The origins of the great pandemic

Abstract

The timing and location of the first cases of the 1918 influenza pandemic are still controversial, a century after the pandemic became widely recognized. Here, we critically review competing hypotheses on the timing and geographical origin of this important outbreak and provide new historical insights into debates within military circles as to the nature of putative pre-1918 influenza activity. We also synthesize current knowledge about why the 1918 pandemic was so intense in young adults. Although it is still not clear precisely when and where the outbreak began and symptom-based reports are unlikely to reveal the answer, indirect methods including phylogenetics provide important clues, and we consider whether intense influenza activity as far back as 1915 in the USA may have been caused by viral strains closely related to the 1918 one.