The 1918 Flu Pandemic: Why It Matters 100 Years Later

Group photo of Red Cross nurses in Boston wearing personal protective equipment.

100 years ago, an influenza (flu) pandemic swept the globe, infecting an estimated one-third of the world’s population and killing at least 50 million people. The pandemic’s death tollAmerican soldiers returning home on the Agamemnon, Hoboken, New Jersey was greater than the total number of military and civilian deaths from World War I, which was happening simultaneously.  At the time, scientists had not yet discovered flu viruses, but we know today that the 1918 pandemic was caused by an influenza A (H1N1) virus. The pandemic is commonly believed to have occurred in three waves. Unusual flu-like activity was first identified in U.S. military personnel during the spring of 1918. Flu spread rapidly in military barracks where men shared close quarters. The second wave occurred during the fall of 1918 and was the most severe. A third wave of illness occurred during the winter and spring of 1919.

Here are 5 things you should know about the 1918 pandemic and why it matters 100 years later.

1. The 1918 Flu Virus Spread Quickly

500 million people were estimated to have been infected by the 1918 H1N1 flu virus. At least 50 million people were killed around the world including an estimated 675,000 Americans. In fact, the 1918 pandemic actually caused the average life expectancy in the United States to drop by about 12 years for both men and women.Flu patients in Iowa

In 1918, many people got very sick, very quickly. In March of that year, outbreaks of flu-like illness were first detected in the United States. More than 100 soldiers at Camp Funston in Fort Riley Kansas became ill with flu. Within a week, the number of flu cases quintupled. There were reports of some people dying within 24 hours or less. 1918 flu illness often progressed to organ failure and pneumonia, with pneumonia the cause of death for most of those who died.  Young adults were hit hard. The average age of those who died during the pandemic was 28 years old.

2. No Prevention and No Treatment for the 1918 Pandemic Virus

In 1918, as scientists had not yet discovered flu viruses, there were no laboratory tests to detect, or characterize these viruses. There were no vaccines to help prevent flu infection, noPolicemen patrol the streets in masks in Seattle to ensure public safety. antiviral drugs to treat flu illness, and no antibiotics to treat secondary bacterial infections that can be associated with flu infections. Available tools to control the spread of flu were largely limited to non-pharmaceutical interventions (NPI’s) such as isolation, quarantine, good personal hygiene, use of disinfectants, and limits on public gatherings, which were used in many cities. The science behind these was very young, and applied inconsistently. City residents were advised to avoid crowds, and instructed to pay particular attention to personal hygiene. In some cities, dance halls were closed. Some streetcar conductors were ordered to keep the windows of their cars open in all but rainy weather. Some municipalities moved court cases outside. Many physicians and nurses were instructed to wear gauze masks when with flu patients.

3. Illness Overburdened the Health Care System

An estimated 195,000 Americans died during October alone. In the fall of 1918, the United States experienced a severe shortage of professional nurses during the flu pandemic because large numbers of them were deployed to military camps in the United States and abroad.A black-and-white advertisement for the Chicago School of Nursing. This shortage was made worse by the failure to use trained African American nurses. The Chicago chapter of the American Red Cross issued an urgent call for volunteers to help nurse the ill. Philadelphia was hit hard by the pandemic with more than 500 corpses awaiting burial, some for more than a week. Many parts of the U.S. had been drained of physicians and nurses due to calls for military service, so there was a shortage of medical personnel to meet the civilian demand for health care during the 1918 flu pandemic. In Massachusetts, for example, Governor McCall asked every able-bodied person across the state with medical training to offer their aid in fighting the outbreak.

As the numbers of sick rose, the Red Cross put out desperate calls for trained nurses as well as untrained volunteers to help at emergency centers. In October of 1918, Congress approved a $1 million budget for the U. S. Public Health Service to recruit 1,000 medical doctors and more than 700 registered nurses.

At one point in Chicago, physicians were reporting a staggering number of new cases, reaching as high as 1,200 people each day. This in turn intensified the shortage of doctors and nurses.  Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

4. Major Advancements in Flu Prevention and Treatment since 1918

The science of influenza has come a long way in 100 years!A man dress in personal protective equipment in a laboratory. Developments since the 1918 pandemic include vaccines to help prevent flu, antiviral drugs to treat flu illness, antibiotics to treat secondary bacterial infections such as pneumonia, and a global influenza surveillance system with 114 World Health Organization member states that constantly monitors flu activity. There also is a much better understanding of non-pharmaceutical interventions–such as social distancing, respiratory and cough etiquette and hand hygiene–and how these measures help slow the spread of flu.

There is still much work to do to improve U.S. and global readiness for the next flu pandemic. More effective vaccines and antiviral drugs are needed in addition to better surveillance of influenza viruses in birds and pigs. CDC also is working to minimize the impact of future flu pandemics by supporting research that can enhance the use of community mitigation measures (i.e., temporarily closing schools, modifying, postponing, or canceling large public events, and creating physical distance between people in settings where they commonly come in contact with one another). These non-pharmaceutical interventions continue to be an integral component of efforts to control the spread of flu, and in the absence of flu vaccine, would be the first line of defense in a pandemic.

