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[[Image:Spanish flu death chart.png|thumb|200px|Chart of deaths in major cities]]
[[Image:Spanish flu death chart.png|thumb|200px|Chart of deaths in major cities]]
The '''1918 flu pandemic''', commonly referred to as the ''Spanish flu'', was a [[Pandemic Severity Index|category 5]] [[influenza pandemic]] between [[1918]] and [[1920]] caused by an unusually severe and deadly [[Influenza A virus]] [[Strain (biology)|strain]] of subtype [[H1N1]]. By far the most destructive pandemic in history, it killed some 50 million to 100 million people worldwide in just 18 months, <ref>[http://www.nap.edu/books/0309095042/html/7.html NAP]</ref><ref> [http://www.influenzareport.com/ir/overview.htm Influenza Report]</ref> dwarfing the bloodshed due to [[World War I]] (1914-1918). Many of its victims were healthy young adults, in contrast to most influenza outbreaks which predominantly affect juvenile, elderly, or otherwise weakened patients.
The '''1918 flu pandemic''', commonly referred to as the ''Spanish flu'', was a [[Pandemic Severity Index|category 5]] [[influenza pandemic]] between [[1918]] and [[1920]] caused by an unusually severe and deadly [[Influenza A virus]] [[Strain (biology)|strain]] of subtype [[H1N1]]. By far the most destructive pandemic in history, it killed some 50 million to 100 million people worldwide in just 18 months, <ref>[http://www.nap.edu/books/0309095042/html/7.html NAP]</ref><ref> [http://www.influenzareport.com/ir/overview.htm Influenza Report]</ref> dwarfing the bloodshed due to [[World War I]] (1914-1918). Many of its victims were healthy young adults, in contrast to most influenza outbreaks which predominantly affect juvenile, elderly, or otherwise weakened patients.

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The disease was first observed at [[Fort Riley]], [[Kansas]], [[United States|U.S.]] on [[March 11]], 1918. One researcher argues that the disease was found in [[Haskell County, Kansas]] as early as [[January]] of 1918.<ref>[http://www.translational-medicine.com/content/2/1/3 The site of origin of the 1918 influenza pandemic and its public health implications]</ref> The [[Allies of World War I]] came to call it the '''Spanish Flu''', primarily because the pandemic received greater press attention in Spain than in the rest of the world, as [[Spain]] was not involved in the war and had not imposed wartime [[censorship]].
The disease was first observed at [[Fort Riley]], [[Kansas]], [[United States|U.S.]] on [[March 11]], 1918. One researcher argues that the disease was found in [[Haskell County, Kansas]] as early as [[January]] of 1918.<ref>[http://www.translational-medicine.com/content/2/1/3 The site of origin of the 1918 influenza pandemic and its public health implications]</ref> The [[Allies of World War I]] came to call it the '''Spanish Flu''', primarily because the pandemic received greater press attention in Spain than in the rest of the world, as [[Spain]] was not involved in the war and had not imposed wartime [[censorship]].

Revision as of 00:53, 28 April 2007

Chart of deaths in major cities

The 1918 flu pandemic, commonly referred to as the Spanish flu, was a category 5 influenza pandemic between 1918 and 1920 caused by an unusually severe and deadly Influenza A virus strain of subtype H1N1. By far the most destructive pandemic in history, it killed some 50 million to 100 million people worldwide in just 18 months, [1][2] dwarfing the bloodshed due to World War I (1914-1918). Many of its victims were healthy young adults, in contrast to most influenza outbreaks which predominantly affect juvenile, elderly, or otherwise weakened patients.

The disease was first observed at Fort Riley, Kansas, U.S. on March 11, 1918. One researcher argues that the disease was found in Haskell County, Kansas as early as January of 1918.[3] The Allies of World War I came to call it the Spanish Flu, primarily because the pandemic received greater press attention in Spain than in the rest of the world, as Spain was not involved in the war and had not imposed wartime censorship.

Scientists have used tissue samples from frozen victims to reproduce the virus for study.[4] Given the strain's extreme virulence and the possibility of accidental escape (or deliberate release) from quarantine, 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.

