Flu: Symptoms, treatment, contagiousness, and do I have it?
From The Plague To Spanish Flu:
Malulani Hospital in Wailuku, which became Maui Memorial Medical Center, was established by St. Marianne in 1884.
The coronavirus is not the first deadly scourge to come ashore in Maui County to cause death and wreak havoc on daily life.
From the time Capt. James Cook arrived to the overthrow of the Hawaiian Kingdom, the Native Hawaiian population collapsed from nearly 1 million to 40,000. So serious was the threat of disease that in 1840, King Kamehameha III adopted a law punishing anyone who knowingly violated the quarantine law with hanging.
By 1850, the Kingdom had instituted a Board of Health that was given very broad powers to prevent the spread of disease as well as the power to provide relief to those affected by quarantines and sanitary cordons.
The Board of Health system of managing infectious disease continued when Hawaii became a territory. Its first big test was the bubonic or "Great Black" plague outbreak late in 1899. Bubonic plague was not well understood and the board had near absolute authority to contain and eliminate it in Hawaii.
The board focused its attention on Honolulu's crowded Chinatown, with controlled burning of buildings where deaths had occurred. Then, on Jan. 20, 1900, unexpected winds caused a controlled fire to jump and 38 acres of downtown Honolulu burned down over the following two weeks. Additional controlled burns, including the burning down of Kahului's own Chinatown, occurred as the plague appeared on Maui.
Isolation wards were set up at Malulani Hospital during the Spanish flu outbreak on Maui.
The bubonic plague quarantine was lifted in April 1900.
Maui suffered isolated child deaths from diphtheria until 1910 when Russian immigrants to Honolulu brought an outbreak to Hawaii. By the end of 1910, an outbreak in Makawao caused the territory to close schools and temporarily quarantine the entire Makawao district. Unlike the bubonic plague, a treatment for diphtheria was known and administered which, The Maui News reported, brought the death rate down from 60 percent of infected children to 10 percent. The quarantine ended, but diphtheria continued to persist with occasional outbreaks until the vaccine was available and widely administered.
Around the same time, the county set aside land and funding for a public health farm at Keokea to address the so-called "Great White Plague," or tuberculosis. The Farm, eventually named Kula Sanitarium, was to be used to isolate and treat tuberculosis patients. The Maui News reported in 1919 that "Kula San" had 100 residents with a wait list of 200 more. These histories of contagion should have readied Hawaii authorities to address a bigger threat.
In 1916, a particularly fatal illness had been affecting British and French troops on the Western Front. When the United States entered World War I in 1917, hundreds of young men from Maui volunteered or were conscripted into the U.S. Army to fight in Europe and would encounter the illness. Because Spain was neutral during the war and did not have press censorship, the outbreak of the disease was widely reported there, and this new illness became known as the Spanish flu.
By July 1918, Oahu military camps reported over 600 soldiers infected with the illness that was being described as similar to "la grippe" — an older French term for influenza.
Ephraim Ezera, a native of Ulupalakua and private in the Army, died at Schofield Barracks that July.
In mid-January 1919, the Spanish flu epidemic arrived in Maui. Over 300 schoolchildren in West Maui were out of school and the hospitals were overflowing with patients. The following week, hundreds of discharged soldiers returned from Europe via Honolulu, landing in Lahaina and Kahului. Hamakuapoko and Paia reported outbreaks.
The Board of Health closed movie theaters, churches or any public gatherings in closed buildings. The County Fair was canceled. The public was encouraged to ventilate closed rooms, to routinely wash hands with soap and to avoid hand-shaking.
Within a week, 1,500 new cases were reported. The county sheriff divided Wailuku up and systematically searched every house — discovering dozens of cases not previously reported. Lahaina and Hamakuapoko seemed to have reached a peak at that point while Hana, Makawao and Kula were just beginning to show signs of outbreak. A controversial decision was made to keep schools open as a way to detect spread of the disease and to better control it.
