SUBJECTS — Health (infectious disease; influenza; pandemics); Medicine; Science-Technology;
SOCIAL-EMOTIONAL LEARNING — Surviving;
MORAL-ETHICAL EMPHASIS — Responsibility.
MPAA Rating: PG-13 (for disturbing content and some language); Drama; 2011, 106 minutes; Color. Available from Amazon.com.
This movie describes a fictional influenza pandemic: the origin of the virus, the human toll, the response of the public health agencies, and the various reactions of people to a public health emergency. The film is a reasonable prediction of what would occur in the event of a moderately lethal influenza pandemic.
Students will understand the risks to modern society from the influenza virus and see a realistic scenario of what might occur in case of moderately lethal influenza pandemic. Students will learn to use the Internet to obtain information on illnesses from various websites, including www.cdc.gov from the Centers for Disease Control (CDC) and www.flu.gov from the U.S. Department of Health & Human Services (HHS).
Seven Types of Symptoms of Influenza
Influenza is a respiratory disease with symptoms that last one to two weeks. Types of influenza symptoms include:
A fever or feeling feverish (although not everyone with the flu has a fever)
A cough and/or sore throat
A runny or stuffy nose
Headaches and/or body aches
Nausea, vomiting, and/or diarrhea (most common in children)
The flu and the common cold have similar symptoms, and it can be difficult to tell them apart. In general, the flu is worse than the common cold. Symptoms such as fever, body aches, tiredness, and cough are more common and intense with the flu. People with colds are more likely to have a runny or stuffy nose. Health care providers have a test that can determine whether a patient is suffering from the flu or a common cold.
For more information, go to Seasonal Flu — Symptoms.
The flu spreads when an infected person coughs, sneezes, or talks and droplets containing the influenza virus are inhaled by another person. The flu can also spread when a person touches an object or a surface which has the virus on it and then touches his or her mouth, eyes or nose.
The best defense against the flu is vaccination. Other preventive measures are to live a healthy lifestyle and particularly get enough sleep and to eat well. Stay away from people who are ill. When exposed, see a physician about getting an antiviral drug. These drugs are more effective the sooner they are taken and can be beneficial to reduce symptoms if they are taken up to two days after a person becomes ill.
The incubation period from first infection until the onset of symptom is 1 – 4 days, averaging two days, in adults who will shed influenza virus beginning one day before they start to have symptoms through the next 5 – 10 days. (These figures are probably the same for otherwise healthy teenagers.) Young children and severely immunocompromised persons can shed virus for longer periods.
For more information, go to Seasonal Flu — Prevention.
Treatment for the flu starts with bed rest, drinking clear fluids such as water, broth, electrolyte beverages (sports drinks) to prevent dehydration, and taking over-the-counter medicines to help with symptoms. A humidifier can also make breathing easier. Saltwater gargles (1:1 ratio warm water to salt) will help with sore throats. Fevers and aches can be reduced with over-the-counter pain relievers and wet cool washcloths applied to the forehead, arms, and legs. For all medications, be sure to read the label and don’t take too much. Pharmacists can be helpful if there are any questions. Be especially careful of acetaminophen (Tylenol®) because it is found in many combination preparations and overdosing can cause serious liver damage. Note that antibiotics do not protect against viruses such as the flu. However, they can be helpful if a secondary bacterial infection develops.
The most common complications of the flu are bacterial pneumonia, ear and sinus infections, dehydration, and the worsening of chronic illnesses. Seek medical attention immediately if any of the following symptoms appear:
Fever over 102 degrees or fever lasts longer than three days
Difficulty breathing, wheezing when breathing, or shortness of breath
Purple or blue discoloration of the lips
Pain or pressure in the chest, abdomen or neck; a severe headache;
Severe or persistent vomiting
flu symptoms that worsen each day;
Flu-like symptoms that improve but then return with fever and worse cough
People who have the following chronic illnesses should seek medical help as soon as flu symptoms appear: heart disease, asthma, COPD, diabetes, or HIV/AIDS.