History

The global mortality rate from the 1918/1919 pandemic is not known, but is estimated at 2.5 – 5% of the human population, with 20% 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. Some estimates put the total killed at over twice that number, possibly even 100 million.

An estimated 17 million died in India, about 5% of India's population at the time. In the Indian Army, almost 22% of troops who caught the disease died of it. In the U.S., about 28% of the population suffered, and 500,000 to 675,000 died. In Britain 200,000 died; in France more than 400,000. Entire villages perished in Alaska and southern Africa. In Australia an estimated 10,000 people died and in the Fiji Islands, 14% of the population died during only two weeks, and in Western Samoa 22%.

While World War I did not cause the flu, the close quarters and mass movement of troops quickened its spread. Researchers speculate that the soldiers' immune systems were weakened by the stresses of combat and chemical attacks, increasing their susceptibility to the disease.

A large factor in the spread of the disease was the increased amount of travel. The modernization of transportation made it easier for sailors to spread the disease more quickly and to a wider range of communities.

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 old, and the immune-compromised. Another oddity was that this influenza outbreak struck hardest in summer and fall (in the Northern Hemisphere). Typically, influenza is worse in the winter months.

People without symptoms could be struck suddenly and within hours be too feeble 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.

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 psychiatric disorders in a minority of cases. Some deaths resulted from malnourishment and even animal attacks in overwhelmed communities.

Devastated communities

Street car conductor in Seattle not allowing passengers aboard without a mask in 1918.

While in most places less than one-third of the population was infected and a fraction of that died, in a number of towns in several countries entire populations were wiped out.

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.

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 Brazil. In the Pacific, American Samoa[5] and the French colony of New Caledonia [6] also succeeded in preventing even a single death from influenza through effective quarantines.

Influenza A virus subtype H1N1
Transmission electron micrograph of influenza A viruses
An electron micrograph of the virus that caused the 1918 flu.
Virus classification Edit this classification
(unranked): Virus
Realm: Riboviria
Kingdom: Orthornavirae
Phylum: Negarnaviricota
Class: Insthoviricetes
Order: Articulavirales
Family: Orthomyxoviridae
Genus: Alphainfluenzavirus
Species:
Influenza A virus
Serotype:
Influenza A virus subtype H1N1
Sampled strains

Spanish flu research concerns studies regarding the causes and characteristics of the Spanish flu, a variety of influenza that in 1918 was responsible for the worst influenza pandemic in modern history. Many theories about the origins and progress of the Spanish flu persisted in the literature, but it was not until 2005, when various samples of lung tissue were recovered from American World War I soldiers and from an Inupiat woman buried in permafrost in a mass grave in Brevig Mission, Alaska, that significant genetic research was made possible.

Origin of virus

There are two prevailing theories usually postulated.[citation needed] One theory by Alfred W. Crosby 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. Though initial data from a recent reconstruction of the virus suggested that it jumped directly from birds to humans, without traveling through swine,[a] this has since been cast into doubt. One researcher published in 2004 argued that the disease was found in Haskell County, Kansas, as early as January 1918.[8] A similar and even more deadly virus had been seen earlier at British camps in France and at Aldershot.[9]

Earlier investigative work published in 2000 by a team led by British virologist, John Oxford[10] of St Bartholomew's Hospital and the Royal London Hospital, suggested that a principal British troop staging camp in Étaples, France, was at the center of the 1918 flu pandemic or at least a significant precursor virus to it. There had been a mysterious respiratory infection at the military base during the winter of 1915–1916.[11]

Discovery of viral genomes

Dr. Jeffery Taubenberger and Ann Reid reviewing a genetic sequence from the 1918 Spanish flu virus.
Centers for Disease Control and Prevention as Dr. Terrence Tumpey examines a reconstructed version of the 1918 flu.