5. Risk of a Flu Pandemic is Ever-Present, but CDC is on the Frontlines Preparing to Protect Americans

Four pandemics have occurred in the past century: 1918, 1957, 1968, and 2009. The 1918 pandemic was the worst of them. But the threat of a future flu pandemic remains. A pandemic flu virus could emerge anywhere and spread globally.A crowd of people with the Washington Monument in the distance.

CDC works tirelessly to protect Americans and the global community from the threat of a future flu pandemic. CDC works with domestic and global public health and animal health partners to monitor human and animal influenza viruses. This helps CDC know what viruses are spreading, where they are spreading, and what kind of illnesses they are causing. CDC also develops and distributes tests and materials to support influenza testing at state, local, territorial, and international laboratories so they can detect and characterize influenza viruses.  In addition, CDC assists global and domestic experts in selecting candidate viruses to include in each year’s seasonal flu vaccine and guides prioritization of pandemic vaccine development. CDC routinely develops vaccine viruses used by manufacturers to make flu vaccines. CDC also supports state and local governments in preparing for the next flu pandemic, including planning and leading pandemic exercises across all levels of government. An effective response will diminish the potential for a repeat of the widespread devastation of the 1918 pandemic.

Visit CDC’s 1918 commemoration website for more information on the 1918 pandemic and CDC’s pandemic flu preparedness work.

Responding to Emerging and Zoonotic Infectious Disease Threats in 2017

Montage of photos. From left: a photo of different raw foods, including salmon, fruits and vegetables. A photo of a boy taking an oral vaccine. A photo of bacteria growing in petri dish.

Photo of Rima F. Khabbaz, MD, Director, National Center for Emerging and Zoonotic Infectious Diseases
Rima F. Khabbaz, MD, Director, National Center for Emerging and Zoonotic Infectious Diseases

The fungal superbug Candida auris causes serious and often fatal infections. It can strike people in the places where they seek care—hospitals and other healthcare facilities. In early 2016, we knew about outbreaks of C. auris infections on multiple continents, but we were not sure whether C. auris was in the United States. Fast forward to 2017: C. auris is a priority for public health workers in the United States, and CDC, along with state and local health departments, has tracked more than 200 cases of C. auris infection in the country. Our experts have worked with healthcare facilities across the nation to implement infection control measures and stop transmission.

The progress to track and prevent C. auris is just one example of the important work experts from CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) tackled in 2017. Some of the other highlights from the NCEZID 2017 Accomplishments report are described below.

A tremendous year for public health

Summarizing last year’s major efforts was a difficult task. The numbers alone depict a tremendous year for public health. Here are just a few examples.  CDC sequenced nearly 45,000 DNA samples by using Advanced Molecular Detection (AMD) technologies. The agency identified more than 1,100 illnesses that were associated with backyard flocks—the highest number ever recorded by CDC in a single year. And the Antibiotic Resistance Lab Network performed more than 12,000 tests to contain the spread of resistant infections, just to name a few accomplishments.

Tracking new and evolving threatsCDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) focuses on emerging diseases and diseases spread between animals and people. Our experts work around the clock to identify, track, control and prevent some of the deadliest diseases on the planet. This work includes tracking diseases across the globe and at home, developing innovations, investigating disease outbreaks in extreme conditions, and helping experts prepare for infectious disease threats.

Every day we are learning more about antibiotic resistance, which continues to be among the biggest health concerns in our country. In 2017, CDC took several important steps to combat antibiotic resistance, including rolling out a containment strategy to slow the spread of drug-resistant diseases in healthcare facilities—starting with a single case—and supporting 25 innovators through a CDC pilot project to develop solutions to antibiotic resistance crises.

Understanding the impact

We are also learning more about Zika virus. Zika was often in the headlines in 2016 and 2017, and the mosquito-borne virus continues to be a threat, especially for pregnant women and their fetuses. Last year, CDC experts shed light on a lesser-known effect of Zika virus infection: a link with Guillain-Barré syndrome (GBS), an uncommon illness of the nervous system. In 2017, CDC and partners conducted the first case-control study in the Americas that showed evidence linking Zika virus infection and GBS. This was just one of many vector-borne diseases CDC tackled in 2017.

Responding to new outbreaks

As we continued to work on lingering threats like antibiotic resistance and Zika, CDC also responded to new outbreaks in 2017, both at home and abroad. In the United States, we saw a range of illnesses connected to food products—from Salmonella infections linked to papayas to an Escherichia coli outbreak from soy nut butter. For the first time, scientists linked an outbreak of Seoul virus infections to pet rats in the United States, and AMD lab techniques proved critical in tracing this and other outbreaks. CDC scientists traveled across the globe in 2017 to investigate a myriad of outbreaks, including an outbreak of anthrax infections in animals in Namibia that posed a threat to human health. Experts helped respond to yellow fever outbreaks in countries including Brazil, and we continue that work today as the yellow fever outbreak in Brazil has expanded over the past two years and could affect US travelers.

