Public Health Rep.
2007 Nov-Dec ; 122 ( 6 ) : 803–810 . department of the interior :10.1177/003335490712200612
Reading: Lessons Learned from the 1918–1919 Influenza Pandemic in Minneapolis and St. Paul, Minnesota
PMID : 18051673
Lessons Learned from the 1918–1919 Influenza Pandemic in Minneapolis and St. Paul, Minnesota
, AB, , MPH, , PhD, MPH, and, MD
Miles Ott is a public Health Graduate Student Worker, Shelly F. Shaw is an epidemiologist, Richard N. Danila is a deputy State Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, in St. Paul, Minnesota. Find articles by Miles Ott
Shelly F. Shaw
Miles Ott is a public Health Graduate Student Worker, Shelly F. Shaw is an epidemiologist, Richard N. Danila is a deputy State Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, in St. Paul, Minnesota. Find articles by Shelly F. Shaw
Richard N. Danila
Miles Ott is a public Health Graduate Student Worker, Shelly F. Shaw is an epidemiologist, Richard N. Danila is a deputy State Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, in St. Paul, Minnesota. Find articles by Richard N. Danila
Miles Ott is a populace Health Graduate Student Worker, Shelly F. Shaw is an epidemiologist, Richard N. Danila is a deputy State Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, in St. Paul, Minnesota. Find articles by Ruth Lynfield Author information Copyright and License information Disclaimer Miles Ott is a public Health Graduate Student Worker, Shelly F. Shaw is an epidemiologist, Richard N. Danila is a deputy State Epidemiologist, and Ruth Lynfield is a Medical Director and State Epidemiologist. All are with the Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, in St. Paul, Minnesota. Address commensurateness to : Richard N. Danila, PhD, MPH, Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division, Acute Disease Investigation and Control Section, 625 Robert St. N, P.O. Box 64975, St. Paul, MN 55164-0975, telephone : 651-201-5414, Fax : 651-201-5743, su.nm.etats.htlaeh @ alinad.drahcir Copyright © 2007 Association of Schools of Public Health
Those who can not remember the by are condemned to repeat it. — George Santayana
spanish Influenza of 1918–1919 killed more than 50 million people worldwide over the course of two years. 1 The true origin of the 1918 influenza pandemic is obscure. During World War I, propaganda in war-engaged countries only permitted encouraging news, so as a neutral party, Spain was the first area to publicly report on the health crisis. 1 frankincense, spanish Influenza became a popular term. however, historic inquiry has shown that Spain was an improbable candidate as the initial source and some suggest that it originated in Kansas in the spring of 1918. Influenza pandemics have occurred regularly every 30 to 40 years since the sixteenth hundred. today, influenza experts consider the hypothesis of another influenza pandemic, not in terms of if but when. Due to the high likelihood of an influenza pandemic, plan is afoot in many U.S. states and other countries. We reviewed the responses of two neighboring Minnesota cities during the 1918–1919 pandemic to gain penetration that might inform planning efforts nowadays. many of the components of current pandemic influenza plans were utilized to some degree in Minneapolis and St. Paul during 1918–1919. coordination between unlike levels and branches of government, improved communications regarding the spread of influenza, hospital billow capability, aggregate dispense of vaccines, guidelines for infection control, containment measures including case isolation and closures of populace places, and disease surveillance were all employed with varying degrees of success. We focus on medical resources, community disease containment measures, populace answer to community containment, contagion control and inoculation, and communications .