In mid-February, nearly 3,500 cases of infection and over 50 deaths had been reported. Puunene had become a hot spot while Hana and Keanae had contained the spread. School absences due to illness were reported at 50 percent and many school teachers were also sick. Half of the county police force was out sick. By the end of February, the number of cases stood at 4,500. The Board of Health lifted restrictions on theaters, churches and public gatherings.
In March, the number of infections had slowed and the peak for each outbreak area had passed. Some, however, were concerned about a recurrence, as was occurring in many other places.
The following January saw infections of the Spanish flu suddenly reappear in Wailuku. Plantations and the government immediately performed a systematic search of homes in the camps to identify the sick and implemented isolation wards at Malulani Hospital and established a field hospital at the Armory. Within two weeks, nearly 500 cases of infection and 15 deaths had been reported. But because of the quick action, in the weeks that followed, the number of infected did not significantly increase and by February's end, the field hospital was closed.
Oahu was not so lucky. The second wave hit Honolulu much harder. Filipino and Japanese sugar workers had joined together to strike for better wages and working conditions. Management responded by evicting over 12,000 workers from plantation housing, sending many workers and their families into the crowded tenements of Honolulu. Over 1,200 Spanish flu deaths in Hawaii were members of striking families.
In March, a resident physician of Ualapue, Molokai, reported that people were flocking to Molokai to escape from the flu or recover from it. He noted Molokai had 90 cases and lacked facilities to care for sick visitors. He also asked that even visitors, who were not ill, not come without ensuring they had a place to stay. By April, leeward Molokai's outbreak had peaked at over 250 cases.
In all, nearly 2,400 people died of Spanish flu in Hawaii between 1918 and 1920. The death rate impacted Native Hawaiians the hardest at 11 percent mortality, Filipinos at 6 percent mortality, Japanese at 4 percent mortality and Caucasians at under 3 percent.
Mortality was highest in children under 5 and people over 60 years old, and lowest for children 5 to 19.
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Inside The Swift, Deadly History Of The Spanish Flu Pandemic
Scientist Johan Hultin traveled to Brevig Mission, Alaska, a town of a few hundred souls in the summer of 1997. He was searching for buried bodies, and Alaska's frozen ground was the perfect place to find them. Digging through the permafrost—with permission from the town's authorities—he eventually uncovered a woman who died almost 80 years previously and was in a state of excellent preservation. Hultin then extracted samples of the woman's lung before reinterring her. He intended to use this to decode the genetic sequence of the virus that had killed this Inuit woman along with 90 percent of the town's population.
Brevig Mission was just one place that was part of a global tragedy, one of the worst ever to befall humanity: the influenza pandemic of 1918-19. The outbreak of this influenza virus, also known as Spanish flu, spread with astonishing speed around the world, overwhelming India, and reaching Australia and the remote Pacific islands. In just 18 months at least a third of the world's population was infected. Estimates on the exact number of fatalities vary wildly, from 20 million to 50 million to 100 million deaths. If the upper end of that estimate is accurate, the 1918 pandemic killed more people than both World Wars put together. (Get the facts on influenza.)
The first official cases of the 1918 Spanish flu pandemic were recorded at the U.S. Army's Camp Funston, Kansas, where this emergency influenza ward held treated patients.
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War and pestilenceSeveral closely related viruses cause influenza, but one strain (type A) is linked to deadly epidemics. The 1918-19 pandemic was caused by an influenza A virus known as H1N1. Despite becoming known as the Spanish flu, the first recorded cases were in the United States in the final year of World War I. (Explore the memorials of World War I.)
A magnified view of the H1N1 virus responsible for the 1918 pandemic.
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By March 1918 the United States had been at war with Germany and the Central Powers for 11 months. During that time America's small, prewar army had grown into a vast fighting force that would eventually send more than two million men to Europe. (How the United States entered World War I.)