Like CDC’s response to yellow fever outbreaks, much of last year’s work continues in 2018. We are closely tracking emerging infections like C. auris, continuing to study the effects of unusual diseases like Zika, and investigating and containing outbreaks of infections caused by a wide range of microbes such as Salmonella bacteria, monkeypox virus, and hemorrhagic fever viruses.

Want to learn more? Read the full NCEZID 2017 Accomplishments report, and follow NCEZID on Twitter @CDC_NCEZID.

Norovirus Illness is Messy – Clean Up Right Away

Hand in pink protective glove wiping tiles with rag in the bathroom.

When norovirus strikes in your own home, you can be prepared by having the supplies you need to immediately clean up after a loved one vomits or has diarrhea.

Norovirus is a tiny germ that spreads quickly and easily. It causes vomiting and diarrhea that come on suddenly. A very small amount of norovirus can make you sick. The number of virus particles that fit on the head of a pin is enough to infect over 1,000 people.

You can get norovirus if poop or vomit from an infected person gets into your mouth. You can get it by:

  • Caring for a person who is infected with norovirus and then touching your hands to your mouth
  • Eating food or drinking liquids that are contaminated with norovirus
  • Touching surfaces or objects with norovirus on them and then putting your hands in your mouth

Clean up the splatter!

Vomiting and diarrhea are messy, especially with norovirus. If you get sick from norovirus, drops of vomit or poop might splatter for many feet in all directions.

It’s extremely important to clean up the entire area immediately after you or someone else vomits or has diarrhea. You must be very thorough so you don’t miss any drops of vomit or poop that you can’t see.

If you find yourself in this situation, follow these steps from start to finish to protect other people from getting sick with norovirus:

Step 1 – Put on disposable plastic gloves and a face maskNorovirus spreads when a person gets poop or vomit from an infected person in their mouth.

Step 2 – Wipe up vomit and poop with paper towels and throw them away

Step 3 – Clean all surfaces thoroughly with a bleach cleaner, or make your own solution (¾ cup of bleach plus 1 gallon of water)

Step 4 – Clean all surfaces again with hot water and soap

Step 5 – Remove your gloves, throw them away, and take out the trash

Step 6 – Wash all laundry that may have vomit or poop on them with hot water and soap

Step 7 – Wash your hands with soap and water

Thorough clean up helps prevent norovirus outbreaks

Cleaning-up immediately after someone with norovirus vomits or has diarrhea protects others from getting sick, and prevents norovirus outbreaks. It’s important for everyone to know the clean-up steps and other ways to prevent norovirus.

CDC and state and local health departments help to raise awareness among healthcare providers and the general public about norovirus and how to prevent it. Learn more about how health departments, CDC, and other agencies work to prevent and stop norovirus outbreaks.

To learn more about norovirus, see CDC’s norovirus website and infographics, videos, and other resources, and state and local health department websites.

Battling Biting Mosquitoes and Jumping Genes in 2016

NCEZID microbiologist Jane Basile shows how to use the new yellow fever test kit that in less than 4 hours yields results that are as accurate as the older 2-day test.

Last year, an expert from the CDC National Center for Emerging and Zoonotic Diseases (NCEZID) found himself in an unlikely position: guest starring on a popular Navajo language radio program to field questions about hantavirus infection. Hantavirus is caused by contact with mouse droppings and can sometimes be fatal.

This is just one example of how NCEZID has worked over the past year to confront a wide range of infectious disease concerns. From antibiotic resistance to Zika, last year’s threats required rapid and innovative responses, and CDC experts stepped up to the plate. Below are just a few of highlights from 2016.

Fighting the bite

In 2016, the mosquito was a major culprit. Zika virus became the first known mosquito-borne virus that can cause major birth defects, and we continue to learn about Zika virus every day. The Zika virus outbreaks in the Americas and other parts of the globe required a massive response, which is hands-down a top accomplishment for 2016. The consequences of Zika can be devastating, and stopping the epidemic has been anything but simple. It has involved expertise from many fields, including mosquito control, pregnancy and birth defects, laboratory, epidemiology, blood safety, communication, and the list goes on. NCEZID led that effort and, by the end of the year, more than 2,000 CDC staff members had been part of the Zika response.

Confronting an imminent threat

Imagine a post-antibiotic world where bacteria no longer respond to the drugs designed to kill them. It’s a real threat, and many consider it the most concerning challenge to our country’s health. CDC has made the fight against antibiotic resistance a priority, and our transformative investments nationwide can be seen using the interactive AR Investment Map. This work includes establishing a new lab network in 2016 with expanded lab capacity in all 50 states.