PANDEMIC BEGINNINGS IN MINNESOTA
Minnesota ‘s first spanish Influenza cases were identified in the last week of September 1918. As in the stay of the nation, Minnesota ‘s first gear cases “ were immediately traceable to soldiers, sailors, or [ their ] friends. ” 2 Every military base and military hospital in the Minneapolis-St. Paul area was badly affected. Case isolation was lento implemented at both Fort Snelling and the Dunwoody Naval Detachment ( military installations in Minneapolis ). On September 30, the first day of isolation, cases numbered in the hundreds. 3 influenza cases were not limited to enlisted men for long. In Minneapolis, the phone number of civilian cases outstripped the number of military cases for the beginning time on October 9, less than two weeks after the inaugural subject was identified in the state ( 700 civilian cases ; 675 cases at Fort Snelling ). 4 Influenza had become a reportable condition in Minnesota on October 8 in answer to the growing epidemic. 5
Two major issues contributed to the gravity of the pandemic : the war effort and limit scientific cognition. World War I was not only dearly-won, it required much of the checkup community to be stationed oversea. In 1918, little was known about influenza. While this miss of cognition did not negatively impingement contagion control actions, effective discussion and prevention methods were not in full utilized. When influenza first appeared in Minnesota on September 27, the state was ill equipped for a health crisis. 2 Although World War I was coming to an end, more than four million Americans were mobilized and the nation ‘s resources were directed to supporting the war effort. An column in the Minneapolis Tribune daily newspaper described the miss of physicians and nurses : “ The checkup fraternity is badly tax already. thus many physicians and surgeons have gone to Europe or to coach that those at home plate have more than they can attend to comfortably and to dependable advantage. ” 6 The number of influenza patients that needed the care of physicians and nurses overpower St. Paul and Minneapolis clinicians. The war ‘s considerable enfeeble on the medical profession was compounded by other factors that hindered nurse and doctor mobilization. Methods to keep them healthy while caring for influenza patients were ineffective. many health-care providers fell ill, and some died. At one detail, Minneapolis ‘s City Hospital reported that “ about half of the nurse staff has been ill with influenza in the last three weeks. ” 7 This bare site discouraged some clinicians from providing their services. Dr. H.M. Bracken, Secretary of the Minnesota State Board of Health, reported to Dr. Rupert Blue, U.S. Surgeon General, on his political campaign to recruit physicians for the influenza effort : “ A issue who we have called for give birth made excuses and have not come at all. ” 8 early physicians who were recruited by Dr. Bracken just did not show up. 9 Dr. Bracken attempted to secure aged medical students for influenza work. Dr. Bracken worked not only with the U.S. Surgeon General but besides with the Surgeon General of the Army, the Committee on Education and Special Training, and the Dean of the University of Minnesota Medical School for three weeks and still was unable to obtain aged medical students for aid, because each party insisted that person else had to authorize it. In the end, Bracken failed to receive any medical students. 10 not amazingly, Minneapolis and St. Paul hospitals proved to be inadequate to handle the large total of patients. Minneapolis ‘s City Hospital and St. Paul ‘s St. John ‘s Hospital were entirely devoted to treating influenza patients. Non-influenza patients were transferred to other area hospitals. This insufficiency was not entirely due to the miss of beds and supplies ; there simply were not adequate healthy nurses. At City Hospital, Superintendent Dr. Harry Britton reported that the “ hospital was caring for about 150 cases, and had about 70 on the waiting list. It had beds available for that waiting number, but not nurses. ” 11 In St. Paul, a system was set up between St. John ‘s Hospital and other hospitals to insure an adequate number of nurses to care for influenza patients, but unfortunately this system failed. Dr. F.C. Plondke, St. John ‘s Hospital ‘s Medical Director, complained that the early hospitals were abandoning their promises to assign avail from their nurse staff. “ The other hospitals had refused to furnish a single nanny to aid the fifteen who are caring for ninety patients at St. John ‘s from their individual nurse staffs. ” 12 In 1918, medical science maintained that influenza was bacterial in origin. Physicians at Fort Snelling claimed that the “ bacillus influenza of Pfeiffer, ” which is today known as Haemophilus influenzae, was the cause of spanish Influenza. 1, 13 Nevertheless, despite this miss of understanding about viruses, advice to curb infection was relatively accurate. The Minnesota State Board of Health recommended the function of handkerchiefs to cover sneezes and coughs, batch of fresh air out, avoidance of the vomit and of herd, and to contact a doctor if ill. 14
