic shift – in viruses in poultry and swine which the fort bred for local consumption, but evidence from a recent reconstruction of the virus suggests that it jumped directly from birds to humans, without traveling through swine.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 [http://www.influenzareport.com/ir/ai.htm Chapter Two : Avian Influenza by Timm C. Harder and Ortrud Werner] , an excellent free on-line Book called "Influenza Report 2006" which is a medical textbook that provides a comprehensive overview of epidemic and pandemic influenza.)]

An effort to recreate the 1918 flu strain (a subtype of avian strain H1N1) was a collaboration among the Armed Forces Institute of Pathology, Southeast Poultry Research Laboratory and Mount Sinai School of Medicine in New York; the effort resulted in the announcement (on October 5, 2005) that the group had successfully determined the virus's genetic sequence, using historic tissue samples recovered from a female flu victim buried in the Alaskan permafrost and samples preserved from American soldiers. [ [http://www.cdc.gov/od/oc/media/pressrel/r051005.htm Center for Disease Control: Researchers Reconstruct 1918 Pandemic Influenza Virus; Effort Designed to Advance Preparedness] Retrieved on 2008-08-14]

On January 18, 2007, Kobasa et al. reported that monkeys (Macaca fascicularis) infected with the recreated strain exhibited classic symptoms of the 1918 pandemic and died from a cytokine storm [ cite journal | last = Kobasa | first = Darwyn | coauthors = "et al." | year = 2007 | month = | title = Aberrant innate immune response in lethal infection of macaques with the 1918 influenza virus | journal = Nature | volume = 445 | issue = | pages = 319–323 | doi = 10.1038/nature05495| quote = ] – 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. [ [http://www.usatoday.com/tech/science/discoveries/flu-research.htm?POE=NEWISVA USA Today: Research on monkeys finds resurrected 1918 flu killed by turning the body against itself] Retrieved on 2008-08-14]

On September 16, 2008, the body of Yorkshire landowner Sir Mark Sykes was exhumed to study the DNA of the Spanish 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 hope will have helped preserve the virus. [ [http://news.bbc.co.uk/1/hi/england/humber/7617968.stm BBC News: Body exhumed in fight against flu] Retrieved on 2008-09-16]

