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Public health interventions and epidemic intensity during the 1918 influenza pandemic

( mitigation | nonpharmaceutical interventions | closures )

Richard J. Hatchett *{dagger}, Carter E. Mecher {ddagger}{sect}, and Marc Lipsitch ¶

*Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892; {ddagger}Department of Veterans Affairs, VA Southeast Network, 3700 Crestwood Parkway, Duluth, GA 30096; {sect}Homeland Security Council, Executive Office of the President, EEOB, 1650 Pennsylvania Avenue NW, Washington, DC 20502; and Department of Epidemiology and Department of Immunology and Infectious Diseases, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115


Edited by Burton H. Singer, Princeton University, Princeton, NJ, and approved February 14, 2007 (received for review December 9, 2006)

Nonpharmaceutical interventions (NPIs) intended to reduce infectious contacts between persons form an integral part of plans to mitigate the impact of the next influenza pandemic. Although the potential benefits of NPIs are supported by mathematical models, the historical evidence for the impact of such interventions in past pandemics has not been systematically examined. We obtained data on the timing of 19 classes of NPI in 17 U.S. cities during the 1918 pandemic and tested the hypothesis that early implementation of multiple interventions was associated with reduced disease transmission. Consistent with this hypothesis, cities in which multiple interventions were implemented at an early phase of the epidemic had peak death rates {approx}50% lower than those that did not and had less-steep epidemic curves. Cities in which multiple interventions were implemented at an early phase of the epidemic also showed a trend toward lower cumulative excess mortality, but the difference was smaller ({approx}20%) and less statistically significant than that for peak death rates. This finding was not unexpected, given that few cities maintained NPIs longer than 6 weeks in 1918. Early implementation of certain interventions, including closure of schools, churches, and theaters, was associated with lower peak death rates, but no single intervention showed an association with improved aggregate outcomes for the 1918 phase of the pandemic. These findings support the hypothesis that rapid implementation of multiple NPIs can significantly reduce influenza transmission, but that viral spread will be renewed upon relaxation of such measures.

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