COMMUNITY DISEASE CONTAINMENT
As influenza was beginning to take hold in the civilian population, there was disagreement between the Minneapolis and St. Paul health commissioners, Dr. Guilford and Dr. Simon, respectively. Their approaches varied ; Dr. Guilford tended to be broadly proactive to prevent cases, whereas Dr. Simon tended toward initiating activities in response to individual cases. Dr. Guilford believed that closing public places was the best course of action and that isolation of individual cases was useless.15 Dr. Simon asserted that isolation of influenza cases would be more effective in preventing the dispersed of disease.14 The St. Paul Health Department and the Minnesota State Board of Health met Dr. Guilford ‘s firm advocacy with opposition. Dr. Bracken, siding with St. Paul, questioned, “ If you begin to close, where are you going to stop ? When are you going to reopen, and what do you accomplish by opening ” ? 11 argue between the two cities on the merits of close schools caused farther tune. Dr. Simon held that St. Paul ‘s school nurses were the best refutation against the spread of the disease, and that close schools would allow cases to go undetected as the children would not be under any checkup supervision. Dr. Guilford disagreed, pointing out that 30 school nurses would not be able to adequately care for the 50,000 pupils in the Minneapolis public school arrangement during a pandemic. 16 Minneapolis closed the schools on two separate occasions ( October 12 to November 17, and December 10 to December 29, 1918 ). Despite Dr. Simon ‘s conviction that the shutting of populace places would be ineffective, on November 6 St. Paul government officials overruled him and enacted a close order for the unharmed city, including schools, theaters, churches, and dance halls. The St. Paul Citizens ‘ Committee—consisting of 15 physicians, church leaders, and community members who were appointed by Dr. Simon—which was concerned by the criminal record of 218 new cases on November 5, a well as 36 deaths between November 4 and November 5, 1918, recommended this policy change ( ). 17 The number of new cases began to decline 10 days belated, with only 24 new cases, and the future day, Dr. Simon reopened St. Paul businesses and churches .Open in a separate window aCases were not uniformly reported on Sundays, so Monday ‘s data may be inflated. Minneapolis and St. Paul both attempted to combat influenza by limiting crowding in places with restricted access to fresh vent. Both cities enacted streetcar regulations aimed to keep the air in the streetcars newly by mandating open windows and limiting the number of passengers to 84 ( streetcars had a seat capability of 46 ). 5, 17, 18 Because the standard limiting the number of car passengers, implemented on October 26 in St. Paul, was deemed successful, Minneapolis enacted a similar regulation on October 30. 17 As an experiment, Dr. Bracken besides proposed that St. Paul regulate the commercial enterprise hours of stores and theaters to keep streetcar congestion to a minimum. once again, Minneapolis followed St. Paul ‘s case on October 16, 1918, by regulating the hours of retail stores, function buildings, and sweeping stores. 19 There were respective complaints that the mandate in Minneapolis to keep three streetcar windows open at all times caused people to get disgusted ascribable to winter colds. A compromise was reached by Dr. Guilford allowing streetcars with heat and breathing systems to close their windows once the temperature dropped to 32 degrees Fahrenheit. 20 St. Paul besides targeted elevators as places where influenza could easily be transmitted ascribable to the compressed quarters and limited bracing air. Buildings with fewer than six stories were no long permitted to use their elevators. 21
Public response to community containment disease
The measures used to contain influenza greatly affected the daily lives of citizens. While some accepted the changes imposed on them, others protested regulations that they considered unfair. Some called for more rigorous methods, while others blatantly broke the new rules that were intended to protect them. The closure of public places in Minneapolis was announced in advance, so people rushed to complete those activities that would soon be banned, resulting in the very lapp crowded conditions the ban sought to prevent. “ downtown theaters were packed last night with patrons who took advantage of their last gamble to see a performance until the banish is lifted. ” 22 While some St. Paul citizens were relieved that Dr. Simon initially pledged to keep public places open, others felt this was wrong. “ fear of influenza contagion in crowd places has reduced the patronize of St. Paul apparent motion picture theaters by about half, according to reports to Dr. H.M. Bracken. ” 23 many sporting organizations responded negatively to closing orders. For model, in November 1918, the bowlers of St. Paul drew up a request that requested license to begin bowling again. 