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Population Health for Nurses

13.1 Pandemics Throughout History

Population Health for Nurses13.1 Pandemics Throughout History

Learning Outcomes

By the end of this section, you should be able to:

  • 13.1.1 Differentiate between pandemics, endemics, and epidemics.
  • 13.1.2 Compare the major pandemics afflicting humanity over the past two centuries.
  • 13.1.3 Discuss how the 1918 pandemic changed history.

Recall from Epidemiology for Informing Population/Community Health Decisions that endemic disease occurs when an infection or disease becomes common in a population or area. Examples include the annual flu strains, influenza A and B. An epidemic is a notable increase in infection that surpasses the criteria for an endemic level within a defined population or area. These terms can also refer to a new infectious agent that emerges or reemerges. A pandemic is an epidemic that spreads worldwide (Centers for Disease Control and Prevention [CDC], 2012). Pandemics have been recorded throughout history. One of the earliest occurred during the Peloponnesian War in 430 BCE as a disease, most likely typhoid fever, passed through Libya, Ethiopia, and Egypt and into Athens, killing as much as two-thirds of the population. The pandemic weakened the Athenians, contributing to their defeat by the Spartans (Onion et al., 2021). Throughout time, pandemics have shaped the course of history and society. The COVID-19 pandemic is the most recent example. This section discusses major pandemics throughout history, beginning with the bubonic plague and then focusing on the 20th- and 21st-century infectious pandemics that have shaped public health and policy.

The Plague

The plague, also called the bubonic plague and the Black Death, has caused a few distinct pandemics. The first recorded outbreak of plague, the Plague of Justinian (541–542), claimed the lives of half of Europe’s population (Piret & Boivin, 2020). Beginning in Egypt, it spread throughout the Roman Empire, killing an estimated 100 million people as it rapidly moved along trade and military routes. After this initial outbreak, the plague returned intermittently (Piret & Boivin, 2020).

Likely originating in East Asia, the Black Death pandemic spread through Central Asia and Europe via trade routes. In 1347, 12 ships from the Black Sea docked at a Sicilian port, with most of the sailors dead or ill, covered in boils oozing blood and pus. The authorities ordered the removal from port of these “death ships,” but it was too late. By this time in Europe, the Black Death had claimed an estimated 200 million lives (Frith, 2012; Piret & Boivin, 2020). In 1347, as the pandemic ravaged Europe, Africa, and Asia, officials in Ragusa, Italy, slowed its spread by isolating arriving boats and sailors for an initial 30, and later 40 days, or quaranta, the origin of quarantine (Frith, 2012; Hajar, 2012). By the 1350s, the plague had dissipated but continued to reappear intermittently.

  • Successive waves of the plague from 1630 to 1722 affected France, Italy, the Netherlands, and England.
  • Throughout the 1800s, outbreaks continued in Asia.
  • In 1865, an outbreak began in Southern China and spread south and west. In 1893, the plague reached colonial India, where public health measures slowed its spread. Approximately 12 million people died during this pandemic (Frith, 2012; Piret & Boivin, 2020).

The plague is spread by a flea-borne bacteria, Yersinia pestis, that is associated with rodents. Fleas ingest an infected rodent’s blood and then transmit the bacteria to new rodent hosts. The plague has three presentations: bubonic, septicemic, and pneumonic. The most common bubonic form begins with flu-like symptoms followed by extreme lymph node swelling and oozing (plague-boils). Untreated, bubonic plague is often fatal. The plague can also present with a blood infection or progress from bubonic to a blood infection, classified as septicemia, with a high fatality rate if untreated. The extremely contagious, rapidly fatal pneumonic plague occurs when infection spreads to the lungs and is spread via droplet contact from person to person. The cause of the plague was unknown until 1897 when, during the plague pandemic in India, it was discovered to be caused by a bacterium (Frith, 2012).

Over the 19th and 20th centuries, sanitation and public health practices alleviated the plague’s high mortality rate and economic devastation, but they did not eradicate it completely. According to the CDC, most U.S. human plague cases occur in northern New Mexico, northern Arizona, southern Colorado, southern Oregon, and western Nevada. More than 80 percent of cases of plague are bubonic (CDC, 2022aa). From 2015 to 2020, 36 cases were documented in the United States, with six recorded deaths. Plague epidemics continue globally today; most cases since 1990 have been in Africa among individuals living in small towns, villages, or agricultural areas (CDC, 2022aa). Many public health measures used during the COVID-19 pandemic, such as medical inspections, isolation of sick individuals, ship restrictions and quarantines, or the control of the movement of individuals and materials, originated during the Black Death (Frith, 2012; Piret & Boivin, 2020).