Tackling illnesses caused by food

What do packaged salads and raw flour have in common? In 2016, both made dozens of people sick. For the first time, NCEZID experts conclusively showed that these foods were linked to specific bacteria that caused outbreaks. Whole genome sequencing helped connect the dots by showing that flour was the cause of an E. coli outbreak that made 60 people in 24 states sick, a third of whom were hospitalized. Some reported eating raw dough or raw batter. Whole genome sequencing also helped determine that an outbreak of listeriosis, which resulted in at least one death and 30 hospitalizations in the United States and Canada, was caused by eating packaged salads. As a result, the company that produced the salads recalled all brands produced at a single US facility.

Responding to rare infections

The jumping gene. A fungus that can cause bloodstream infections. A rare bacteria found in water. These are brief descriptions of three new or rarely seen emerging infectious threats that caused heightened concern in 2016. We worked to identify and contain the mcr-1 – or “jumping” – gene, which can make bacteria resistant to an antibiotic that is a last resort for some infections. A report by our experts also detailed the first US cases of Candida auris, an emerging fungus that is resistant to drugs and can cause serious – and sometimes deadly – blood infections. And, after the first cases of the rare Elizabethkingia infection were reported in Wisconsin, our scientists assisted the Wisconsin and Michigan state health laboratories in investigating the outbreak that would sicken almost 60 people and cause 20 deaths.

Assisting the response to hantavirus in Navajo Nation

NCEZID’s Craig Manning (left) fields a question about hantavirus from KTNN-AM radio host Navajo Bob during the live call-in program.

When a young woman from Navajo Nation in western United States died from an uncommon respiratory infection in early 2016, CDC experts stepped in to help. The problem was hantavirus which is spread by deer mice and causes a serious, sometimes lethal, respiratory infection. NCEZID experts worked with Navajo leaders to share information about hantavirus and create messages on preventing infection, including messages broadcast on a popular Navajo language radio station.

For more on the top infectious threats of 2016 and how we confronted them, please see the NCEZID 2016 Accomplishments.

10 Ways CDC Gets Ready For Emergencies

Dr. Stephen Redd, Director, Office of Public Health Preparedness and Response
Dr. Stephen Redd, Director, Office of Public Health Preparedness and Response

One of the best parts of my job is the opportunity to learn from a wide range of experiences. We have an obligation to not only respond to emergencies today, but to prepare for tomorrow by learning from the past. Our work extends to households affected by disease, communities ravaged by disasters, and U.S. territories battling new and changing threats. In fact, all over the world – we try to get ahead of, and manage, complex responses that touch many lives through ever changing circumstances. In an ideal world the health in every community would be at a level that would make recovery and reliance easier. The reality is that emergencies happen in all kinds of environments and populations.

The Public Health Preparedness and Response National Snapshot is our annual report that gives us an opportunity to showcase the work that we and our state partners do. The report reminds us that no matter how big the emergency, we need to work together to respond to the best of our ability—with the cards we are dealt.

Here are 10 ways CDC’s Office of Public Health Preparedness and Emergency Response worked to keep people safer in 2016 that can inform our work going forward.

1) Four Responses at Once: An Unprecedented Challenge

CDC experts continue to provide 24/7 monitoring, staffing, resources, and coordination in response to natural disasters, terrorist attacks, and infectious disease threats. In early 2016, CDC managed four public health emergencies at the same time through our Emergency Operations Center :

  • Ebola
  • Flint, Michigan, Water Quality
  • Zika Virus
  • Polio Eradication

See us in action:

2) A Complex Threat: Zika Hits the U.S.

CDC scientists and responders were activated in CDC’s Emergency Operations Center, where they combed through research, developed and distributed diagnostic tests, and provided on-the-ground mosquito control and education to protect people at higher risk for the virus, including pregnant women and infants.

3) Right Resources, Right Place, Right Time

CDC’s Strategic National Stockpile is ready to send critical medical supplies quickly to where they are needed most to save lives. The stockpile is the nation’s largest supply of life-saving pharmaceuticals and medical supplies that can be used in a public health emergency if local supplies run out.

Last year, we helped conduct 18 full-scale exercises and provided training for 2,232 federal and state, local, tribal, and territorial emergency responders to ensure that systems for delivering medicines are functioning well before they are needed in an actual emergency. We continue to work with our federal, state, local, and commercial partners to make sure every step of the medical supply chain – from manufacture to delivery – is coordinated.

4) State and Local Readiness

CDC connects with state and local partners to provide support and guidance, helping every community get ready to handle emergencies like floods, hurricanes, wildfires, or disease outbreaks.

This year, we created a new process to evaluate how well state and local jurisdictions can plan and execute a large-scale response requiring the rapid distribution of critical medicines and supplies. Through this program, we conducted assessments of 487 state and local public health departments. The information from these assessments will be used to help improve the ability to get emergency supplies quickly to those who need them most.

5) Cutting-Edge Science to Find and Stop Disease

To protect lifesaving research, CDC experts in biosafety and biosecurity conducted approximately 200 laboratory inspections and thousands of assessments of those who handle dangerous select agents and toxins like anthrax, plague, and ricin to keep these materials safe, secure, and out of the hands of those who might misuse them.