24 Minneapolis football teams chose to ignore the ban and attempted to play against each other in front of large push. Police were called in to disperse the crowd and halt the games. 25 Minneapolis teams found a way to play despite the close order. Because Minneapolis high school football games were banned, commit games were scheduled with St. Paul team. 26 several establishments serving alcohol and food measuredly broke the close club to continue their even clientele. “ One barroom was discovered with the back door route loose. ” 27 The elevator regulations in St. Paul were particularly unpopular. “ Some of the downtown hotels objected to stopping their elevators, saying that they would lose guests. This caused a change in the rule to permit hotel elevators and those in apartment houses to operate. ” 28 many insisted it was insalubrious for the vomit to be forced to climb stairs in their afflicted country, while others felt implicated that people would be shut off from clean atmosphere if they were not allowed to use their elevators. consequently, the city compromised and all elevators were rear in use starting November 9, 1918, although merely one person per 5 square feet was permitted. 29 The Hennepin County School Board ( where Minneapolis is located ) was exceptionally defiant to the close order. The school board was concerned for the health of the students equally well as the “ 12,000 dollars a day ” that the closing orders cost because teachers continued to be paid, and extra school days would have to be added to the school year. 30 Against the denotative orders of Dr. Guilford, and the plead of respective Parent-Teacher Association officers, the school board reopened schools on October 21, lone to be shut down on the same day under terror of patrol action. 31 In St. Paul, all influenza cases were supposed to be reported to a doctor, who in call on was required to isolate the case in his or her own dwelling and notify the health department. respective problems sprung up with these requirements that hampered surveillance, the worry of patients, and protecting people from getting vomit. For one, both physicians and patients were frequently hesitant to bring care to cases. “ Physicians are not reporting their cases to prevent homes from being quarantined. ” 21 ( note : At the clock time of the 1918 influenza pandemic, the separation of the ill from the general population, what is now referred to as isolation, was termed “ quarantine. ” ) The ill besides sought to evade isolation in their homes by not seeking medical attention, or only seeking aesculapian attention when they became badly ill. “ Hundreds of persons in the city do not call for aesculapian aid until the second, third, or fourth day and in many cases pneumonia already has developed when aesculapian attention is beginning given. ” 29 Staffing shortages made isolation evening less desirable. Because there were a circumscribed number of inspectors to release houses from isolation, houses were not released promptly from isolation. 32 Starting on November 15, St. Paul telephone operators went on strike. According to the Pioneer Press day by day newspaper, “ Less than one third the newfangled cases [ are ] being reported to the health department, ” as a result of the call rap. 33 This strike not only affected the report of cases, but besides isolation, equally well as their release from such a measure. After all of the difficulties involved in establishing isolation for each case, some flagrantly disobeyed the isolation orders all in all. “ Disregard of the city quarantine yesterday caused the halt of one man who insisted on taking his child from the city hospital before the affected role was ready to be discharged. The beget and don and the child later were found mingling with early persons in the neighborhood. ” 29
INFECTION CONTROL AND VACCINATION
In addition to closing public places and isolating cases in their homes, both Minneapolis and St. Paul health departments took other steps to keep people from getting infected. The use of gauze masks, more rigorous sanitation laws, and vaccination campaigns were deployed in this attempt. Directions for wearing the masks were issued to the public. “ The outside of a face dissemble is marked with a black thread waver into it. Always wear this side away from the confront. Wear the mask to cover the nose and the mouth, tying two tapes around the head above the ears. Tie the early tapes rather tightly around the neck. never wear the mask of another person. When the mask is removed … it should be cautiously folded with the inside folded in, immediately boiled and disinfected. When the dissemble is removed by one seeking to protect himself from the influenza it should be folded with the inside folded out and boiled ten minutes. Persons well exposed to the disease should boil their masks at least once a day. ” 21 however, there was inconsistent advice on the use of gauze masks. Dr. Bracken, of the State Board of Health, advocated the erosion of masks, though he did not wear one himself, saying, “ I personally prefer to take my chances. ” 34 aesculapian students working in clinics in each district of St. Paul distributed gauze masks. 