Influenza Pandemic of 1918

The avian vector-borne influenza pandemic of 1918, also called the Spanish Flu, was one of the most severe pandemics in recent history. Caused by the influenza A H1N1 virus, it spread globally in 1918–1919, coinciding with World War I (WWI) (CDC, 2019a). The overcrowding and global troop movements associated with WWI likely facilitated its global transmission. A main characteristic of this influenza virus was that it resulted in a high mortality in healthy people aged 20–40 (CDC, 2019a; Klein, 2020). Lack of a vaccine and treatment and the susceptibility of young, healthy adults created a public health crisis, resulting in almost 700,000 deaths in the United States and at least 50 million deaths globally (CDC, 2018a; CDC, 2019a). This flu lowered the average life expectancy in the United States by more than 12 years (Klein, 2020).

1918 Flu Pandemic

This video describes this pandemic and how it changed history. As you watch this video, keep in mind it was produced before the COVID-19 pandemic.

Watch the video, and then respond to the following questions.

  1. How was the 1918 flu pandemic similar to the COVID-19 pandemic?
  2. Do you feel public health preparedness has evolved enough over the past 100 years? Explain your reasoning.
  3. How well do you feel the CDC was prepared for the COVID-19 pandemic?

The response to the 1918 flu pandemic was fragmented. No pharmacologic treatments or vaccines existed, and the United States lacked a government agency dedicated to disease control and prevention. In the fall of 1918, the number of professional nurses deployed to military camps throughout the United States and abroad to aid in the war effort resulted in a significant nursing shortage, further exacerbated by the failure to use trained Black nurses (CDC, 2018a). The American Red Cross issued urgent requests for volunteers to assist in nursing the sick. In Philadelphia, where the pandemic hit hard, hundreds of corpses awaited burial in cold-storage plants that served as temporary morgues (CDC, 2018a). Many cities closed theaters, movie houses, and night schools and prohibited public gatherings. By the end of 1918, public health officials began educating the public about the danger of coughing, sneezing, and carelessly disposing of nasal discharge (CDC, 2018a). The American Public Health Association encouraged businesses to stagger their hours to prevent public transportation overcrowding (CDC, 2018a). Cities like San Francisco implemented mask mandates, physical distancing, isolation, quarantine, disinfection, and hygiene measures. The implementation of these measures and reporting of actual disease numbers were inconsistent (CDC, 2018a; CDC, 2019a). Although the military created field hospitals dedicated to soldiers infected with influenza to isolate them from healthy soldiers, more soldiers died from the flu than in combat (Figure 13.2) (National Archives and Records Administration, n.d.; CDC, 2019a). Finally, by the summer of 1919, the flu faded as immunity developed (CDC, 2019a).

A nurse stands outside on a porch with a cloth covering over her nose and mouth. Behind her is a row of metal cots separated from one another with a hanging sheet.
Figure 13.2 During the 1918 flu pandemic, some clients were isolated in outdoor sick wards. (credit: “Influenza ward, Walter Reed Hospital, Wash., D.C. [Nurse taking patient’s pulse]” by Harris & Ewing/Library of Congress, No Known Restrictions)

Pandemic Viruses of 1957, 1968, and 2009

In 1957, 1968, and 2009 , new strains of the flu virus to which people lacked immunity caused flu pandemics (CDC, 2019a; Jordan et al., 2019; see Table 13.1). Following the 1918 pandemic, public health policies and practices continued to improve with each subsequent pandemic due to surveillance and education, sanitation, and isolation strategies (Matta et al., 2020).

Name Virus Most at Risk Estimated Deaths Public Health Significance
Pandemic of 1957
Asian Flu
Duration: 1957–1959
Avian influenza A
Those with underlying heart or lung disease
  • 1 to 2 million global deaths
  • 116,000 in the United States
  • Disease surveillance measures rapidly recognized H2N2 as a new influenza virus
  • Rapid vaccine development saved many lives
Pandemic of 1968
Hong Kong Flu
Duration: 1968–1972
Avian influenza A
Individuals > age 65 experience more severe illness, death
  • 1 million global deaths
  • 100,000 in the United States
  • Vaccine was developed in 1970
  • Virus continues to circulate as seasonal influenza A virus
Pandemic of 2009
Swine Flu
Duration: 1968–1970
Influenza A similar to 1918 strain but with new genes
Children, young- to middle-age adults (< 65)
  • 151,700–575,400 global deaths
  • 12,469 in the United States
  • Older adults had some immunity due to previous H1N1 infection
  • This pandemic had less global impact
  • Virus still circulates seasonally in the United States and has caused illness, hospitalization, and death
Table 13.1 Comparison of the Flu Pandemics of 1957, 1968, and 2009 (See CDC, 2019a, 2019b, 2019c, 2019d, 2019e; Jester et al., 2020; Jordan et al., 2019; Little, 2020; Piret & Boivin, 2020.)