In 1995, Jeffery Taubenberger of the US Armed Forces Institute of Pathology (AFIP), wondered if it might be possible to recover the virus of 1918 flu pandemic from the dried and fixed tissue of victims. He and his colleagues, tested 10 slides of tissue sample and 2 came out positive. Taubenberger, Ann H. Reid and Thomas G. Fanning were able to amplify short segments of the viral nucleic acid using polymerase chain reaction (PCR).[12] The results were published in the journal Science in March 1997.[13]

On August 20, 1997, Johan Hultin recovered samples of the 1918 influenza from the frozen corpse of a Native Alaskan woman buried for nearly eight decades in permafrost near Brevig Mission, Alaska.[14] He brought the samples to a team in Rockville, Maryland led by Jeffery Taubenberger of the US Armed Forces Institute of Pathology (AFIP). Brevig Mission lost approximately 85% of its population to the 1918 flu in November 1918. One of the four recovered samples contained viable genetic material of the virus. This sample provided scientists a first-hand opportunity to study the virus, which was inactivated with guanidinium thiocyanate before transport. This sample and others found in AFIP archives allowed researchers to completely analyze the critical gene structures of the 1918 virus.

"We have now identified three cases: The Brevig Mission case and two archival cases that represent the only known sources of genetic material of the 1918 influenza virus," said Taubenberger, chief of AFIP's molecular pathology division and principal investigator on the project.[15][b]

The archived autopsy samples had been taken from WWI Army privates Roscoe Vaughan and James Downs.[17]

Wikinews has related news:

The 6 February 2004 edition of Science magazine reported that two research teams, one led by Sir John Skehel, director of the National Institute for Medical Research in London, another by professor Ian Wilson of The Scripps Research Institute in San Diego, had managed to synthesize the hemagglutinin protein responsible for the flu outbreak of 1918. They did this by piecing together DNA from a lung sample from an Inuit woman buried in the Alaskan tundra and a number of preserved samples from American soldiers of the First World War. The teams had analyzed the structure of the gene and discovered how subtle alterations to the shape of a protein molecule had allowed it to move from birds to humans with such devastating effects.

In 2005 the virus' polymerase genes were sequenced, thus completing the entire genome of the virus.[18][19] This enabled researchers at the Centers for Disease Control and Prevention (CDC) and the Mount Sinai School of Medicine, led by Dr Terrence Tumpey to synthesize RNA segments from the H1N1 virus and ultimately reconstruct infective virus particles.[19] These were subsequently used to experimentally infect mice, ferrets, and macaques giving valuable insights into influenza virus biology and pathogenesis, providing important information about how to prevent and control future pandemics.[20]

Characteristics of virus

Influenza viruses have a relatively high mutation rate that is characteristic of RNA viruses. The H5N1 virus has mutated into a variety of types with differing pathogenic profiles; some pathogenic to one species but not others, some pathogenic to multiple species.[21] The ability of various influenza strains to show species-selectivity is largely due to variation in the hemagglutinin genes. Genetic mutations in the hemagglutinin gene that cause single amino acid substitutions can significantly alter the ability of viral hemagglutinin proteins to bind to receptors on the surface of host cells. Such mutations in avian H5N1 viruses can change virus strains from being inefficient at infecting human cells to being as efficient in causing human infections as more common human influenza virus types.[22]

In July 2004, researchers led by H. Deng of the Harbin Veterinary Research Institute, Harbin, China, and Robert Webster of the St. Jude Children's Research Hospital, Memphis, Tennessee, reported results of experiments in which mice had been exposed to 21 isolates of confirmed H5N1 strains obtained from ducks in China between 1999 and 2002. They found "a clear temporal pattern of progressively increasing pathogenicity."[23] Results reported by Webster in July 2005 reveal further progression toward pathogenicity in mice and longer virus shedding by ducks.

In December 2008, research by Yoshihiro Kawaoka of University of Wisconsin showed the presence of the three specific genes (termed PA, PB1, and PB2) and a nucleoprotein derived from the H1N1 1918 flu samples was enough to trigger similar symptoms in animal testing.[24]

Research of viral pathogenesis

Recent research of Taubenberger et al. has suggested that the 1918 virus, like H5N1, could have arisen directly from an avian influenza virus.[25] However, researchers at University of Virginia and Australian National University have suggested that there may be an alternative interpretation of the data used in the Taubenberger et al. paper.[26][27] Taubenberger et al. responded to these letters and defended their original interpretation.[28]