12 But the Citizens ‘ Committee rejected an regulation requiring the exhausting of masks at all times, even though, “ All physicians were united in the public opinion that the gauze covering should be worn in hospitals or in the presence of doubtful cases. ” 35 Despite the miss of official orders requiring the wear of masks and Dr. Bracken ‘s indecipherable message, many people sought out masks for themselves. The Northern Division of the American Red Cross manufactured tens of thousands of masks. Minneapolis ordered 15,000 masks from the Red Cross on October 1, 1918. 36 These masks were used by nurses in schools and hospitals, doctors, hospital visitors, and those suspected of being infected with influenza. 37 As the total of cases increased in St. Paul, employers sought ways to keep their workers healthy and productive. several companies requested masks to distribute to their workers. Despite the thousands of masks provided by the Red Cross, even more were needed to fulfill the demand. The Citizens ‘ Committee suggested that companies ask their female employees to fabricate masks for all their employees. 21 St. Paul introduced newly sanitation laws that called for the sterilization of dishes and cups in restaurants and bars, and the ban of curler towels and common drink cups in public restrooms. 38 At least two different vaccines were administered in Minneapolis-St. Paul, neither of them effective as neither actually contained influenza virus. One made by bacteriologists at the University of Minnesota was purported to prevent pneumonia. 39 The Mayo Clinic in Rochester, Minnesota, made another vaccine that was intended to prevent both pneumonia and influenza. 40 This latter vaccination was composed of Streptococcus pneumoniae types I, II, and III, S. pneumoniae group IV, hemolytic streptococcus, Staphylococcus aureus, and “ influenza bacillus. ” 41 military personnel a well as civilians were inoculate begin equally early as October 4, 1918. 37 Both city health departments purchased vaccine and distributed it to physicians at no charge to encourage far-flung use. In Minneapolis, people desiring the vaccine “ thronged ” the offices of doctors hoping to be vaccinated, and in St. Paul it was reported that “ thousands of persons have been inoculated. ” 39, 42 Some physicians took advantage of their access to vaccine and the public ‘s reverence of influenza. According to St. Paul ‘s Citizens ‘ Committee, it was discovered that “ a few physicians were charging a fat tip for inoculations. ” 29 This was particularly disturbing as the vaccinations were supplied to the physicians for free .
postal workers, Boy Scouts, and teachers were enlisted to provide educational materials to the public and to teach health precautions. Mail carriers distributed educational materials on their routes. Boy Scouts distributed posters to stores, offices, and factories in downtown Minneapolis. 22 Minneapolis teachers who were put out of ferment by the conclude of schools were asked to volunteer for a health education campaign. The main goals of the campaign were to get rid of shared drink cups, which were the precursor of the water spring, adenine well as the roller towels, which were used to dry hands after washing. 43 St. Paul teachers were sent “ to ascertain the betroth of families worst affected by the epidemic. ” 28 This was accomplished through a sail of homes where the teachers learned if anyone was ghastly, needed to see a doctor, or needed food. 27 St. Paul set up a populace kitchen, a children ‘s home plate, and an emergency hospital for these cases. 21
Although the two cities chose different methods of disease containment, determining which method acting was more successful is challenging. information on cases in both cities depended on ill individuals seeking the attention of physicians, who were in light provision. The physicians were then required to report the count of newly cases each day to their city health department. The city then reported the sum number of cases to the newspapers, which published the count of new cases and deaths each day. This range of information left much room for error and possible falsification. Because St. Paul chose to utilize isolation and Minneapolis did not, sheath report varied greatly between the two cities. Individuals with influenza who had their status reported in St. Paul had to endure isolation until they were released with a doctor ‘s approval. This may have discouraged people from seeking the attention of physicians, and thus being reported—an undesired consequence of enforce isolation ( ). Because those with influenza were not isolated in Minneapolis, more people might have felt comfortable seeking medical attention. This could explain why St. Paul had such a high shell fatality rate compared with Minneapolis (, and ) .Open in a separate window aCases were not uniformly reported on Sundays, so Monday ‘s data may be inflated .Open in a separate window aCases were not uniformly reported on Sundays, so Monday ‘s data may be inflated .