Victims

Notable Fatalities

* "Admiral Dot" (1864-1918), circus performer under P. T. Barnum [ [http://www.pbs.org/wgbh/amex/influenza/sfeature/victims.html PBS. Influenza 1918. "Victims"] ]
* Francisco de Paula Rodrigues Alves, Brazilian elected president, (†January 16, 1919)
* Guillaume Apollinaire, French poet († November 9, 1918)
* Felix Arndt, American pianist († October 16, 1918)
* Louis Botha, first Prime Minister of the Union of South Africa, († August 27, 1919) [cite book |title=Hunting the 1918 Flu: One Scientist's Search for a Killer Virus |last=Duncan |first=Kirsty |year=2003 |publisher=University of Toronto Press |isbn=0802087485 |pages=304 ]
* Randolph Bourne, American progressive writer and public intellectual, († December 22, 1918) [ [http://www.dmacdigest.com/flu1918.html dMAC Health Digest] ]
* Larry Chappell, American baseball player, († November 8, 1918)
* Angus Douglas, Scottish international footballer, († December 14, 1918)
* Harry Elionsky, American champion long-distance swimmer [cite book |title=Hunting the 1918 Flu: One Scientist's Search for a Killer Virus |last=Duncan |first=Kirsty |year=2003 |publisher=University of Toronto Press |isbn=0802087485 |pages=304 ]
* George Freeth, father of modern surfing and lifeguard († April 7, 1919)
* Sophie Halberstadt-Freud, daughter of Austrian psychoanalyst Sigmund Freud, († 1920)
* Irmy Cody Garlow, daughter of Buffalo Bill Cody [ [http://www.pbs.org/wgbh/amex/influenza/sfeature/victims.html PBS. Influenza 1918. "Victims"] ]
* Harold Gilman, British painter († February 12, 1919)
* Henry G. Ginaca, American engineer, inventor of the Ginaca machine († October 19, 1918)
* Myrtle Gonzalez, American film actress († October 22, 1918) [ [http://www.dmacdigest.com/flu1918.html dMAC Health Digest] ]
* Charles Tomlinson Griffes, American composer († April 8, 1920)
* Joe Hall, Montreal Canadiens defenceman, a member of the Hockey Hall of Fame († April 6, 1919)
* Phoebe Hearst, mother of William Randolph Hearst, († April 13, 1919)
* Hans E. Lau, Danish astronomer, (†October 16, 1918) [ [http://www.dmacdigest.com/flu1918.html dMAC Health Digest] ]
* Harold Lockwood, American silent film star, († October 19, 1918) [ [http://www.pbs.org/wgbh/amex/influenza/sfeature/victims.html PBS. Influenza 1918. "Victims"] ]
* Francisco Marto, "Fátima child" († April 4, 1919)
* Jacinta Marto, "Fátima child" († February 20, 1920)
* Alan Arnett McLeod, Victoria Cross winner, († 6 November, 1918)
* Sir Hubert Parry, British composer, († October 7, 1918)
* John Reed, American journalist, poet, and communist activist, († October 19 1920)
* William Leefe Robinson, Victoria Cross winner, († December 31, 1918)
* Edmond Rostand, French dramatist, best known for his play Cyrano de Bergerac, († December 2, 1918)
* Egon Schiele, Austrian painter († October 31, 1918). His wife Edith, who was six months pregnant, succumbed to the disease only three days before
* Reggie Schwarz, South African crickter and rugby player (†November 18, 1918) [ [http://www.dmacdigest.com/flu1918.html dMAC Health Digest] ]
* Yakov Sverdlov, Bolshevik party leader and official of pre-USSR Russia († March 16 1919)
* Mark Sykes, British politician and diplomat - body exhumed 2008 for research († February 16, 1919)
* Max Weber, German political economist and sociologist († June 14, 1920)
* Prince Erik, Duke of Västmanland ("Erik Gustav Ludvig Albert Bernadotte"), Prince of Sweden, Duke of Västmanland († September 20, 1918)
* Vera Kholodnaya, Russian actress († February 16, 1919)
* Dark Cloud (actor), aka Elijah Tahamont, American Indian actor, in Los Angeles (1918).
* Franz Karl Salvator (1893-1918), son of Archduchess Marie Valerie of Austria and Archduke Franz Salvator, grandson of Empress Elisabeth of Bavaria and Emperor Franz Joseph I of Austria, died unmarried and childless.
* Anaseini Takipō, Queen of Tonga from 1909, consort of King George Tupou II of Tonga, survived by one daughter, († November 26, 1918)
* King Watzke, American violinist and bandleader, († 1920) [ [http://www.dmacdigest.com/flu1918.html dMAC Health Digest] ]

Notable survivors

* Mary Pickford, (1892 – 1979), early motion picture star.Collier, Richard (1974). The Plague of the Spanish Lady - The Influenza Pandemic of 1918-19. USA: Atheneum. ISBN 0-8371-8376-6.]
* John J. Pershing, (1860 – 1948) American general.
* Franklin D. Roosevelt, (1882 – 1945), American president
* Woodrow Wilson, (1856 — 1924) American president.
* Prince Maximilian of Baden, (1867 – 1929), Chancellor of Germany during the armistice.
* Walt Disney, (1901 – 1966), cartoonist.
* Wilhelm II, German Emperor, (1859 - 1941)
* Joseph Joffre, (1852 - 1931), "Papa" Joffre, victor of the Marne.
* Alexandrine of Mecklenburg-Schwerin, (1879 – 1952), Queen of Denmark
* David Lloyd George (1863 – 1945) British prime minister.
* Peter Fraser (1884 - 1950), longest serving New Zealand prime minister.