CDC’s Laboratory Response Network (LRN)l also develops and deploys tests to combat our country’s most pressing infectious and non-infectious health issues, from Ebola to Zika virus to opioid overdose. The network connects over 150 labs to respond quickly to high priority public health emergencies.

6) Protecting Our Most Vulnerable

CDC supports efforts all across the country to help those who may not be able to help themselves when a crisis strikes. Some populations, like children, older adults, and others with functional and access needs may need extra help during and after an emergency.

From planning for the 69 million children who may be in school when disaster strikes to the millions of Americans who need to make sure prescriptions are filled, medical equipment is working, and help arrives even if power is out and roads are blocked, it’s up to us to protect our most vulnerable in emergencies.

7) Emergency Leaders: The Future of Incident Response

When every minute counts, we need people who have the knowledge to step in and take immediate action. Learning and using a common framework like the CDC Incident Management System helps responders “speak the same language” during an event and work more seamlessly together.

CDC experts train leaders from around the world—25 countries in 2016—through an innovative, four-month fellowship based at our Atlanta headquarters. Lessons learned from this course were put to work immediately to head off an outbreak of H5N1 influenza in Cameroon.

8) The Power of Preparedness: National Preparedness Month

Throughout September, CDC and more than 3,000 organizations—national, regional, and local governments, as well as private and public organizations— supported emergency preparedness efforts and encouraged Americans to take action.

The theme for National Preparedness Month 2016 was “The Power of Preparedness.” During our 2016 campaign , we recognized the successes of countries and cities who have seen the direct benefits of being prepared, looked at innovative programs to help children and people with disabilities get ready for emergencies, and provided tips for home and family on making emergency kits.

9) Health Security: How is the U.S. Doing?

As part of the Global Health Security Agenda, teams of international experts travel to countries to report on how well public health systems are working to prevent, detect, and respond to outbreaks. In May, a team made a five-day visit to the U.S. to look at how well we’re doing.

In the final report, the assessment team concluded that, “the U.S. has extensive and effective systems to reduce the risks and impacts of major public health emergencies, and actively participates in the global health security system.” They recognized the high level of scientific expertise within CDC and other federal agencies, and the excellent reporting mechanisms managed by the federal government.

10) Helping YOU Make a Difference

Get a flu shot. Wash your hands. Make a kit. Be careful in winter weather. Prepare for your holidays. Be aware of natural disasters or circulating illnesses that may affect you or those you care about. There are many ways to prepare, and in 2016 we provided the latest science and information to empower every one of us to take action.

Every person needs knowledge to prepare their home, family, and community against disease or disaster before an emergency strikes. Whether it’s how to clean mold from a flooded home, how to wash your hands the right way, or how to use your brain in emergencies, our timely tips and advice put the power of preparedness in your hands. From the hidden dangers of hurricanes to the heartbreaking dangers of flu, there are steps we can all take to stay safe every day as we work toward a healthy and protected future.

For more ways we are helping protect America’s health, check out the new National Preparedness Snapshot.

To find out more about the issues and why this work matters, visit our website.

 

John Snow: A Legacy of Disease Detectives

Snow cholera map
Map of cholera cases in Soho, London, 1854. Source: Wikimedia Commons.

John Snow, known as the father of epidemiology, was born on March 15, 1813. This week, we honor the birthday of the first true disease detective.

The Story of the Broad Street Pump

London, 1854: A cramped Soho neighborhood teems with people and animals living in cramped and dirty quarters. A deadly outbreak of cholera is spreading. Doctors and scientists believe it’s caused by “miasma,” or bad air. They theorize that particles from rotting matter and waste are getting into the air and making people sick.

Enter John Snow. An accomplished physician, he becomes convinced that something other than the air might be responsible for the illness. Through carefully mapping the outbreak, he finds that everyone affected has a single connection in common: they have all retrieved water from the local Broad Street pump.

On September 8, 1854, Snow tests his theory by removing the pump’s handle, effectively stopping the outbreak, proving his theory, and opening the door to modern epidemiology.

Valuable Lessons for a Modern Age

In 1854, John Snow was the first to use maps and records to track the spread of a disease back to its source. Today, his ideas provide the foundation for how we find and stop disease all over the world.

We have better, more modern tools now for identifying and tracking illness, like access to state-of-the-art labs and computer systems. We have in-depth knowledge of germs and how they spread. But when we train today’s disease detectives, we still return to the basics. CDC disease detectives are trained to look for clues by asking:

  • WHO is sick?
  • WHAT are their symptoms?
  • WHEN did they get sick?
  • WHERE could they have been exposed to the cause of the illness?

We live in a world where disease can travel across the globe in a matter of hours. This means we must not only apply these basic lessons of epidemiology, but we must constantly be looking for ways to find better answers, faster.

Disease Detectives Make a DifferenceEpidemic Intelligence Service

When outbreaks or other threats emerge, CDC’s disease detectives, some of whom are trained through our Epidemic Intelligence Service (EIS), are on the scene. These boots-on-the ground staff, called EIS officers, support over 100 public health investigations (Epi-Aids) each year in the U.S. and worldwide.