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several factors impede aim comparisons of the two cities ‘ approaches. The cities border each other and residents travel back and forth. Although the containment philosophies differed greatly, in reality St. Paul government officials overruled public health, and schools and populace meet places were closed in both cities for varying lengths of clock time. Although the effects of isolation vs. settlement of public places can not be specifically determined, other lessons can be learned from what happened in 1918. many steps could have been taken to prevent illness and save lives. Prior plan, open orders, adenine well as consistent and guileless advice and information to the public may have made a significant difference in the number of cases and deaths ascribable to influenza in 1918. There was a dearth of planning for a health emergency when influenza first appeared. While the actions that the two city health departments took to stem the spread of influenza align closely with stream pandemic plans, health officials had the disadvantage of trying to conceive and realize plans during a health crisis. many current recommendations were implemented, including the use of masks, the use of vaccines ( albeit ineffective ones ), increasing the strictness of sanitation measures, limiting crowding in public places, and trying to coordinate hospitals, nurses, physicians, and aesculapian students to maximize resources. As region of maximizing human resources during an influenza pandemic, it is imperative mood that the base hit of health-care workers is insured. The number of nurses and physicians who fell ill and even died as a solution of assisting in the fight against the pandemic scared other nurses and physicians away. Had these ideas been generated prior to such a big hand brake, several problems could have been averted. The debates and disagreements between different public officials and health agencies, as with the Hennepin County School Board and the Minneapolis Health Department or between the Minneapolis Health Department and the St. Paul Health Department, could have been discussed in advance. Supplies could have been stockpiled, occupation leaders and community members could have provided remark on controversial disease containment policies, and checkup students could have been put to work in hospitals and communities that lacked physicians. unfortunately, these disputes arose and continued throughout the pandemic. clear authority and management by public health officials were broadly lacking at the federal and submit levels. It was about as if the fear of using their authority led Surgeon General Blue and Dr. Bracken to fail to take decisive action. Surgeon General Blue suggested to Dr. Bracken, and all other submit health officials, “ the advisability [ of ] discontinuing all public meetings, closing all schools and places of public entertainment on appearance of local anesthetic outbreaks. ” 44 Because this was merely a trace, and local outbreaks were not defined objectively, Blue ‘s pressing telegram had no effect. On the department of state level, Dr. Bracken acknowledged that the St. Paul Health Department “ followed his advice ” to not close public places, and went on to say that St. Paul, “ has the world power to do the opposite any time it wants to. ” 11 This statement forced local health departments to define their own rules while attempting to decipher conflicting messages from the state and federal level. Because clear orders were not being given to public health officials, the public in turn was not receiving crystalline and consistent advice and information. Should the public wear masks ? Why was it allowable to be future to person in a streetcar and not in an elevator ? Why were church services closed while Red Cross workers gathered in crowded conditions in those very same churches ? Was influenza a dangerous condition, or was panic the most dangerous chemical element of the influenza pandemic ? In Minneapolis and St. Paul. there was no unmarried message on any of these issues. In many cases, the public had to decide for itself. In which subject, the effect of the messages that were communicated alone served to contradict each other. In reviewing this history, some lessons stand out. late analyses of nonpharmaceutical interventions during 1918 argue cities in which multiple interventions were implemented early in the pandemic fared better. 45 Of primary coil importance is developing a design ahead of time that incorporates all levels of government health infrastructure and describes clear lines of responsibilities and roles. Plans for billow capacity and community containment must be discussed with stakeholders and consensus must be achieved. further, general approaches should be put away for populace comment and approval. The public health profit of isolation should be weighed against the possibility that some people would be discouraged from seeking care. net explanations of the cause for isolation, generous employer accompaniment, and providing food, medicate, and social servicing to those in isolation may mitigate fears and increase cooperation. The public must besides be educated about the intelligent behind other health measures ( i.e., closures ), should those methods be implemented. Approaches and plans should be based on scientific data whenever possible, and include stimulation from ethicists. Unlike in 1918, a pandemic influenza vaccine will probably be available today, albeit four to six months after the pandemic starts. But similar to 1918, the challenge will be designing an orderly and ethical distribution of a scarce commodity. Further, experts in gamble communication should assist in developing messages that are scientifically accurate, apprehensible, clear, and utilitarian. ultimately, we need to take careful note of local and national lessons from the past so we do not repeat them .
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Spanish Influenza gains headway here. Minneapolis Tribune 1918 Oct 1; 8.
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Influenza gains slowly in city. Minneapolis Tribune 1918 Oct 10; 1,8.