Do not treat this information as medical advice. The above descriptions of symptom paraphrases several apparently authoritative websites such as Seasonal Flu — Treatment from the CDC; Flu: What to do if you get sick from the CDC, and When to Call the Doctor About the Flu from WebMD.
The Seasonal Flu
Despite vaccines and advances in modern medicine, every year three hundred million to one billion people worldwide get sick from the flu; that’s between 5 and 15% of the human population. Seasonal flu is a mild to severe disease. Some years are worse than others, but the seasonal flu causes between 250,000 and 500,000 deaths each year. Most susceptible are the elderly, the chronically ill, and the very young. Actually, spread over the world, the deaths from flu are less than one-tenth of one percent of the population (or less than 1 in 1000). The U.S. is not immune from influenza. The Centers for Disease Control (CDC) estimates that each year 41,400 Americans die from the seasonal flu.
Vaccines protect people from getting sick, but they don’t kill the viruses that continue to live in various animal population reservoirs. Animals harboring influenza virus such as wild birds, pigs and chickens can have few symptoms or they are not sick at all. The viruses mutate frequently and some of these mutations allow them to cross from one species to another. Other mutations may make an existing human virus more communicable or more deadly.
Each year scientists are on the lookout for new influenza viruses. They create vaccines for these new viruses and put the vaccinates into the flu shots that many people get each fall. Hopefully, the doctors find all the new viruses, but sometimes they don’t. It is also possible that a new virus that is very infectious and very lethal, like the virus portrayed in the movie Contagion, will spread before the doctors even know it exists.
An example of how close disaster can come is the H5N1 Avian flu virus that first appeared in 2002. Scientists rate the danger of a strain of a virus using two measures: how infectious it is (how easily it passes from one person to another) and how lethal it is (what percentage of people die once they become ill). World Health Organization (WHO) confirms that as of February 2012, 584 people had contracted H5N1 and that 345 of those people died of the disease. That’s a mortality rate of 59%. However, and very fortunately, it is very hard for this virus to spread from one person to another – it cannot spread through the air or casual contact between people. The virus is found in some migratory bird populations. Recently, some scientists have suggested that this rate is too high based on the fact that only serious cases will be reported to international public health authorities, see Dread Reckoning: H5N1 Bird Flu May Be Less Deadly to Humans Than Previously Thought–or Not by Helen Branswell Scientific American, February 14, 2012. But even if mortality estimate for H5N1 is off by 75%, the resulting death rate of 14% would be about 5 times higher than the 1918/1919 pandemic which had a death rate of greater than 2.5%
Because the H5N1 virus has not developed the ability to spread easily from person to person and it has been around since 1997, scientists have had time to develop a vaccine against it that is safe and effective. If the virus mutates in a way that makes the vaccine ineffective, it will take several months to develop a new vaccine and in that time millions of people could die. However, just as there is no way to accurately predict how deadly and communicable the next mutation of the influenza virus might be, there is no way to predict the effectiveness of new ways of combatting its spread or new ways of treating the disease.
As shown in the film, modern life with international air travel has made influenza outbreaks more difficult to control. However, modern medicine, with vaccines and antibiotics, has worked in the other direction and has also made influenza easier to survive.
The Flu Pandemics of the Last 100 Years
A pandemic is a disease that occurs over a wide geographic area and affects an exceptionally high portion of the human population. In the last 100 years, there have been four influenza pandemics. They are compared to the seasonal flu in the following table.
* Some estimates are that as many as 100 million people died of the Spanish Flu.
** These are from verified lab results and probably are substantially under-reported.
The actual numbers are thought to be much higher.
While the Spanish Flu was the worst flu pandemic in modern history, in some ways the world was lucky. While it was 20 times more lethal than ordinary seasonal flu, the Spanish Flu was not as infectious as other illness such as the common cold, smallpox or measles. Still, more people died from the Spanish Flu pandemic than from the hostilities in World War I. It is estimated that half of the U.S. soldiers who died in Europe were killed by the influenza virus, and a total of 675,000 people died from the pandemic in the U.S. (550,000 of these were excess deaths, that is deaths that would not have happened but for the flu.) The life expectancy in the U.S. was cut by 11.8 years due to the Spanish Flu.