American forts experienced a massive expansion as the entire nation mobilized for war. One of these was Fort Riley, Kansas, where a new training facility, Camp Funston, was built to house some of the 50,000 men who would be inducted into the Army. It was here in early March that a feverish soldier reported to the infirmary. Within a few hours more than a hundred other soldiers had come down with a similar condition, and more would fall ill over the following weeks. In April more American troops arrived in Europe and brought the virus with them. The first wave of the pandemic had arrived. (What is the difference between an epidemic and a pandemic?)
Deadly speedThe Spanish flu strain killed its victims with a swiftness never seen before. In the United States stories abounded of people waking up sick and dying on their way to work. The symptoms were gruesome: Sufferers would develop a fever and become short of breath. Lack of oxygen meant their faces appeared tinged with blue. Hemorrhages filled the lungs with blood and caused catastrophic vomiting and nosebleeds, with victims drowning in their own fluids. Unlike so many strains of influenza before it, Spanish flu attacked not only the very young and the very old, but also healthy adults between the ages of 20 and 40.
Biologists at St. Bartholomew's Hospital in London are analyzing brain and lung tissue from victims of the 1918 pandemic as part of global efforts to understand the virus. Here, wax-mounted tissue samples sit on a list of children's names who fell victims to influenza in 1918.
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The principal factor in the virus's spread was, of course, the international conflict then in its last phase. Epidemiologists still dispute the exact origins of the virus, but there is some consensus it was the result of a genetic mutation that perhaps took place in China. But what is clear is that the new strain went global thanks to the massive and rapid movement of troops around the world.
The drama of the war also served to obscure the unusually high mortality rates of the new virus. At this early stage, the illness was not well understood and deaths were often attributed to pneumonia. Strict wartime censorship meant that the European and North American press were unable to report outbreaks. Only in neutral Spain could the press speak freely about what was happening, and it was from this media coverage that the disease took its nickname.
Deadly Contact
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Native Americans treat patients infected by European diseases in this 1591 engraving by Theodor de Bry.
GRANGER/ALBUMEpidemics are as old as civilization: Signs of smallpox appear on 12th-century B.C. Egyptian mummies. Increased contact led to the spread of disease. In the sixth century A.D. The Plague of Justinian moved along trade routes, killing 25 million people across Asia, Africa, Arabia, and Europe. Eight centuries later, the Black Death wiped out 60 percent of Europe's population. When Europeans settled in the Americas in the 16th and 17th centuries, they introduced smallpox, influenza, and measles to the native peoples, killing an estimated 90 percent of the population. Here, Native Americans treat patients infected by European diseases in a 1591 engraving by Theodor de Bry.
The second waveThe overcrowded trenches and encampments of the First World War became the perfect hosts for the disease. As troops moved, so the infection traveled with them. The wave that had first appeared in Kansas abated after a few weeks, but this was only a temporary reprieve. By September 1918 the epidemic was ready to enter its most lethal phase.
It has been calculated that the 13 weeks between September and December 1918 constituted the most intense period, taking the greatest number of lives. At least 195,000 Americans died in October alone. In comparison, total American military casualties for the whole of World War I came in at just over 116,000. Once again, it was the crowded military encampments where the second wave initially gained a hold. In September an outbreak of 6,674 cases was reported at Camp Devens, a military base in Massachusetts.
As the crisis reached its zenith, the medical services began to be overwhelmed. Morticians and gravediggers struggled, and conducting individual funerals became impossible. Many of the dead ended up in mass graves. The end of 1918 brought a hiatus in the spread of the illness and January 1919 saw the beginning of the third and final phase. By then the disease was a much diminished force. The ferocity of the autumn and winter of the previous year was not repeated and mortality rates fell.
Although the final wave was much less lethal than its predecessors, it was still able to wreak considerable damage. Australia, which had quickly enacted quarantine restrictions, managed to escape the worst of the flu until the beginning of 1919, when the disease finally arrived and took the lives of several thousand Australians.
The Spanish flu did not strike in Australia until 1919. Quarantine camps like this one, in Wallangarra, Queensland, were set up to treat and contain the illness.