Influenza gains among civilians. Minneapolis Tribune 1918 Oct 9; 1,7.
Editorial. Minneapolis Tribune 1918 Oct 3; 16.
Sailors may attend influenza patients. Minneapolis Tribune 1918 Nov 3; 4.
Henry Bracken to Rupert Blue, 1918 Nov 13, Minnesota Department of Health Correspondence and Miscellaneous Records, 1895–1954, Minnesota Historical Society.
Henry Bracken to Rupert Blue, 1918 Nov 2, Minnesota Department of Health Correspondence and Miscellaneous Records, 1895–1954, Minnesota Historical Society.
Henry Bracken to Dr. Merritte W. Ireland, 1918 Nov 16, Minnesota Department of Health Correspondence and Miscellaneous Records, 1895–1954, Minnesota Historical Society.
Business hours may be changed to curb epidemic. Minneapolis Tribune 1918 Oct 15; 1,10.
Lid on tomorrow includes schools. St. Paul Pioneer Press 1918 Nov 5; 6.
150 cases of influenza in Minneapolis. Minneapolis Tribune 1918 Sep 30; 1.
Mill City closed. St. Paul Pioneer Press 1918 Oct 12; 1,6.
Doctors propose drastic lid be clamped on city. Minneapolis Tribune 1918 Oct 11; 1,2.
Clash over school order due Monday. Minneapolis Tribune 1918 Oct 20; 1.
Push grip fight. St. Paul Pioneer Press 1918 Oct 30; 1.
Epidemic controlled in city’s army camps car crowds, 558 pupils stricken. Minneapolis Tribune 1918 Oct 29; 10.
Trade hours set to stem Spanish Influenza here. Minneapolis Tribune 1918 Oct 16; 1,2.
Ban on until deaths decrease to 7 a day. Minneapolis Tribune 1918 Nov 10; 14.
Sweeping order against influenza in effect here today. St. Paul Pioneer Press 1918 Nov 6; 1,7.
Influenza lid clamped tight all over city. Minneapolis Tribune 1918 Oct 13; 1,10.
See less influenza. St. Paul Pioneer Press 1918 Oct 15; 8.
Pins will fall. St. Paul Pioneer Press 1918 Nov 17; 7.
“Flu” order stops park grid games. Minneapolis Tribune 1918 Oct 14; 18,12.
High school games neither on nor off. Minneapolis Tribune 1918 Oct 15; 18,12.
Fail to report grip. St. Paul Pioneer Press 1918 Nov 8; 10.
Plan survey of influenza cases. St. Paul Pioneer Press 1918 Nov 7; 1.
All lifts to run. St. Paul Pioneer Press 1918 Nov 9; 1,7.
School chiefs face arrest or injunction, city officials to use law as directors defy influenza ban. Minneapolis Tribune 1918 Oct 21; 1,2.
Guilford wins fight to keep schools shut. Minneapolis Tribune 1918 Oct 22; 1.
Shows open today. St. Paul Pioneer Press 1918 Nov 15; 1.
Influenza relief work disrupted as a result of telephone strike. St. Paul Pioneer Press 1918 Nov 16 1.
Influenza lid to go on city today. St. Paul Pioneer Press 1918 Nov 4; 1,3.
Speed grip fight. St. Paul Pioneer Press 1918 Nov 2; 1.
Influenza spread held slight here. Minneapolis Tribune 1918 Oct 2; 1,4.
Influenza halts “U” opening to all but S.A.T.C. Minneapolis Tribune 1918 Oct 5; 1,22.
Cafes and bars hit by grip ban. St. Paul Pioneer Press 1918 Dec 14; 1.
Serum to be issued. St. Paul Pioneer Press 1918 Oct 19; 6.
Epidemic statistics show decline in city. Minneapolis Tribune 1918 Oct 25; 15.
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Epidemic brings mercy problems. St. Paul Pioneer Press 1918 Nov 17; 1.
Teachers released for school closing period. Minneapolis Tribune 1918 Oct 15; 11.
Telegram from Rupert Blue to Dr. Henry Bracken, 1918 Oct 6, 6:49 pm, Minnesota Department of Health Correspondence and Miscellaneous Records, 1895–1954, Minnesota Historical Society.
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