Influenza epidemics can exhibit different infection patterns from the seasonal flu which kills the elderly, the chronically ill, and very young children. The Spanish Flu was most deadly for people ages 20 to 40. It struck down the strong and vigorous. people sometimes died rapid deaths, sometimes within hours of the onset of symptoms. Entire families were wiped out; in other families, just one or two people survived. Children lost their parents, parents lost their children, husbands their wives, etc. The emotional toll on the survivors was devastating. The deaths were painful. One physician described his patients as dying while “struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth.” Diary of Isaac Starr, a third-year medical student recruited to treat victims
Outbreaks swept the globe. In India, the mortality rate was 50 deaths per 1,000 people. Doctors of the time were powerless against the disease. The influenza virus was not even identified until 1933.
Public health officials of the affected areas were unable to stop the spread of the disease. They tried everything they could think of from distributing gauze masks to prohibiting stores from holding sales, limiting funerals to 15 minutes, banning meetings, restricting entry into the town, to name a few. Nothing worked. There was also a lack of health care workers due to illness or death. There was also a shortage of coffins and bodies piled up in morgues and funeral homes.
Scientists now think that most of the deaths from the 1918/1919 flu pandemic were the result of secondary bacterial pneumonia. Bacteria from the nose and throat were able to infect the lungs because the virus damaged the bronchial tubes and the lining of the lungs. With the development of antibiotics that can treat pneumonia, later pandemics have caused many fewer fatalities
Lasting a little over a year and killing between 20 million and 50 million people, the Spanish Flu was one of the worst pandemics in history. It compares to the Plague of Justinian, 541 – 590 A.D., in which 25 – 100 million lost their lives over 50 years, the Black Death of 1348-1351 in which 62 million lives were lost in about three years, and the current AIDS epidemic in which 34 million have died over 20 years. All of these numbers are approximate.
The 1918/1919 outbreak was dubbed the “Spanish Flu” because reporters in Spain, a country which was not a combatant in WWI, were not focused on reporting the war and were the first to realize that a new and dreadful disease was killing people. The strain of influenza responsible for the pandemic didn’t originate in Spain nor was it any worse there than in other places.
Scientists have recently been able to reconstruct the Spanish Flu virus from samples preserved in wax and tissues from people who were frozen in the Alaskan permafrost and recently unearthed. It appears to have bird genes which means that it jumped from birds to humans.
There are, on the average, three influenza pandemics every century. Dr. Robert Webster, a renowned virologist has stated that “All the genes of all influenza viruses in the world are being maintained in aquatic birds, and periodically they transmit to other species. . . . The 1918 viruses are still being maintained in the bird reservoir. So even though these viruses are very ancient, they still have the capacity to evolve, to acquire new genes, new hosts. The potential is still there for the catastrophe of 1918 to happen again.” The 1918 Spanish Flu Pandemic, and the Emerging Swine Flu Pandemic from NinthDay.com; accessed February 12, 2012.
THE POWER OF THE STATE TO QUARANTINE PEOPLE AND COMMUNITIES WITH INFECTIOUS DISEASES
When the people, acting through their government, enact laws or take action to protect the peace, security, safety, morals, health, and well-being of the community, they are said to be acting pursuant to the “police power.” This power is broad and flexible. It has no clear limits, permitting the state to act as necessary to protect the public welfare. Other examples of police power include zoning ordinances, building codes, the regulation of sanitation in dwellings and businesses, traffic laws, as well as safety regulations in the workplace. The power of the government to quarantine persons with contagious disease derives from the police power of the state.