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The general trend of mortality, however, was downward. There were cases of deaths from influenza—possibly a different strain—as late as 1920, but by the summer of 1919 health care policies and the natural genetic mutation of the virus brought the epidemic to a close. Even so, its effects, for those left bereaved or suffering long-term health complications, were to last decades.
Lasting impactThe pandemic left almost no part of the world untouched. In Great Britain 228,000 people died. The United States lost as many as 675,000 people, Japan some 400,000. The south Pacific island of Western Samoa (modern-day Samoa) lost one-fifth of its population. Researchers estimate that in India alone, fatalities totaled between 12 and 17 million. Exact data in the number of deaths is elusive, but global mortality figures are estimated to have been between 10 and 20 percent of those who were infected.
In 1997 the samples taken by Johan Hultin from the woman found in the frozen mass grave in Brevig Mission added to scientists' knowledge as to how flu viruses mutate and spread. Drugs and improved public hygiene—in conjunction with international institutions such as the World Health Organization and national bodies such as the Centers for Disease Control and Prevention in the United States—put the international community in a much better position to meet the challenges of a new outbreak. However, scientists know a lethal mutation could occur at any time, and a century on from the mother of all pandemics, its effects on a crowded, interconnected world would be devastating.
Soldier's Letters Give First-hand Look At Spanish Flu Pandemic
By Larry ShaughnessyCNN Pentagon producer
Editor's note: With fears of a swine flu pandemic rising daily, CNN Pentagon producer Larry Shaughnessy remembered a batch of letters from his grandfather, a World War I soldier who battled the Spanish flu pandemic of 1918-1919.
Martin "Al" Culhane, left, is pictured with his older brother, Frank, around 1918 or 1919.
WASHINGTON (CNN) -- "I'm coming, I'm comingFor my head is bending lowI hear those gentle voices callingOld Black Joe"
As World War I rages in Europe, fresh U.S. Army soldiers pass the time on a train ride to to Camp Forrest, Georgia. "The boys are just starting to sing," Martin Aloysius Culhane wrote on September 6, 1918, to his friend back home. "They've gotten back to 'Old Black Joe' so far."
Stephen Foster's classic song from the Civil War is about the death of slaves who had become his friends. But Culhane, known as "Al," and the soldiers who sang along could not know how much death would hunt the recruits on that train, most of whom never made it to Europe to fight in the Great War.
They would find themselves in the deadliest influenza pandemic in history.
Culhane's letters to his older brother Frank and his long-time "chum" Clif Pinter are a young soldier's firsthand account of life as a draftee private and how he coped with a disease that would haunt Army camps around the United States and eventually infect people around the world. Some estimates say as many as 50 million people were killed by what's called the Spanish influenza in 1918 and 1919, far more than the number killed in combat during the war.
Three weeks after the train trip to Georgia, Culhane, a 21-year-old clothing salesman from Chicago, Illinois, writes again. Already the flu occupies his thoughts. 
"Received a nice letter from Phil Byrne he reports he is getting along fine, is feeling better than he has ever before." Byrne, a friend from Chicago, was one of the early survivors of the Spanish flu. Other members of the Byrne family took ill a few months later, according to the letters.
In the same letter he mentions how the Army was trying to protect the troops at Camp Forrest:
"Since noon today our camp has been under quarantine to prevent an epidemic of Spanish influenza. We have had no cases thus far but it is the intention of the medical officers to prevent any case of the disease from making an appearance. All the men who have even slight colds have been put into separate barrack which, of course, were immediately christened 'the TB ward' by the rest of the company."
That same day, September 28, 1918, he wrote his brother Frank, a Navy sailor at home awaiting orders, "Well the Spanish Influenza has made an appearance here and we are under strict orders no visits to Chattanooga, we are certainly the hard luck guys when it comes to this quarantine proposition."
At first the threat of Spanish flu is just an inconvenience for Culhane: "I am just about fed up with staying in a district about a block square for three weeks. There is no canteen in the quarantine district and we have a hell of a time getting small supplies."
Just six days after complaining about the inconvenience, a brief but frightening note: "Receive the enclosed letter for your information then see that Frank gets it unknown to the rest of the family."