CDC’s disease detectives have been instrumental in tracking down threats like:

Anthrax: During the 2001 anthrax outbreak among U.S. postal workers, disease detectives investigated the route of contaminated envelopes and how workers became infected.

E. coli: For the first time, disease detectives conclusively showed that flour was the source of a 2016 E. coli outbreak. Millions of pounds of flour were taken off the shelves, including flour-containing products like bread, cake, and muffin mixes.

Seoul virus: Disease detectives have been working to track and stop an outbreak of Seoul virus, an emerging rodent-borne hantavirus, involving home-based rat breeders this year. The outbreak was first identified after two Wisconsin rat breeders became ill in December and, as of March 13, the investigation has so far included rat-breeding facilities in 15 states, with 17 people infected in seven states.

Like Snow’s map that revealed cases of cholera congregated around the Broad Street pump, we must keep tabs on where and how disease is spreading. Once the source of disease is identified, it is crucial to develop and implement interventions to help prevent people from getting sick. We must remain innovative and creative, like Snow when he removed the handle of the Broad Street pump to stop disease at the source.

References

West Nile to Zika: How One Virus Helped New York City Prepare for Another

New York City helicopter used for larviciding.

No one told the Aedes mosquito that New York is the city that never sleeps.

The type of mosquito that can spread Zika virus (Zika) is most active during the day and hides at night when our city’s mosquito control efforts are in full swing, meaning that our scientists had to find a way to reach it during pre-dawn hours. The solution? Wake it up, force it to take flight, and then kill it.

This is just one of many innovations New York is using to bolster the fight against Zika.

A tale of two mosquitoes

By the time the Zika outbreak was making news, causing birth defects and threatening pregnant women, New York City already had over a decade of experience in tackling mosquito problems related to the spread of West Nile virus. In facing Zika, we have been able to apply many of our existing resources and lessons learned from the West Nile virus response.

However, the mosquito that carries Zika is different than the one that carries West Nile virus, and it needs to be handled differently. New York is home to Aedes albopictus, which has been known to carry Zika – although, unlike the Aedes aegypti of the south, it has not yet been determined how likely Aedes albopictus is to spread the virus to humans in the United States. Because this is still unknown, people need to protect themselves.

To find out more about the risks, we need to catch the mosquitoes and test them. But we can’t use the same traps to catch the Aedes albopictus that we use to catch the West Nile virus-carrying Culex. Culex mosquitoes can be trapped with a combination of carbon dioxide and light. Being daytime creatures that prey mostly on people, Aedes albopictus don’t fall for the same tricks. So we developed traps that use human pheromones to lure them in.

Building on what we have

Aedes albopictus mosquito feeding.
Aedes albopictus mosquito

Meanwhile, some of the things we have always done for West Nile virus work well in the current response.

We know from previous mosquito-control efforts that pesticides are a last resort. Although there are lots of ways to kill a mosquito, West Nile virus taught us that an effective response takes cooperation on many fronts. In New York, we have laboratories for testing, disease control experts to track cases in people, and a call center that manages tests and information from clinicians. Our communication department gets the word out because the best thing we can do for viruses like West Nile and Zika is educate people about how to prevent mosquito bites – wearing the right repellent, removing standing water, and staying indoors when you can.

Many of the resources we acquired for fighting West Nile virus are proving indispensable for fighting Zika. Ten years ago, we got a hand-me-down helicopter from the NYPD, and we’ve been able to use this for aerial spraying over marshlands and unpopulated areas. In the city, we use the same late-night spray trucks. A police car moves ahead of the truck, warning anyone who may still be out on the street. The distinctly New York voice bellowing from the loudspeaker (that of retired assistant commissioner Allan Goldberg) is even the same one we’ve always used.

 Sharing what we know

Zika presents us with a very steep learning curve, and it reinforces the need for transparent communication. We’ve set up an interactive website where we can share what we’re discovering with the public. We put out data on a weekly basis: people can zoom in and out on their screens to see where we’re finding mosquitoes. We want everyone to understand about the preventive work we’re doing to help keep Zika at bay.

The complex nature of Zika reveals the strongest and weakest points of the public health system. One thing in particular public health has always struggled with is how to change people’s behavior, which is critical and must happen if we want to stop Zika. We really hope that pregnant women or women who plan to become pregnant will not travel to areas with Zika, but it’s hard to stop people from visiting family or simply enjoying the world.

So far, all of the reported Zika cases in New York – including, as of August, 49 among pregnant women – have been the result of global travel. But just because we haven’t seen local transmission doesn’t mean the potential isn’t there.

This is why we’ve expanded our efforts by hiring extra staff and extending the areas where we do mosquito control and education. We need to continue to collaborate across agencies and in the field – and, in fact, all over the world – to manage a complex response that touches on so many areas. Working together and staying vigilant is our only hope for getting – and staying – ahead of this potentially devastating disease.

