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Coronavirus And The Sun: A Lesson From The 1918 Influenza Pandemic

Fresh air, sunlight and improvised face masks seemed to work a century ago; and they might help us now.

Influenza-patients-getting-sunlight-at-the-Camp-Brooks-emergency-open-air-hospital-in-Boston.-Medical-staff-were-not-supposed-to-remove-their-masks
Influenza patients getting sunlight at the Camp Brooks emergency open-air hospital in Boston. Medical staff were not supposed to remove their masks. (National Archives)

When new, virulent diseases emerge, such SARS and Covid-19, the race begins to find new vaccines and treatments for those affected.

As the current crisis unfolds, governments are enforcing quarantine and isolation, and public gatherings are being discouraged.

Health officials took the same approach 100 years ago, when influenza was spreading around the world.

The results were mixed. But records from the 1918 pandemic suggest one technique for dealing with influenza — little-known today — was effective.

Some hard-won experience from the greatest pandemic in recorded history could help us in the weeks and months ahead.

 

Put simply, medics found that severely ill flu patients nursed outdoors recovered better than those treated indoors.

A combination of fresh air and sunlight seems to have prevented deaths among patients; and infections among medical staff.[1]

There is scientific support for this. Research shows that outdoor air is a natural disinfectant. Fresh air can kill the flu virus and other harmful germs.

Equally, sunlight is germicidal and there is now evidence it can kill the flu virus.

`Open-Air’ Treatment in 1918

During the great pandemic, two of the worst places to be were military barracks and troop-ships. Overcrowding and bad ventilation put soldiers and sailors at high risk of catching influenza and the other infections that often followed it.[2,3]

As with the current Covid-19 outbreak, most of the victims of so-called `Spanish flu’ did not die from influenza: they died of pneumonia and other complications.

When the influenza pandemic reached the East coast of the United States in 1918, the city of Boston was particularly badly hit. So the State Guard set up an emergency hospital.

They took in the worst cases among sailors on ships in Boston harbour. The hospital’s medical officer had noticed the most seriously ill sailors had been in badly-ventilated spaces.

So he gave them as much fresh air as possible by putting them in tents. And in good weather they were taken out of their tents and put in the sun.

At this time, it was common practice to put sick soldiers outdoors. Open-air therapy, as it was known, was widely used on casualties from the Western Front.

And it became the treatment of choice for another common and often deadly respiratory infection of the time; tuberculosis.

Patients were put outside in their beds to breathe fresh outdoor air. Or they were nursed in cross-ventilated wards with the windows open day and night. The open-air regimen remained popular until antibiotics replaced it in the 1950s.

Doctors who had first-hand experience of open-air therapy at the hospital in Boston were convinced the regimen was effective. It was adopted elsewhere.

If one report is correct, it reduced deaths among hospital patients from 40 per cent to about 13 per cent.[4]

According to the Surgeon General of the Massachusetts State Guard:

`The efficacy of open air treatment has been absolutely proven, and one has only to try it to discover its value.’

Fresh Air is a Disinfectant

Patients treated outdoors were less likely to be exposed to the infectious germs that are often present in conventional hospital wards.

They were breathing clean air in what must have been a largely sterile environment. We know this because, in the 1960s, Ministry of Defence scientists proved that fresh air is a natural disinfectant.[5]

Something in it, which they called the Open Air Factor, is far more harmful to airborne bacteria — and the influenza virus — than indoor air.

They couldn’t identify exactly what the Open Air Factor is. But they found it was effective both at night and during the daytime.

Their research also revealed that the Open Air Factor’s disinfecting powers can be preserved in enclosures — if ventilation rates are kept high enough.

Significantly, the rates they identified are the same ones that cross-ventilated hospital wards, with high ceilings and big windows, were designed for.[6]

But by the time the scientists made their discoveries, antibiotic therapy had replaced open-air treatment. Since then the germicidal effects of fresh air have not featured in infection control, or hospital design. Yet harmful bacteria have become increasingly resistant to antibiotics.

