The historical background and initial stages of the COVID-19 pandemic

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The 1918 Influenza has been described as the mother of all pandemics. The COVID pandemic is certainly challenging that long-held characterization.

It has been estimated that at least one-third of the world’s population (or approximately 500 million people) were clinically infected during the Spanish flu more than a hundred years ago.

The case fatality rate for the 1918 Influenza pandemic has been estimated to be greater than 2.5 percent, as compared to a typical flu that has a less than 0.1 percent lethality. Worldwide, total deaths were estimated at 50 million and arguably as high as 100 million.

Case fatality rate for the fly pandemic of 1918. Source AJPH Research and Analysis. 3. Soldiers resting in field cots in November 1918.

Placing this into context, World War I itself caused far less loss of life, with 20 million deaths. There were 9.7 million military personnel that died and about 10 million civilians. Both sides saw an essentially equal number of combat casualties.

Many comrades have been following the epidemiological graphs of the current pandemic and are now familiar with them. The accompanying graphs that describe the death rates over time show how different social distancing and mitigation measures employed in various cities across the US led to different mortality outcomes. They proved that rapid and sustained social distancing and mitigation measures saved lives.

In Philadelphia, as the deadly wave of influenza was just beginning to surge, city officials went ahead and hosted the Philadelphia Liberty Loans Parade in which more than 200,000 people were in attendance. The city oversaw raising $259 million for war-time efforts. That was on September 19, 1918. Twenty-four hours later, 118 Philadelphians were coming down with the mysterious deadly influenza. On the third day after the parade, every bed in Philadelphia’s 31 hospitals was filled. A week later, 4,500 were dead and 47,000 infected. The outbreak was so bad, by October 3, the city essentially shut down.

Philadelphia Liberty Loans Parade in front of liberty statue at Philadelphia city hall.

The US suffered 675,000 excess deaths during the 1918 Influenza pandemic. Using today’s population size, this would translate to approximately 2.16 million deaths. Placing the COVID pandemic into context, though reported deaths are now at 625,000, recent estimates have found that there have been approximately185,000 additional unrecognized COVID-related deaths, putting the figure closer to 800,000. Additionally, the IHME (Institute for Health Metrics and Evaluation) modeling placed the figure of excess deaths closer to 900,000 back in the spring.

So, we are speaking about a pandemic that is in the same ballpark as the death caused by the Spanish flu in the US despite all the added innovations and technological capacity we now possess. We have ICUs. We can ventilate and provide oxygen in high concentrations. We have medications to blunt the immune response. We have even been able to develop very effective vaccines with unprecedented speed. What we have been unable to do is place the appropriate priority on the well-being of the population.

The descendants of the Spanish flu

Yet, the impact of the Spanish flu was not limited to the period 1918–1919.

All influenza A pandemics since that time, and indeed almost all cases of influenza worldwide have been caused by descendants of the 1918 virus. For instance, the H2N2 pandemic of 1957–1958 that originated in Southern China killed between one and four million worldwide. It was a descendent of the 1918 influenza virus, as was the 1968–1969 flu pandemic caused by H3N2, which also killed another one to four million people globally.

It took another 80 years when a scientific team led by Dr. Jeffery K. Taubenberger was able to completely sequence the genome of one virus and partial sequence four others.

And in 2011, Drs. Watanabe and Kawaoka, using advancements in reverse genetics, were able to re-create the 1918 virus entirely from complementary DNA. With an artificially resurrected and intact virus bearing all eight RNA segments, molecular analysis into the unusual virulence of the 1918 pandemic was now possible.

These studies showed that the re-created 1918 virus from the second wave could replicate efficiently in the lungs of infected ferrets and non-human primates, inducing the type of fatal pneumonia encountered in the 1918–1919 pandemic.

Though the first wave caused extensive infection, it was not highly lethal as compared to the second and third waves. It is not known whether the virus in the first wave was the same as in the second wave or if it underwent a genetic shift or reassorted with another flu virus that made it so lethal. There is evidence that suggests those who developed the flu in the first wave had protection against the second wave.

Various theories exist as to the origin of this novel Influenza A virus, though many have noted the emergence of the illness in March of 1918 in Kansas, which quickly spread throughout the Eastern seaboard in recruit camps and cities and then to Europe and globally thereafter.

What was unusual about these deaths was that they cut down young adults in the prime of their lives. The W-shaped death curve was a unique finding that suggested the older population may have had partial immune protection from a possible exposure to a then-circulating virus circa 1889.

Perhaps most sobering is what Dr. David Morens, Office of the Director at the NIAID, wrote about the influenza pandemic in April of 2019.

“As deadly as the 1918 pandemic was, US mortality data, adjusted for population growth, suggest that over the past century about three times as many deaths have been caused by descendants of the 1918 pandemic virus than by the pandemic virus itself.” These have considerable relevance to the generations that will be forced to live with the SARS-CoV-2 virus.

Woodrow Wilson’s response to the flu pandemic

As the 1918 flu pandemic was killing hundreds of thousands of Americans, it is worth reviewing President Woodrow Wilson and the White House’s response to the pandemic, which have perhaps interesting parallels to the COVID pandemic.

Focusing his attention completely on the war effort, Wilson never uttered a single public statement about the 1918–1919 flu epidemic. Historian John M. Barry, author of The Great Influenza: The Story of the Deadliest Pandemic in History, noted, “In terms of managing a federal response to the pandemic, there was no leadership or guidance of any kind from the White House. Wilson wanted the focus to remain on the war effort. Anything negative was viewed as hurting morale and hurting the war effort.”

Tevi Troy who wrote Shall We Wake the President: Two Centuries of Disaster Management from the Oval Office, ranked Wilson as the worst president. “The federal response to the influenza outbreak in 1918 can best be described as neglectful. Hundreds of thousands of Americans died without President Wilson saying anything or mobilizing nonmilitary components of the U.S. government to help the civilian population.” He also faulted Wilson for contributing to the massive spread of the disease by continuing troop mobilizations “even as World War I was winding to a close.”

Barry notes that Wilson was quite aware of how serious the disease was. He heard and read reports on the way the
illness would strike young and healthy soldiers in the barracks or on troop transports that were sailing across the Atlantic Ocean. Though the US lost almost 54,000 soldiers in combat during the war, another 45,000 (a number in equal magnitude to combat deaths) perished from influenza and related pneumonia by the end of 1918.

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