Read our other National Preparedness Month blogs:

 

When Preparation Meets Opportunity: Cameroon Gets a Jump on Outbreak Response

 Buea-Regional-Hospital-at-the-foot-of-Mt-Cameroon

When Dr. Aristide Abah stepped off the plane that brought him from Atlanta back to his home in Cameroon, there was no time to waste. An outbreak of H5N1 flu threatened the country, and it was up to Dr. Abah to lead the response.

Fortunately, he was prepared.

Dr. Abah had just spent four months at CDC headquarters as part of CDC’s Public Health Emergency Management Fellowship, which invites public health experts from all over the world to learn how to organize an emergency response in their country.

A deadly threat

In Cameroon, H5N1 was raging in poultry, putting people at risk. The virus can spread to people who come into contact with infected birds, and the result can be devastating. An estimated 60% of people who get the disease, die.

A swarm of activity took place around Cameroon’s response: culling chickens, contact tracing, delivering Tamiflu to people who needed it, providing personal protective equipment (PPE) to workers, and more. The country faced challenges; with over 500 sets of PPE needed each day, animal health workers ran out and had to repurpose supplies that were never used for the 2014 Ebola outbreak.

If they were to stop the deadly virus from spreading to humans, the country needed to act fast and be efficient. For Dr. Abah – and for Cameroon’s public health emergency operations center – it was time to put some newfound knowledge to the test.

From fellowship to field

Dr. Abah leads Cameroon H5N1 response
Dr. Abah leads Cameroon’s H5N1 response

Dr. Abah returned home from his fellowship on a Sunday night. On Tuesday, he stepped in as Incident Manager for the response. On Wednesday, he walked around the room and put nameplates at every desk.

This simple action served two important purposes.

The first was to make sure everyone knew their designated roles. In an emergency, we use an organizational structure called an Incident Management System to assign specific roles and responsibilities to every person. This ensures that everyone knows exactly what they and others are doing.

Nameplates also meant that everyone had an assigned seat, so that people who worked on the same tasks sat near each other. When information has to travel fast, proximity is priceless.

After he organized the people, Dr. Abah organized their time. He set up a system that gave everyone an allotted number of minutes to speak at meetings. He even appointed a timekeeper to help stay on track. “As you may or may not know,” joked Kerre Avery, a CDC Emergency Management Specialist who works closely with Cameroon, “it’s the French custom to talk a lot.”

Dr. Abah also improved the way information traveled, both within the response and outside it.  He adopted the CDC template for daily update slides and situation reports in the EOC, and added a communications team to the incident management structure to help get critical messages out to the public.

For Dr. Abah, these were the opening steps of a wider plan to respond to the crisis. During his fellowship, he had learned the critical importance of planning and organization. “For me, the planning was key,” he said. “I now know that we can’t do anything without a plan.”

Knowledge can’t wait                                                                  

When Dr. Abah first learned of the H5N1 outbreak, he had not yet completed his fellowship, but he knew that the lessons he was learning would help his colleagues back home. He set up an internet-based platform so they could all see and benefit from the lessons. He also reached out with new ideas: “I wanted to speak to higher management,” he said. “I told them they had to have an Incident Manager [in the EOC].”

Cameroon was already getting better and better at responding to health threats. A year ago, it took the country eight weeks to activate their public health emergency operations center in response to a cholera outbreak. Several months later, when Lassa fever erupted, they had reduced their response time to a week. By the time H5N1 appeared in local poultry, it took the country less than 24 hours to activate the PHEOC.

Cameroon’s recent improvements – including their investment in sending Dr. Abah to the fellowship – are all part of a worldwide effort to better prevent, detect, and respond to public health emergencies. And their efforts in preparedness are paying off: during the latest outbreak, there were zero transmissions of H5N1 to humans.

Inspiring lessons

The lessons the Public Health Emergency Management Fellowship teaches are designed to be applied to virtually any crisis situation. Since the 2013 inaugural class, CDC has hosted 39 fellows from 25 countries, giving them important education they can take back and use in their home countries.

While in the U.S., Dr. Abah was particularly inspired by a visit to meet Dr. Nicole Lurie, the Assistant Secretary for Preparedness and Response in Washington, D.C. Her advice to him summarizes perhaps the most important lessons from the fellowship.

“I keep in my memories three words of advice from Dr. Lurie.” Dr. Abah recalls. “Never give up, stay connected, and get better.”

The Public Health Emergency Management Fellowship is implemented by CDC’s Division of Emergency Operations. The program helps countries meet the goals of the Global Health Security Agenda, including having an emergency operations center that can respond within two hours of a public health emergency.

Learn More

 Read our other National Preparedness Month blogs:

Safe Travels for Zika and Other Dangerous Samples

Barcoded medical samples in transparent tubes

As Zika virus spreads across the globe, scientists in the United States are finding ways to fight it. Currently, there are no vaccines to prevent Zika or medicines for treatment. To create better tests – including rapid tests – and develop vaccines, scientists need to conduct research with the virus in their labs.