Sunlight and Influenza Infection

Putting infected patients out in the sun may have helped because it inactivates the influenza virus.[7] It also kills bacteria that cause lung and other infections in hospitals.[8] During the First World War, military surgeons routinely used sunlight to heal infected wounds.[9]

They knew it was a disinfectant. What they didn’t know is that one advantage of placing patients outside in the sun is they can synthesise vitamin D in their skin if sunlight is strong enough.

This was not discovered until the 1920s. Low vitamin D levels are now linked to respiratory infections and may increase susceptibility to influenza.[10]

Also, our body’s biological rhythms appear to influence how we resist infections.[11] New research suggests they can alter our inflammatory response to the flu virus.[12]

As with vitamin D, at the time of the 1918 pandemic, the important part played by sunlight in synchronizing these rhythms was not known.

Face Masks Coronavirus and Flu

Surgical masks are currently in short supply in China and elsewhere. They were worn 100 years ago, during the great pandemic, to try and stop the influenza virus spreading.

While surgical masks may offer some protection from infection they do not seal around the face.

So they don’t filter out small airborne particles. In 1918, anyone at the emergency hospital in Boston who had contact with patients had to wear an improvised face mask. This comprised five layers of gauze fitted to a wire frame which covered the nose and mouth.

The frame was shaped to fit the face of the wearer and prevent the gauze filter touching the mouth and nostrils. The masks were replaced every two hours; properly sterilized and with fresh gauze put on.

They were a forerunner of the N95 respirators in use in hospitals today to protect medical staff against airborne infection.

Temporary Hospitals

Staff at the hospital kept up high standards of personal and environmental hygiene. No doubt this played a big part in the relatively low rates of infection and deaths reported there.

The speed with which their hospital and other temporary open-air facilities were erected to cope with the surge in pneumonia patients was another factor.

Today, many countries are not prepared for a severe influenza pandemic.[13]

Their health services will be overwhelmed if there is one. Vaccines and antiviral drugs might help. Antibiotics may be effective for pneumonia and other complications. But much of the world’s population will not have access to them.

If another 1918 comes, or the Covid-19 crisis gets worse, history suggests it might be prudent to have tents and pre-fabricated wards ready to deal with large numbers of seriously ill cases. Plenty of fresh air and a little sunlight might help too.

Dr. Richard Hobday is an independent researcher working in the fields of infection control, public health and building design. He is the author of `The Healing Sun’.

References:

  1. Hobday RA and Cason JW. The open-air treatment of pandemic influenza. Am J Public Health 2009;99 Suppl 2:S236–42. doi:10.2105/AJPH.2008.134627.
  2. Aligne CA. Overcrowding and mortality during the influenza pandemic of 1918. Am J Public Health 2016 Apr;106(4):642–4. doi:10.2105/AJPH.2015.303018.
  3. Summers JA, Wilson N, Baker MG, Shanks GD. Mortality risk factors for pandemic influenza on New Zealand troop ship, 1918. Emerg Infect Dis 2010 Dec;16(12):1931–7. doi:10.3201/eid1612.100429.
  4. Anon. Weapons against influenza. Am J Public Health 1918 Oct;8(10):787–8. doi: 10.2105/ajph.8.10.787.
  5. May KP, Druett HA. A micro-thread technique for studying the viability of microbes in a simulated airborne state. J Gen Micro-biol 1968;51:353e66. Doi: 10.1099/00221287–51–3–353.
  6. Hobday RA. The open-air factor and infection control. J Hosp Infect 2019;103:e23-e24 doi.org/10.1016/j.jhin.2019.04.003.
  7. Schuit M, Gardner S, Wood S et al. The influence of simulated sunlight on the inactivation of influenza virus in aerosols. J Infect Dis 2020 Jan 14;221(3):372–378. doi: 10.1093/infdis/jiz582.
  8. Hobday RA, Dancer SJ. Roles of sunlight and natural ventilation for controlling infection: historical and current perspectives. J Hosp Infect 2013;84:271–282. doi: 10.1016/j.jhin.2013.04.011.
  9. Hobday RA. Sunlight therapy and solar architecture. Med Hist 1997 Oct;41(4):455–72. doi:10.1017/s0025727300063043.
  10. Gruber-Bzura BM. Vitamin D and influenza-prevention or therapy? Int J Mol Sci 2018 Aug 16;19(8). pii: E2419. doi: 10.3390/ijms19082419.
  11. Costantini C, Renga G, Sellitto F, et al. Microbes in the era of circadian medicine. Front Cell Infect Microbiol. 2020 Feb 5;10:30. doi: 10.3389/fcimb.2020.00030.
  12. Sengupta S, Tang SY, Devine JC et al. Circadian control of lung inflammation in influenza infection. Nat Commun 2019 Sep 11;10(1):4107. doi: 10.1038/s41467–019–11400–9.
  13. Jester BJ, Uyeki TM, Patel A, Koonin L, Jernigan DB. 100 Years of medical countermeasures and pandemic influenza preparedness. Am J Public Health. 2018 Nov;108(11):1469–1472. doi: 10.2105/AJPH.2018.304586.