HIV Pandemic

In June 1981, the CDC went on alert when five healthy young men in California developed Pneumocystis carinii pneumonia (PCP), a rare and often deadly disease. Health officials next recognized an unusual increase in Kaposi’s sarcoma (KS) cases among gay men in New York. Outbreaks of these rare diseases were alarming, especially since they occured within the same population (CDC, 2021a). The media and health care professionals used the term gay-related immune deficiency (GRID) to describe the new virus, resulting in severe stigmatization of the gay community (Ayala & Spieldenner, 2021). In late 1981, cases appeared in heterosexual intravenous (IV) drug users and, shortly thereafter, in individuals with hemophilia. In response, the CDC issued guidelines on the care of individuals with HIV, including wearing gloves when exposed to blood and other specific bodily fluids (CDC, 2021a). At the start of the pandemic, the median survival time for a person with AIDS was one to two years (Eisinger & Fauci, 2018). The identification in 1983 of a retrovirus that causes HIV led to the first HIV test in 1985 (Beyrer, 2021).

While the pandemic officially began in 1981, the infection is believed to have developed in the late 1800s from a chimpanzee virus in Central Africa that spread slowly, reaching the United States in the mid-to-late 1970s (CDC, 2022a). At that time, sporadic cases in the United States were not known to be caused by HIV (CDC, 2022a). In the 21st century, AIDS has become one of the largest public health challenges, killing more than 39 million people worldwide, including 500,000 in the United States (CDC, 2021a). Today, an estimated 1.2 million people in the United States (CDC, 2023a) and an estimated 39 million people globally, the majority in sub-Saharan Africa, live with HIV or AIDS (UNAIDS, n.d.). The United Nations (2022) reports that the “AIDS pandemic continues to be responsible for more than 13,000 deaths each week” (paragraph 1). Although the number of new HIV infections in the Sub-Saharan Africa has declined, and despite better treatment options and decreased U.S. mortality rates, HIV and AIDS is still a global pandemic (Eisinger & Fauci, 2018). HIV infections continue to expand in parts of eastern Europe, central Asia, the Middle East, and North Africa (Beyrer, 2021). While HIV can be managed with antiretroviral drug therapy, no current vaccine or cure for AIDS exists (CDC, 2021a).

HIV Survivors Reflect on the AIDS Epidemic

This ABC News video discusses the beginning of the AIDS epidemic, when this new disease created fear within the health care workforce and among many Americans. The video shows how fear and stigma around the illness prevailed for years.

Watch the video, and then respond to the following questions.

  1. What parallels do you see between the AIDS epidemic and the COVID-19 pandemic?
  2. After listening to the survivor’s stories, what inequities in care can you identify that these individuals face?
  3. Do you feel these inequities still exist today? Why or why not?

COVID-19 Pandemic

In December 2019, a cluster of individuals in Wuhan, China, began experiencing symptoms of an atypical pneumonia-like illness that was unresponsive to standard treatments. In January 2020, the WHO announced that these outbreaks were caused by the 2019 Novel Coronavirus, or 2019-nCoV (CDC, 2022e). The organization officially named the disease COVID-19 and declared the outbreak a pandemic in March 2020, after it had affected over 100 countries and caused over 4,000 deaths. By August 2020, COVID-19 had become the third leading cause of death in the United States. More than 1,000 people died each day, with the number of confirmed cases surpassing 5.4 million. In a 10-month period, the reported mortality from COVID-19 exceeded 1 million globally (Figure 13.3) (CDC, 2022e).

Developing a vaccine to prevent COVID-19 became a global imperative. Approximately one year after the initial outbreak, in December 2020, the U.S. Food and Drug Administration (FDA) issued an Emergency Use Authorization for two different COVID-19 vaccines for people age 16 years and older.

Like other pandemics throughout history, COVID-19 helped shape the public health system and the government response to public health threats. Pandemic responses have led to advances like sanitation, isolation, quarantine, and vaccine development and have taught public health workers lessons about the importance of early response and mitigation efforts to decrease morbidity and mortality. The HIV and AIDS pandemic shaped domestic public health policy by challenging the stigmatization of groups of individuals, protecting human rights, and ensuring scientific evidence guides the actions of public health with the dissemination of correct information on modes of transmission, prevention, and potential treatments (Somse & Eba, 2020).

A line graph shows the number of deaths per million people from Covid-19 from March 2020 through September 2023. There are separate lines for each of the following countries: United States, Canada, France, Germany, India, United Kingdom. The largest peaks on the graph are in March 2020 and February 2021, with The United Kingdom showing approximately 20 deaths per million people during these times. A smaller peak occurs in March 2022, with the United States showing around 8 deaths per million people. Cases for all countries dip to near zero in June 2022, then rise back to 1-2 deaths per million until approaching zero again in October 2023.
Figure 13.3 This chart presents COVID-19 deaths per million people from March 2020 through April 2023. (data source: World Health Organization, COVID-19 Dashboard; credit: “Daily new confirmed COVID-19 deaths per million people” by Our World in Data, CC BY 4.0 International)

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