Other research by Tumpey and colleagues who reconstructed the H1N1 virus of 1918 came to the conclusion that it was most notably the polymerase genes and the HA and NA genes that caused the extreme virulence of this virus.[29] On 18 January 2007, Kobasa et al. reported that infected monkeys (Macaca fascicularis) exhibited classic symptoms of the 1918 pandemic and died from a cytokine storm.[30]

The sequences of the polymerase proteins (PA, PB1, and PB2) of the 1918 virus and subsequent human viruses differ by only 10 amino acids from the avian influenza viruses. Viruses with 7 of the 10 amino acids in the human influenza locations have already been identified in currently circulating H5N1. This has led some researchers to suggest that other mutations may surface and make the H5N1 virus capable of human-to-human transmission.

Another important factor is the change of the HA protein to a binding preference for alpha-2,6 sialic acid (the major form found in the human respiratory tract). In avian virus the HA protein preferentially binds to alpha-2,3 sialic acid, which is the major form in the avian enteric tract. It has been shown that only a single amino acid change can result in the change of this binding preference. Altogether, only a handful of mutations may need to take place in order for H5N1 avian flu to become a pandemic virus like the one of 1918. However it is important to note that likelihood of mutation does not indicate the likelihood for the evolution of such a strain, since some of the necessary mutations may be constrained by stabilizing selection.

Blood plasma as an effective treatment

See also: passive immunity

In the event of another pandemic, US military researchers have proposed reusing a treatment from the deadly pandemic of 1918 in order to blunt the effects of the flu: Some military doctors injected severely afflicted patients with blood or blood plasma from people who had recovered from the flu. Data collected during that time indicates that the blood-injection treatment reduced mortality rates by as much as 50 percent.[31]

Navy researchers have launched a test to see if the 1918 treatment will work against deadly Asian bird flu. Results thus far have been inconclusive[31] Human H5N1 plasma may be an effective, timely, and widely available treatment for the next flu pandemic.[citation needed] A new international study using modern data collection methods, would be a difficult, slow process. Citing the months-long wait for a vaccine for the next pandemic, many flu experts are of the opinion that the 1918 method is something to consider.[31]

In the worldwide 1918 flu pandemic, "physicians tried everything they knew, everything they had ever heard of, from the ancient art of bleeding patients, to administering oxygen, to developing new vaccines and sera (chiefly against what we now call Hemophilus influenzae – a name derived from the fact that it was originally considered the etiological agent – and several types of pneumococci). Only one therapeutic measure showed any hint of success: Transfusing blood from recovered patients to new victims."[32]

See also

Footnotes

  1. ^ 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)[7]
  2. ^ Johan Hultin first attempted to recover samples from Brevig in 1951, but was unsuccessful. In 1997, by then a seventy-two-year-old retired pathologist, Hultin decided that science had advanced enough to make another attempt worthwhile. Taubenberger had already recovered RNA of limited quality from samples of two servicemen who had died in the pandemic, and Hultin wrote offering his services to try to get better quality samples from Brevig permafrost. Taubenberger accepted, and Hultin went alone to Brevig in August 1997, and recovered the sample from the Alaskan woman, which Taubenberger and his team then analysed.[16]