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Coronavirus: Facts vs. Panic

Separating facts from irrational fear in the global virus pandemic.

Coronavirus Facts vs Panic
A hospital sign in Switzerland urges patients to consider working from home. FABRICE COFFRINI/AFP via Getty Images

Coronavirus is nothing to sneeze at. But so far, widespread panic may not be justified.

You should know:

  • Almost all of the reported coronavirus deaths in the U.S. happened in long-term care facilities in Washington State. And almost all of those occurred at the same facility.
  • Most people who get coronavirus have mild or no symptoms.
  • No young or middle-age people have died of coronavirus in the U.S. 
  • Most around the world diagnosed from January-March 1 have already recovered.

Obviously, this is a fast-moving news target. For the latest information from the government, you can visit the Centers for Disease Control (CDC) coronavirus page at CDC.gov. The following information is accurate as of Thursday.

Q: What is the average American’s risk of getting coronavirus?

A: Low. CDC reports: “For the majority of people, the immediate risk of being exposed to the virus that causes COVID-19 is thought to be low.”

Q: What’s the likelihood that coronavirus is in my community?

A: Low. CDC reports: “There is not widespread circulation in most communities in the United States.”

Q: How many coronavirus deaths have there been in the U.S.?

A: So far, not many. CDC reports 36 deaths. Adding various news reports, the number could be about 40 and growing. Although one death is too many, the reported deaths are among 43 states (including the District of Columbia) reporting outbreaks since January in a population of more than 327 million people.

Q: How many young people have died of coronavirus in the U.S.?

A: So far, there are no reports of deaths among young people in the U.S. The U.S. Surgeon General reports the average age of people who have died from coronavirus in the U.S. is 80. Additionally, he says those who are most impacted have chronic, serious health problems such as heart disease, diabetes, and lung disease.

Q: Who has died so far?

A. These were compiled using CDC reports plus news and local health department reports: 

  • 31 Washington State elderly. That includes 27 in King County, (22 at the same elderly nursing facility in Kirkland), three in Snohomish county, and one in Grant County, a patient in their 80s.
  • Four California elderly: A woman in assisted living in her 90s, a hospitalized woman Santa Clara in her 60s, an “elderly man” in assisted living, and a 71-year-old man with underlying health conditions who’d been on a Grand Princess cruise ship. 
  • Two Florida residents in their 70s who had traveled overseas. 
  • One New Jersey diabetic man, 69, who suffered two cardiac arrests. 
  • One South Dakota man aged 60-69, with “underlying medical conditions”
  • One Georgia man, 67, with “underlying medical conditions”

Q: How many people have recovered?