What Culhane didn't want his mother, sister and younger brother to know was that he was in the infirmary with the Spanish flu. He asks his friend Clif to write often and encourage letters from "my friends, without of course, telling them that I am a little under the weather." His euphemism hid the fact that in some places more than 30 percent of people who contracted Spanish flu died. In the United States the mortality rate was lower, but still a devastating 3 percent.
It was a crisis for the Army. Military bases, with thousands of men from all over the country in tightly packed barracks, were fertile breeding grounds for the flu, especially one as easily spread as this one. And unlike most flu strains that mostly strike the elderly, the very young or the sick, Spanish flu hit healthy, young adults like Army draftees.
Just three days after telling his friend about being sick, Culhane wrote that he was feeling better.
"I am still in quarantine but will be released today. I am feeling great and the two day's rest has done me a world of good. I have done nothing at all but sit in the shade, read and write letters."
His recovery from the Spanish flu was swift, but the very next day, October 7, 1918, he wrote to give "all the details of the death of a very good friend, my Bunkie, Thomas Birdie. His body will go north today, I think," Culhane wrote, asking Pinter to attend the wake. "At his side, say a few prayers for the repose of his soul."
When not writing about the flu, Culhane dropped none-too-subtle hints about wanting care packages full of cookies from home. And he regularly questioned why other friends didn't write.
He also worried that he was "neglecting the ladies." He pelts his friend Clif with questions about Ursula ("Her Majesty," he jokingly refers to her), Ella (the young woman to whom he promised a prized golf club) Ida ("I had a long letter from Ida Flynn. Boy! I will have a job on my hands when I get home") and the Marys (Mary Rose, Mary English, Mary Anne).
While Culhane writes about and to a lot of young ladies, there is no sign in the letters which one, if any, held a special place in his heart. Still he worried about one young man named "Hank" who remained in Chicago.
"Keep the ladies amused by all means, but I look to you to protect my interests. Hank is too darn nice a chap to be safe around the ladies. However, if he seems to get extra strong I will write a note and have him made Admiral of the Arctic Circle."
After recovering from the flu, Culhane bemoans the fact that war was about to end.
"It is almost over now and thirty days will see at least a cessation of hostilities. Xmas will see peace. I will never see France and as long as that is impossible I might as well be out of the Army as soon as it is over." Nine days later, on the 11th hour of the 11th day of the 11th month the war ended.
And just four days after the fighting in Europe ended, the letters from Camp Forrest stopped. Al Culhane was sick again. This time he was taken to U.S. General Hospital #14 at Fort Oglethorpe, Georgia. And he couldn't keep the latest illness a secret from his family back home in Chicago. A Catholic chaplain wrote the family that he was sick and not able to write himself.
When he was well enough, he wrote Pinter, "I don't know just what I have but it felt like old fashioned grip or perhaps 'The Flu.'".
It took about two weeks before he was out of the Fort Oglethorpe hospital and back at Camp Forrest. He had twice survived the deadliest flu in history and lived to write home about it.
After his second recovery his concerns turned to getting back to Chicago by Christmas. "Clif I have seen my discharge all written out and from that moment on my usefulness as a soldier ceased."
But again illness got in the way. This time it was a completely different one: "Measles has broken out in our company and we are quarantined. Did you ever hear of harder luck in all your life?"
Culhane didn't make it back to Chicago for Christmas. But he eventually did return home alive and well.
He never did make it to France, but traveled the United States extensively with his wife, Evelyn, a woman never mentioned in his letters home, but someone he'd known since they went through First Holy Communion together.
As for Clif Pinter, who saved the letters, he and Al Culhane remained "old chums" for life.
After Pinter's death, his son passed the letters on to Al's daughter, Dorothy Clarke, who passed them onto Al's grandchildren, including Lawrence Aloysius Shaughnessy, who works for CNN's Pentagon unit and occasionally writes stories about soldiers for CNN.Com.
All About World War I • Influenza
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