References

  1. ^ NAP
  2. ^ Influenza Report
  3. ^ The site of origin of the 1918 influenza pandemic and its public health implications
  4. ^ [1]
  5. ^ Influenza of 1918 (Spanish Flu) and the US Navy
  6. ^ World Health Organization Writing Group (2006). "Nonpharmaceutical interventions for pandemic influenza, international measures". Centers for Disease Control and Prevention (CDC) Emerging Infectious Diseases (EID) Journal. 12 (1): 189.
  7. ^ Harder TC, Werner O (2006). "Chapter Two: Avian Influenza" (free on-line book). Influenza Report (Report). a medical textbook that provides a comprehensive overview of epidemic and pandemic influenza.
  8. ^ Barry JM (January 2004). "The site of origin of the 1918 influenza pandemic and its public health implications". Journal of Translational Medicine. 2 (1): 3. doi:10.1186/1479-5876-2-3. PMC 340389. PMID 14733617.
  9. ^ Valentine V (20 February 2006). "Origins of the 1918 pandemic: The case for France". NPR. National Public Radio (NPR). 5222069.
  10. ^ "Dr. John Oxford". EU Research Profile. Archived from the original on 26 December 2008.
  11. ^ Connor S (8 January 2000). "Flu epidemic traced to Great War transit camp". The Independent. UK. Archived from the original on 8 August 2009. Retrieved 26 March 2020. An investigation into the global epidemic of influenza in 1918, which killed an estimated 40 million people, has shown it almost certainly started in an army camp in France in the middle of the First World War.
  12. ^ "Resurrecting 1918 Flu Virus Took Many Turns". The Washington Post. 2005-10-10. ISSN 0190-8286. Retrieved 2020-07-25.
  13. ^ Taubenberger JK, Reid AH, Krafft AE, Bijwaard KE, Fanning TG (March 1997). "Initial genetic characterization of the 1918 "Spanish" influenza virus". Science. 275 (5307): 1793–1796. doi:10.1126/science.275.5307.1793. PMID 9065404. S2CID 8976173.
  14. ^ Brown D (10 October 2005). "Resurrecting 1918 flu virus took many turns". Washington Post.
  15. ^ "Lethal secrets of 1918 flu virus". BBC News.
  16. ^ Kolata G (1999). Flu: The story of the great influenza pandemic of 1918 and the search for the virus that caused it. Farrar, Straus, and Giroux. pp. 255–265. ISBN 978-0-374-15706-7.
  17. ^ "Closing in on a killer: Scientists unlock clues to the Spanish influenza virus". National Museum of Health and Medicine. Archived from the original on 2 May 2020. Retrieved 23 March 2020.
  18. ^ Taubenberger JK, Reid AH, Lourens RM, Wang R, Jin G, Fanning TG (October 2005). "Characterization of the 1918 influenza virus polymerase genes". Nature. 437 (7060): 889–893. Bibcode:2005Natur.437..889T. doi:10.1038/nature04230. PMID 16208372.
  19. ^ a b Jordan D, Tumpey T, Jester B. "The Deadliest Flu: The Complete Story of the Discovery and Reconstruction of the 1918 Pandemic Virus". archive.cdc.gov. Retrieved 2024-06-22.
  20. ^ Taubenberger JK, Baltimore D, Doherty PC, Markel H, Morens DM, Webster RG, Wilson IA (November 2012). "Reconstruction of the 1918 influenza virus: unexpected rewards from the past". mBio. 3 (5). doi:10.1128/mBio.00201-12. PMC 3448162. PMID 22967978.
  21. ^ Kou Z, Lei FM, Yu J, Fan ZJ, Yin ZH, Jia CX, Xiong KJ, Sun YH, Zhang XW, Wu XM, Gao XB, Li TX (December 2005). "New genotype of avian influenza H5N1 viruses isolated from tree sparrows in China". Journal of Virology. 79 (24): 15460–15466. doi:10.1128/JVI.79.24.15460-15466.2005. PMC 1316012. PMID 16306617.
  22. ^ Gambaryan A, Tuzikov A, Pazynina G, Bovin N, Balish A, Klimov A (January 2006). "Evolution of the receptor binding phenotype of influenza A (H5) viruses". Virology. 344 (2): 432–438. doi:10.1016/j.virol.2005.08.035. PMID 16226289.
  23. ^ Chen H, Deng G, Li Z, Tian G, Li Y, Jiao P, Zhang L, Liu Z, Webster RG, Yu K (July 2004). "The evolution of H5N1 influenza viruses in ducks in southern China". Proceedings of the National Academy of Sciences of the United States of America. 101 (28): 10452–10457. Bibcode:2004PNAS..10110452C. doi:10.1073/pnas.0403212101. PMC 478602. PMID 15235128.
  24. ^ "Researchers unlock secrets of 1918 flu pandemic". Reuters. 29 December 2008.
  25. ^ Taubenberger JK, Reid AH, Lourens RM, Wang R, Jin G, Fanning TG (October 2005). "Characterization of the 1918 influenza virus polymerase genes". Nature. 437 (7060): 889–893. Bibcode:2005Natur.437..889T. doi:10.1038/nature04230. PMID 16208372. S2CID 4405787.
  26. ^ Gibbs MJ, Gibbs AJ (April 2006). "Molecular virology: was the 1918 pandemic caused by a bird flu?". Nature. 440 (7088): E8, discussion E9-E8, discussion 10. Bibcode:2006Natur.440E...8G. doi:10.1038/nature04823. PMID 16641948. S2CID 4422599.
  27. ^ Antonovics J, Hood ME, Baker CH (April 2006). "Molecular virology: was the 1918 flu avian in origin?". Nature. 440 (7088): E9, discussion E9-E9, discussion 10. Bibcode:2006Natur.440E...9A. doi:10.1038/nature04824. PMID 16641950. S2CID 4382489.
  28. ^ Taubenberger JK, Reid AH, Lourens RM, Wang R, Jin G, Fanning TG (April 2006). "Molecular virology: Was the 1918 pandemic caused by a bird flu? Was the 1918 flu avian in origin? (Reply)". Nature. 440 (7088): E9–E10. Bibcode:2006Natur.440E...9T. doi:10.1038/nature04825. S2CID 4308033.
  29. ^ Tumpey TM, Basler CF, Aguilar PV, Zeng H, Solórzano A, Swayne DE, Cox NJ, Katz JM, Taubenberger JK, Palese P, García-Sastre A (October 2005). "Characterization of the reconstructed 1918 Spanish influenza pandemic virus". Science. 310 (5745): 77–80. Bibcode:2005Sci...310...77T. CiteSeerX 10.1.1.418.9059. doi:10.1126/science.1119392. PMID 16210530. S2CID 14773861.
  30. ^ Kobasa D, Jones SM, Shinya K, Kash JC, Copps J, Ebihara H, Hatta Y, Kim JH, Halfmann P, Hatta M, Feldmann F, Alimonti JB, Fernando L, Li Y, Katze MG, Feldmann H, Kawaoka Y (January 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. S2CID 4431644.
  31. ^ a b c Knox R (29 August 2006). "Experts: Use 1918 Methods to Fight Pandemic". National Public Radio (NPR). 5731688.
  32. ^ Barry JM (2005). "1918 Revisited: Lessons and Suggestions for Further Inquiry". In Knobler SL, Mack A, Mahmoud A, Lemon SM (eds.). The threat of pandemic influenza: are we ready?: workshop summary. Washington, DC: National Academies Press. p. 62. ISBN 978-0-309-54685-0.