A: News reports say that in China alone, out of 80,000 diagnosed, nearly 60,000 have already recovered. However, the true number of recovered is likely far higher since most of those who get the virus have mild or no symptoms, and so are not diagnosed at all.

Q: Why have there been so many coronavirus deaths in Italy?

A: Italy has reported 827 coronavirus deaths. Experts say the high number is partly because Italy has more residents in the vulnerable age category. Italy has the oldest population in Europe and more elderly per capita than the U.S. Most of the Italian deaths are in patients in their 80s and 90s. In addition, Italy has a great number of direct China contacts. Italy was the first to join China’s “silk road” economic partnership project. The coronavirus is believed to have originated in China. Italy’s 827 deaths are out of a population of 60 million people. Even though one death is too many, it is still a small relative number.

Q: Why am I hearing so many different fatality rates?

A: Experts say all coronavirus death rates are nothing more than estimates at the moment. That’s because it is impossible to know how many people have or had the virus. And that total number is needed to calculate an accurate rate. What makes it more difficult is the fact that most people have few or no symptoms, and so it is impossible to count them.

Some current death rates that sound high are being calculated in a particular age group. The rate will be highest among the elderly and, in the U.S., there have been zero deaths among people age 50 and under. Some death rates are being calculated as deaths among the sickest patients, those are diagnosed and treated, which will produce a much higher number than a more accurate death rate that takes into consideration those patients who are infected but do not become ill at all.

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How long can the new coronavirus last on surfaces?

A new study suggests the virus can live on surfaces for up to 3 days.

How long can the new coronavirus last on surfaces
The new SARS-CoV-2 remains a mystery. (Image: © NIAID-RML)

As the coronavirus outbreak continues to accelerate in the U.S., cleaning supplies are disappearing off the shelves and people are worried about every subway rail, deli counter and toilet seat they touch. 

But how long can the new coronavirus linger on surfaces, anyway? The short answer is, we don’t know. A new analysis found that the virus can remain viable in the air for up to 3 hours, on copper for up to 4 hours, on cardboard up to 24 hours and on plastic and stainless steel up to 2 to 3 days. However, this study, which was published in the preprint database medRxiv on Wednesday (March 11),  has not yet yet been peer-reviewed.

Another study published in February in The Journal of Hospital Infection analyzed several dozen previously published papers on human coronaviruses (other than the new coronavirus) to get a better idea of how long they can survive outside of the body. 

They concluded that if this new coronavirus resembles other human coronaviruses, such as its “cousins” that cause SARS and MERS, it can stay on surfaces —  such as metal, glass or plastic — for as long as nine days (In comparison, flu viruses can last on surfaces for only about 48 hours.)

But some of them don’t remain active for as long at temperatures higher than 86 degrees Fahrenheit (30 degrees Celsius). The authors also found that these coronaviruses can be effectively wiped away by household disinfectants. 

For example, disinfectants with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite (bleach) can “efficiently” inactivate coronaviruses within a minute, according to the study. “We expect a similar effect against the 2019-nCoV,” the researchers wrote, referring to the new coronavirus. But even though the new coronavirus is a similar strain to the SARS coronavirus, it’s not clear if it will behave the same.

It’s also not clear how frequently hands become contaminated with coronaviruses after touching a sick patient or contaminated surface, according to the study. The World Health Organization recommends washing hands or using alcohol-based hand rubs for decontamination of the hands, the authors wrote.

It’s possible that a person can be infected with the virus by touching a contaminated surface or object, “then touching their own mouth, nose, or possibly their eyes,” according to the Centers for Disease Control and Prevention (CDC). “But this is not thought to be the main way the virus spreads.” Though the virus remains viable in the air, the new study can’t say whether people can become infected by breathing it in from the air,  according to the Associated Press

The virus is most likely to spread from person to person through close contact and respiratory droplets from coughs and sneezes that can land on a nearby person’s mouth or nose, according to the CDC.

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