In the United States, the police power is limited by those rights reserved to individuals by the Bill of Rights (as to the Federal Government), the Fourteenth Amendment to the Constitution (which requires the states to recognize most of the provisions of the Bill of Rights), and various state constitutional provisions which on occasion grant more rights than the U.S. Constitution. The Fifth Amendment and the Fourteenth Amendment specifically prohibit the Federal Government and the states from taking life, liberty or property from individuals without due process of law. This means that the government cannot punish, imprison or kill anyone unless that person has been convicted of a crime. The police power often comes into conflict with these individual rights. The courts in the United States are constantly required to decide disputes about which will prevail in specific situations: the power of the state to provide for the general welfare or the rights of individuals reserved to them by various constitutional provisions. (Another film which raises the conflict between the power of the people as a whole and the rights of individuals is Inherit the Wind. In that case, the conflict was between the power of the people to regulate what was taught in the public schools and freedom of speech, guaranteed by the First Amendment.)
Quarantine deprives people of their liberty not because they have committed any crime, but due to their exposure to a dangerous communicable disease. The power of the state to impose quarantines has been recognized for many hundreds of years.
There have been situations in the past when constitutional rights have been suspended or ignored as a matter of policy by the government. Usually, these occur in the time of war. During the Civil War, President Lincoln suspended the right of habeas corpus. (The right of habeas corpus is exercised when a person who has been imprisoned by the government petitions a court to review the correctness of the government’s action.) Another example was the detention of Japanese Americans during World War II.
USING IN THE CLASSROOM
Make students aware of the Potential Problems of Influenza Pandemics: This can be accomplished in a number of ways. The teacher can provide direct instruction on pandemics by way of an introduction to the film; see Pandemics below. Individual students, or groups of students can be assigned to research and give class presentations on topics such as: (a) each of the influenza pandemics of the last 100 years,(b) the H5N1 Avian Flu, (c) the efforts of agencies such as the CDC and WHO to combat the influenza virus, and (d) influenza vaccines. Another alternative is to require students to research the Spanish Flu influenza pandemic of 1918/1919 and write a short essay. TWM suggests that teachers require that some of the research be on the Internet with sources cited. The length of the paper, its structure, and the scaffolding necessary will depend upon the level of the class. Consider enlisting an ELA teacher to make the essay an assignment for English class. Use the rubric usually used in written work for the class or get one from an ELA teacher.
Make sure the class is informed that: (1) The mortality rate from the H5N1 Avian influenza virus is very high, from 30% to 80% of the people infected have died from the disease. Fortunately, it has spread only to several hundred people. (2) 20 to 50 million people died from the Spanish Flu influenza pandemic of 1918/1919. This information will be asked of students if they take the Comprehension test.
Get Students Thinking: Ask students, as they watch the movie, to think about how they would react in the various situations shown in the film?
Play the Movie: Teachers who want to use a movie worksheet can download TWM’s Film Study Worksheet for a Documentary. The only modification necessary will be to change the title and to delete the following language from question #4, “Nonfiction can enrich viewers in several important ways.” Otherwise, the worksheet is well-suited for this film without further modification.
Class Discussion: Immediately after the movie, start a discussion about whether the right thing to do in a pandemic situation is to obey the instructions of the authorities or to do whatever you can for your family or loved ones, even if it frustrates the efforts of the authorities. You can raise this issue with the following question, “In this film, the people from the Chinese village took the law into their own hands in their attempts to survive. One of the characters, Dr. Cheever, gave a female relative advance notice to leave a city about to be quarantined. Were these efforts to survive wrong? What would you have done?
Influenza Internet Research: Have students search the Internet to obtain brief authoritative information on the following subjects that are covered by the comprehension test set out below: influenza symptoms, how it spreads, treatment for influenza, why flu shots change every year, the most common complication of influenza, seasonal flu, sources of new strains of the influenza virus, the two criteria for assessing the dangerousness of a strain of the virus, and influenza pandemics of the last 100 years. Students should be required to use the websites of the CDC and HHS as well other sources. Students should be required to take notes on what they found, citing their sources. These notes should be turned in to make sure that the work has been performed.