Further reading


Further reading

Influenza (flu)
H1N1 virus
Types
Vaccines
Treatment
Pandemics
Outbreaks
See also
  • Niall Johnson (2006) Britain and the 1918-19 Influenza Pandemic: A Dark Epilogue. Routledge, London and New York. ISBN 0-415-36560-0
  • Terrence M. Tumpey, Adolfo García-Sastre, Andrea Mikulasova, Jeffery K. Taubenberger, David E. Swayne, Peter Palese, and Christopher F. Basler (2002) "Existing antivirals are effective against influenza viruses with genes from the 1918 pandemic virus". Proceedings of the National Academy of Sciences 99, 13849–13854.
  • Alfred W. Crosby (1990). America's Forgotten Pandemic: The Influenza of 1918. Cambridge University Press. ISBN 0-521-38695-0.
  • John M. Barry (2004). The Great Influenza: The Epic Story of the Greatest Plague in History. Viking Penguin. ISBN 0-670-89473-7.
  • Andrew Noymer and 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.
  • Geoffrey W. Rice and Edwina Palmer (1993). "Pandemic Influenza in Japan, 1918–19: Mortality Patterns and Official Responses". Journal of Japanese Studies, 19(2):389–420.
  • Geoffrey W. Rice, Black November: the 1918 Influenza Pandemic in New Zealand , Canterbury University Press, 2005 ISBN 1-877257-35-4
  • Jean Little, Dear Canada: If I Die Before I Wake: The Flu Epidemic Diary of Fiona Macgregor, Toronto, Ontario, 1918, Scholastic Canada, 2007
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