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Spanish Flu Epidemic: Non-Pharmaceutical Health Policies

The “Spanish” influenza pandemic in 1918–1919 claimed 50 million lives worldwide (Johnson and Mueller 2002) and significantly disrupted social and economic life of many countries. However, both mortality and the shape of the epidemic differed considerably around the world. Even within one country some cities went through a single large peak of infection and mortality, while others endured two smaller waves spaced by a few weeks. Why did the dynamics of the pandemic differ and how did the public health policy affect that?

We have turned to the publications on the Spanish flu. For the review, we have performed a systematic search in the scientific literature database Scopus and have built a map of publications based on their reference lists (Figure 1). Proximity in this map and belonging to the same cluster mean that the papers cite the same publications, therefore the papers are likely to consider similar issues. The map is built using VOSviewer software.

The publications roughly split into six clusters:

  • navy, top left: epidemiology,
  • yellow, top center: medicine,
  • blue, top right: molecular biology,  
  • light blue, center right: pathology, immunology,  
  • purple, bottom right: virology, genetics,
  • light gray, bottom left: public health, demographic research, medical history.
Figure 1. Bibliographic coupling map of documents on Spanish flu
Nodes are colored according to the automatically identified clusters. Links indicate overlaps in reference lists between two publications. Proximity in the map and belonging to the same cluster both reflect the higher probability that the papers are devoted to a related subject matters. Node sizes correspond to the citation count of the paper according to Scopus. Only the connected items are included in the map (N = 1259). Click on the map to see the full resolution (opens in the same tab)

Central on the map are the papers by virologist Jeffery K. Taubenberger and epidemiologist David M. Morens, which appear in all the clusters of the right biology-medical part of the map. They wrote the most famous publications on the 1918 virus, its origins and pathogenicity:

  • Taubenberger, Jeffery K., John C. Kash, and David M. Morens. 2019. “The 1918 Influenza Pandemic: 100 Years of Questions Answered and Unanswered.” Science Translational Medicine 11(502).
  • Taubenberger, Jeffery K., and David M. Morens. 2006. “1918 Influenza: The Mother of All Pandemics.” Emerging Infectious Diseases 12(1):15–22.

From the map we can see that biology-medical publications (to the right) and epidemiology-demographic ones (to the left) rarely address the same literature. Still, it is in the upper left part of the network where the papers on non-pharmaceutical interventions are located.

Non-pharmaceutical interventions (NPIs) – restrictive public health policies intended to reduce disease incidence and epidemic-related death rate until the cure arrives.

Non-pharmaceutical interventions were used during the Spanish flu in various forms. They are studied especially thoroughly on the U.S. material. Across the United States, 19 types of NPIs were introduced, in complex or separately: mandatory quarantine of infected households, isolation of their close contacts, closure of schools, churches, bans on public gatherings and other restrictions and prescriptions.

Read about the impact of different public health policies on pandemic-related mortality and the shape of its peaks:

  • Aiello, Allison E., Rebecca M. Coulborn, Tomas J. Aragon, Michael G. Baker, Barri B. Burrus, Benjamin J. Cowling, Alasdair Duncan, Wayne Enanoria, M. Patricia Fabian, Yu hui Ferng, Elaine L. Larson, Gabriel M. Leung, Howard Markel, Donald K. Milton, Arnold S. Monto, Stephen S. Morse, J. Alexander Navarro, Sarah Y. Park, Patricia Priest, Samuel Stebbins, Alexandra M. Stern, Monica Uddin, Scott F. Wetterhall, and Charles J. Vukotich. 2010. “Research Findings from Nonpharmaceutical Intervention Studies for Pandemic Influenza and Current Gaps in the Research.” American Journal of Infection Control 38(4):251–58.
  • Bakalar, Nicholas. 2007. “How (and How Not) to Battle Flu: A Tale of 23 Cities.” The New York Times, April 17.
  • Bootsma, Martin C. J., and Neil M. Ferguson. 2007. “The Effect of Public Health Measures on the 1918 Influenza Pandemic in U.S. Cities.” Proceedings of the National Academy of Sciences 104(18):7588–93.
  • Caley, Peter, David J. Philp, and Kevin McCracken. 2008. “Quantifying Social Distancing Arising from Pandemic Influenza.” Journal of the Royal Society Interface 5(23):631–39.
  • Hatchett, Richard J., Carter E. Mecher, and Marc Lipsitch. 2007. “Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic.” Proceedings of the National Academy of Sciences 104(18):7582–87.
  • Markel, Howard, Harvey B. Lipman, J. Alexander Navarro, Alexandra Sloan, Joseph R. Michalsen, Alexandra Minna Stern, and Martin S. Cetron. 2007. “Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic.” JAMA 298(6):644–54.
  • Morse, Stephen S. 2007. “Pandemic Influenza: Studying the Lessons of History.” Proceedings of the National Academy of Sciences 104(18):7313–7314.
  • Morse, Stephen S., Richard L. Garwin, and Paula J. Olsiewski. 2006. “Next Flu Pandemic: What to Do Until the Vaccine Arrives?” Science 314(5801):929–929.

Data source: Scopus bibliographic database. We’ve run the search by titles, abstracts and keywords of publications using the terms Spanish flu and Spanish/1918 influenza pandemic. The search resulted in 1668 publications, excluding books. Search query:
TITLE-ABS-KEY ( “spanish flu” OR ( influenza W/5 1918) OR ( influenza W/0 pandemi AND 1918* OR spanish ) )