Test or Concluding Assignment: The culmination of the Lesson can be a Comprehension Test. TWM recommends that the day before the test, teachers go over questions 1 – 8 (or the topics of these questions) with the class so that students will know what to focus on when they study. Another possibility for a concluding assignment is to require students to write an essay on the results of their research from Step 5 divided into sections on symptoms, prevention and treatment, citing sources. Students should be required to obtain information from the CDC and HHS websites, as well as others. An example of a good response (except that citations have not been included) is set out in the Helpful Background section below.
Students can perform in-depth research on the human toll of the 1918/1919 Spanish Flu pandemic and then choose from a number of projects: (1) create a work of art such as a song, a story, a poem, a drawing, a dance or a collage of photographs, describing the effects of the pandemic or (2) write a research report on the experience of their hometown during the pandemic.
COMPREHENSION TEST FOR A UNIT ON INFLUENZA
1. Influenza is a disease of the respiratory system lasting one or two weeks. Name five of the seven most common types of symptoms of the disease. One type of symptoms is most common in children; identify it in your answer.
Here are the seven types of symptoms: 1) A fever or feeling feverish (although not everyone with the flu has a fever); 2) A cough and/or sore throat; 3) A runny or stuffy nose; 4) Headaches and/or body aches; 5) Chills; 6) Fatigue; 7) Nausea, vomiting, and/or diarrhea (most common in children)
2. Describe the two major ways in which influenza is spread.
1) inhaling droplets in the air from someone who has sneezed or coughed and 2) touching an object or a surface which has the virus on it and then touching the mouth, eyes, or nose.
3. What are the usual treatments for influenza?
Bed rest, hydration, and alleviation of symptoms with over-the-counter medication.
4. Flu shots are changed each year to include protection from newly mutated versions of the influenza virus. How does vaccination rate when compared with other methods to avoid getting the seasonal flu?
Vaccination is the best way to avoid getting influenza.
5. The most common complication of influenza is pneumonia. What are the types of symptoms of an influenza attack that indicate that an immediate visit to a doctor or to the Emergency Room is necessary? There are ten of these types of symptoms. Name eight of them.
The ten types of symptoms are: 1) Fever over 102 degrees or fever lasts longer than three days; 2) Difficulty breathing, wheezing when breathing, or shortness of breath; 3) purple or blue discoloration of the lips; 4) Pain or pressure in the chest, abdomen or neck; severe headache; 5) Sudden dizziness; 6) Confusion; 7) Severe or persistent vomiting; 8) Seizures; 9) Flu symptoms that worsen each day; and 10) Flu-like symptoms that improve but then return with fever and worse cough.
6. What is the seasonal flu, and for an average year how many people catch it, and how many does it kill, in the world and in the U.S.?
Seasonal flu is a mild to severe disease caused by a mutation of the flu virus. It causes sickness in 300,000 to one billion people worldwide and kills between 250,000 and 500,000 people each year, about 41,400 people die in the U.S. each year from seasonal flu.
7. What are the sources of the new strains of the influenza virus that appear each year?
There are two. 1) Viruses that continue to live in various animal population reservoirs is one. Animals harboring influenza virus such as wild birds, pigs, and chickens can have few symptoms or they might not be sick at all. Influenza viruses mutate frequently and some of these mutations allow them to cross from one species to another. 2) Other mutations may make an existing human influenza virus more communicable or more deadly.
8. There are two major criteria used to evaluate the danger posed to mankind by an influenza virus. What are they?
The first is how infectious the virus is, i.e., how easily it passes from one person to another. The second is lethality, i.e., how many people who get sick will die.
9. What is a pandemic, and how often have influenza pandemics appeared during the last century?
A pandemic is a disease that occurs over a wide geographic area and affects an exceptionally high portion of the human population. Some pandemics have a high degree of lethality but most do not. In the last 100 years, there have been at least three influenza pandemics.
