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Here's what Medicare Part D will cost and cover in By contrast, American Samoa recorded no casualties. The severity of the pandemic and the peculiar death pattern puzzle scientists to this day.

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Few epidemiologists believe the pandemic began in Spain, pointing instead to pre-pandemic waves in Copenhagen and other northern European cities in the summer of Where the virus first leapt from birds to humans or some other mammal is even more perplexing, with some scientists favouring a Kansas point of origin and others northern France or China.

Jeffrey Taubenberger, a molecular pathologist at the National Institute of Allergy and Infectious Diseases, has been studying the Spanish flu virus for more than 30 years. In the late s he succeeded in retrieving fragments of viral RNA from stored pathology specimens taken from American soldiers who had died of flu at US army camps in and an Inuit woman who been buried on a beach in Alaska, where the permafrost had preserved her lung tissue from decay. Their findings were a shock.

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Previously, epidemiologists had observed that flu pandemics were preceded or followed by outbreaks of influenza-like illnesses in dogs, cats, and horses. It was also known that from time to time flu viruses could infect pigs and, of course, humans, and that wild flu viruses circulated in migratory waterfowl. However, when Taubenberger analysed the genome of the Spanish flu, he found that most of its genes were derived from a bird flu virus. It also begged the question, why bring the Spanish flu back to life, and what if the virus escaped the laboratory and fell into the hands of terrorists?

To prevent that happening, Taubenberger and other scientists with access to the freezer containing the virus are screened by the FBI and must wear double-gloves, a respirator and a full body suit — like the ones worn by medical workers during the west African Ebola epidemic. They must also submit to an iris scan. Continued experimentation is necessary for the development of vaccines and other medical interventions.

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In mice, the H1N1 Spanish flu is extremely virulent, generating 39, times more virus particles than a modern flu strain. By targeting the inflammatory response, Taubenberger has shown that mice can be protected. But scientists are a long way from finding a cure for flu, much less a universal vaccine against seasonal and future pandemic strains.

Frustratingly, it is still not known where and when the Spanish flu acquired its avian genes and first began spreading in humans. Certainly, there were explosive outbreaks of an influenza-like illness at Camp Funston, Fort Riley, in March , followed by similar outbreaks along the eastern seaboard of the US and on the transatlantic troop carriers that ferried American troops to France. However, the earliest fragments of the pandemic virus obtained by Taubenberger date from May , so there is no way of telling whether outbreaks prior to this were caused by the pandemic strain, as opposed to an ordinary seasonal influenza.

Another prominent feature was cyanosis, a distinctive purple-blue discolouration of the lips, ears and cheeks, caused by the loss of oxygen to the heart. Another puzzle is why, in some cases of pneumonia associated with the Spanish flu, the onset was rapid and the lung damage highly localised, while in others, the infection resembled an aggressive bronchopneumonia with extensive haemorrhaging and swelling throughout the lungs. These features have never been adequately explained, with some pathologists arguing that the virus triggered an unusual auto-immune response known as a cytokine storm and others that extensive lung damage is better explained by bacterial infections that followed the flu — a big danger in the days before antibiotics.

But perhaps the biggest unanswered question is why the Spanish flu proved so deadly to young adults. Here, present-day science has hypotheses but no good answers. One suggestion is that the elderly enjoyed greater immunity because, as children, they had been exposed to a pandemic virus with a similar genetic makeup to the H1N1 Spanish flu. Or it could be that the unusual mortality pattern seen in was the result of an as yet unidentified environmental exposure or stressor peculiar to young adults at the time.