Fictional

* Hazel Forrest Bellamy, a fictional character in the television series "Upstairs, Downstairs" (played by Meg Wynn Owen) († 1918)
* William Krichinsky, a fictional character in the film "Avalon", directed by Barry Levinson
* Fanny and Jemma Macgregor in If I Die Before I Wake by Jean Little
* Elizabeth Masen and Edward Masen Sr., fictional characters in the "Twilight" series by Stephenie Meyer. († 1918) Main character Edward Cullen was saved from a similar influenza death by being bitten by a vampire.

See also

* Pandemic
* List of epidemics

References

Further reading

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External links

* [http://www.scribemedia.org/2006/11/22/avian-flu/ Video from Expert Panel Discussion on Avian Flu]
* [http://www.nature.com/nature/focus/1918flu/index.html "Nature" "Web Focus" on 1918 flu, including new research]
* [http://www.stanford.edu/group/virus/uda/ Influenza Pandemic on stanford.edu]
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* [http://www.pbs.org/wgbh/amex/influenza/ Influenza 1918 in the United States on pbs.org]
* [http://www.pbs.org/wnet/secrets/case_killerflu/index.html Secrets of the Dead: Killer Flu (PBS)]
* [http://www.upenn.edu/gazette/1198/lynch.html Flu by Eileen A. Lynch. The devastating effect of the Spanish flu in the city of Philadelphia, PA, USA]
* [http://www.ninthday.com/tauben.htm Dialog: An Interview with Dr. Jeffery Taubenberger on Reconstructing the Spanish Flu]
* [http://www.archives.gov/exhibits/influenza-epidemic/ The Deadly Virus - The Influenza Epidemic of 1918] , by the National Archives and Records Administration (see actual pictures and records of the time).
* [http://www.nzhistory.net.nz/culture/1003 The 1918 Influenza Pandemic in New Zealand - includes recorded recollections of people who lived through it]
* [http://www.nytimes.com/2005/10/06/health/06flu.html?ex=1286251200&en=3f9a510cfd4c3d45&ei=5090 Experts Unlock Clues to Spread of 1918 Flu Virus] - "The New York Times"
* [http://www.pbs.org/wgbh/amex/influenza/sfeature/latest.html PBS - recovery of flu samples from Alaskan flu victims]
* [http://www.medsci.org/v02p0087.htm An Avian Connection as a Catalyst to the 1918-1919 Influenza Pandemic]
* [http://www.gi.alaska.edu/ScienceForum/ASF13/1386.html Alaska Science Forum - Permafrost Preserves Clues to Deadly 1918 Flu]
* [http://www.vlib.us/medical/mja.htm Pathology of Influenza in France, 1920 Report]
* [http://www.cosmosmagazine.com/node/694 "Deadly secret of 1918 flu virus unmasked"] , "Cosmos" magazine, September 2006
* [http://ww3.startribune.com/blogs/oldnews/archives/43 Yesterday's News blog] , 1918 newspaper account on impact of flu on Minneapolis
* [http://news.bbc.co.uk/1/hi/health/6271833.stm "Lethal secrets of 1918 flu virus"] BBC News, January 2007
* [http://www.news.wisc.edu/13360.html "Study uncovers a lethal secret of 1918 influenza virus"] University of Wisconsin - Madison, January 17, 2007
* [http://www.translational-medicine.com/content/2/1/3 "The site of origin of the 1918 influenza pandemic and its public health implications"] Journal of Translational Medicine, January 20, 2004
* [http://ocp.hul.harvard.edu/contagion/influenza.html Spanish Influenza in North America, 1918–1919]
* [http://www.scientistlive.com/lab/?/Opinion/2008/09/16/21042/Exposure_to_1918_influenza_virus_activates_memory_B-cells/ 1918 Influenza Virus and memory B-cells] - Exposure to virus generates life-long immune response.