CDC manages the permit process for researchers to bring samples of Zika virus safely from other countries into the U.S. for studies, paving the way for lifesaving discoveries.

“Samples come from all over the world,” says LCDR Meredith Pyle, a CDC microbiologist. “While so far, most samples have come from Brazil and Colombia, we have received samples from countries ranging from India to South Korea to Switzerland to Zambia.”

Sending a virus sample from one place to another has to be done safely and securely. Samples of Zika virus can be brought into the U.S. in a variety of forms, including in a tube of blood (plasma or serum), a spot of dried blood, an isolate of the virus itself that has been separated from the blood, or even a live mosquito.

How researchers get a permit

Most permit requests come from laboratories at academic and private institutions. Permits are requested through the Import Permit Program (IPP), which is managed by CDC’s Division of Select Agents and Toxins (DSAT). The program makes sure infectious germs, like Zika virus, as well as other materials that could cause disease in people will be handled appropriately after they arrive in the U.S.

“IPP helps to ensure biological agents imported into the US that could cause disease in people are tracked,” said Dr. Dan Sosin, acting director of DSAT. “We also take steps to ensure that the facilities receiving these permits have appropriate biosafety measures in place to work with the materials.”

When a researcher or institution submits an application to get an import permit for Zika virus, CDC reviews the application to make sure the facility has the appropriate biosafety measures in place to prevent the virus from accidentally being released. The program goal is to approve all Zika virus import permit applications within 24 hours for known, appropriate facilities. DSAT may also conduct an in-person inspection before issuing a permit.

Since last year, the number of permits issued for Zika virus has increased by more than eightfold. As of August 1, 2016, the program had expedited the approval of 137 Zika virus import permits this year alone.

Get more information on the Import Permit Program.

Mosquito Control Awareness Week: Say Goodbye to Mosquitoes at Home

FemaleAedes aegypti mosquito in the process of acquiring a blood meal from her human host.

This week is Mosquito Control Awareness Week! Now that it’s mosquito season, it is the perfect time to look in and around your home for ways to control mosquitoes that can carry viruses like Zika and West Nile.

Man putting screen in window.
Install or repair window and door screens.

There are many options when it comes to mosquito control for your home. No single activity will effectively control mosquitoes, so you should combine both indoor and outdoor mosquito control activities to keep in and around your home free of mosquitoes.

Control mosquitoes inside your home

No one likes having a mosquito flying inside their house. Luckily, there are easy steps you and your family can take to keep mosquitoes out and to get rid of the ones that do get in.

First, keep mosquitoes from getting in by making sure you have screens installed on your windows and doors, and fix any holes in them. Although a summer breeze is nice, keeping windows and doors shut and using air conditioning when possible will help keep mosquitoes out.

Mosquitoes lay their eggs near water. Those that get into your home will look for vases or flower pot saucers with water to lay their eggs on. To eliminate these areas and prevent eggs from hatching, once a week, empty and scrub, turn over, or throw out any items that hold water.

Finally, if you have a hard time keeping mosquitoes out, you can apply an indoor insect fogger or spray according to label instructions to kill mosquitoes that get inside. Mosquitoes like dark and humid places, so make sure to spray under sinks and furniture and in the laundry room.

Control mosquitoes outside your home

Person dumping water out of a bucket
Empty areas of standing water where mosquito can lay eggs.

Summer is the time for backyard barbeques and fun, but that can quickly be interrupted if your yard is full of mosquitoes. There are many things you can do to reduce mosquitoes in your yard and make time outdoors more enjoyable.

Areas with standing water around your yard are perfect places for mosquitoes to lay their eggs. Once a week, you should empty and scrub, turn over, cover, or throw out any items that hold water like tires, buckets, planters, toys, pools, birdbaths, or trash containers. Water storage containers should be tightly covered and for those without lids, wire mesh with small holes than an adult mosquito can’t fit through.

For areas of standing water that will not be used for drinking and cannot be covered or emptied, like backyard ponds, use larvicides to kill young mosquitoes.

You can use an outdoor insect fogger or spray in your backyard to reduce the number of mosquitoes. Always follow the instructions on the label.  Make sure to spray under patio furniture or under the carport or garage where mosquitoes like to rest.

If your home has a septic tank, repair cracks or gaps and cover open vent or plumbing pipes with wire mesh that has holes smaller than an adult mosquito.

 

Help with mosquito control

If you do not want to apply indoor or outdoor mosquito control products yourself, you can hire a pest control professional. Tips on finding a pest control profession are available.

Prevent mosquito bites

In addition to controlling mosquitoes in and around your home, you should also protect yourself and your family from mosquito bites. Use Environmental Protection Agency (EPA)-registered insect repellents with one of the following active ingredients: DEET, picaridin, IR3535, oil of lemon eucalyptus or para-menthane-diol. Apply insect repellents according to label instructions. When used as directed, EPA-registered insect repellents are proven safe and effective, even for pregnant and breastfeeding women. Wearing long-sleeved shirts and pants will also help prevent bites.

More information on how to control mosquitoes in and around your home.