10. The Spanish Flu of 1918/1919 was the worst pandemic of the last 100 years infecting some 500 million people, at that time more than one-third of the world population. How many peopled died worldwide from the Spanish flu, and what was the death rate among those infected?
20 to 50 million people died from the Spanish flu. The death rate was estimated to be greater than 2.5%.
11. What is the bird flu, also called Avian flu? What is its mortality rate, and why hasn’t it become a pandemic? In your answer cover both lethality and infectiousness.
H5N1, a virus that exists in migratory birds, has mortality rates in humans varying from 30 to 80% of those who contract the disease. Some scientists believe that this number is too high because many cases in which people get better on their own are not reported. However, H5N1 virus has not developed the ability to spread easily from person to person.
12. There is now a vaccine for H5N1, why are doctors still worried that it could become the next pandemic?
If the virus mutates in a way that makes the existing vaccine ineffective, and if the virus also mutates to become more infectious, it will take several months to develop a new vaccine that would be effective against it. In that time millions of people could die.
Click here for a copy of the Comprehension Test in word processing format.
Discussion Question for a Health Class
1. In this film, the people from the Chinese village took the law into their own hands in their attempts to survive. One of the characters gave a female relative advance notice to leave a town infected with the virus. Were these efforts to survive wrong? What would you have done?
The purpose of this question is to set up a discussion about whether the right thing to do is to control your panic and obey the instructions of the authorities or whether it is ok to do whatever you can for your family or loved ones, even if it frustrates the efforts of the authorities.
Discussion Questions for an ELA Class
For ELA classes, see Discussion Questions for Use With any Film that is a Work of Fiction.
MORAL-ETHICAL EMPHASIS (CHARACTER COUNTS)
Discussion Questions Relating to Ethical Issues will facilitate the use of this film to teach ethical principles and critical viewing. Additional questions are set out below.
(Do what you are supposed to do; Persevere: keep on trying!; Always do your best; Use self-control; Be self-disciplined; Think before you act — consider the consequences; Be accountable for your choices)
See Discussion question for a Health Class, above.
LINKS TO THE INTERNET
- Seasonal Flu — Symptoms from Flu.gov, U.S. Department of Health & Human Services; accessed 2/12/12;
- Seasonal Flu — Prevention from Flu.gov, U.S. Department of Health & Human Services; accessed 2/12/12;
- Seasonal Flu — Treatment from Flu.gov, U.S. Department of Health & Human Services; accessed 2/12/12;
- Clinical Signs and Symptoms of Influenza from the CDC;
- Flu: What to do if you get sick from the CDC;
- HHS Pandemic Influenza Plan- Part 1: Strategic Plan, accessed 2/12/12;
- The Next Flu Pandemic: What to Expect from U.S. Dept.. of Health & Human Services, accessed 2/12/12;
- Deadliest pandemics of the 20th century from CNN Health accessed 2/12/12;
- 2009 flu pandemic from Wikipedia, accessed 2/12/12;
- Swine flu danger appears to be ebbing;
- 2009 Swine Flu Epidemic from the CDC;
- Updated CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April 2009 – April 10, 2010;
- The Influenza Epidemic of 1918 from Stanford University;
- 1918 killer flu secrets revealed by the BBC;
- The 1918 Spanish Flu Pandemic, and the Emerging Swine Flu Pandemic from NinthDay.com;
- The Economic Effects of the 1918 Influenza Epidemic* Elizabeth Brainerd and Mark V. Siegler study published in June 2002 and accessed February 12, 2012;
- What us a Pandemic from Medical News.net;
- Flu Pandemic Morbidity/Mortality from GlobalSecurity.org;
- Pandemic Influenza from GlobalSecurity.org;
- Single-Dose H5N1 Vaccine Safe and Effective in Adults and Elderly from Science Daily;
- Flu: What to do if you get sick from the CDC;
- The Real Threat of Contagion by W. Ian Lipkin, New York Times, 9/12/11;
In addition to websites which may be linked in the Guide and selected film reviews listed on the Movie Review Query Engine.