By Dr. Jennifer Sedillo
Faculty Member, Public Health, American Military University
The first recorded flu pandemic was in 1918. It would go on to kill 50 million people worldwide. Since then, there have been other flu pandemics but none that has proven as deadly.
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The current coronavirus disease, COVID-19, is new but it has already far surpassed the number of reported cases in two recent virus outbreaks. Globally, COVID-19 has been responsible for over 73,000 cases and 1,870 deaths, 99 percent of them in China, according to the World Health Organization (WHO).
Previous coronavirus pandemics included 8,437 cases and 813 deaths from SARS in 2003. The MERS-CoV virus in 2012 has sickened 2,400 people and killed 850 others and still continues to cause cases today.
Both SARS and COVID-19, both of which originated in China, are zoonotic in nature. They are transmissible from vertebrate animals to humans: SARS from civet cats while the source of COVID-19 is still unknown.
Pandemic Response Then and Now
Why the 1918 flu pandemic was the worst in history is still not fully known. It is believed that biology played a role because the virus killed mostly young adults in the prime of life. Later, genetic examination of the virus showed that it was adept at invading the lower parts of the lungs, which led to more severe illness.
However, there were also societal issues that permitted the continued transmission of the disease. These issues included a shortage of nurses, poor nutrition and sanitation, and the lack of treatment or a vaccine. Other contributing factors of the societal breakdown were the many troops overseas at war and those who were infirm in the U.S.
By contrast, the 2003 SARS pandemic – which had many of the same attributes of the 1918 flu pandemic – was quickly brought under control. In fact, there have been no new cases of SARS since July 2003.
SARS was an unknown virus whose mode of transmission was also unknown. Plus, there were no appropriate diagnostic tests, treatments or vaccines. However, response and surveillance networks were rapidly put in place to respond internationally and control the disease with the support of healthcare workers and medical tools in the most affected regions.
In January, WHO Director-General Dr. Tedros Adhanom Ghebreyesus declared the COVID-19 virus epidemic “an emergency for that country, but one that holds a very grave threat for the rest of the world.”
The U.S. promptly declared a national public health emergency, and President Trump signed a proclamation barring entry to the United States all non-U.S. citizens who had been in China in the previous 14 days. Further, the proclamation implemented medical screening and quarantine for any persons entering the U.S. who were suspected of having been exposed to the virus or traveled in China.
Public Health Interventions in Pandemics Then and Now
Many of the public health intervention practices that were in place in the U.S. in 1918 still exist today, including quarantine, isolation and limitations on public gatherings. However, quarantine is far more effective today at preventing disease transmission then it was in 1918. For one, the federal government plays a centralized role to enact such health orders at a national level.
The mandatory quarantine of Americans returning from China is the first use of the Federal Quarantine law since 1963, when there was a suspected case of smallpox. In addition, global health organizations oversee quarantines at the international level.
The current coronavirus pandemic is similar to the 1918 pandemic in that initially there was only supportive therapy available. However, diagnostic testing for the virus was quickly developed and deployed for all healthcare workers who suspect a case of COVID-19. This type of testing can help to quickly identify cases as we have seen in the current mandated quarantine in the U.S.
Furthermore, there have already been advancements in studying the virus in vitro, which is critical to developing a vaccine and studying its biological properties. In 1918, advanced biomedical technology like this was not available.
In both outbreaks, the virus is not the sole cause of death; instead, death is mostly due to secondary bacterial infections. Today, we have supportive therapy for those with severe infections as well as effective antibiotics that did not exist in 1918. Therefore, the survival rate of those with severe infections is far greater today.
Global Response to Pandemics
Not only is U.S. disease surveillance and communication far superior to that in 1918, but today there are worldwide networks to alert nations when there is an outbreak of international concern that did not exist in 1918.
For example, the International Health Regulations (IHR), established in 2005, is an agreement among 196 countries. This agreement ensures international communication, helps countries that need assistance during disease outbreaks, and sets minimum standards for disease surveillance and response to outbreaks.
The WHO is the global leader for disease surveillance and response. It ensures that countries experiencing a viral disease outbreak that poses an international threat alert the international community.
Some governments may not want to alert the international community for fear of the imposition of trade and travel restrictions. Therefore, disease can spread across borders.
However, countries that are party to the IHR are required to alert the WHO when they find increasing numbers of cases of a disease. The IHR uses four criteria for countries to assess the risk of disease:
- The seriousness of the event's public health impact
- The unusual or unexpected nature of the event
- The risk of international disease spread
- The risk that travel or trade restrictions will be imposed by other countries
Countries must assess the situation if only one criterion is met, but notification to the WHO is required when two or more criteria are met. This multinational agreement is critical for the communication of disease outbreaks and for preventing their transmission. The document also gives guidance for securing international points of entry to prevent further disease transmission across borders.
Emerging and reemerging diseases will remain an international threat. And as global travel increases, disease transmission may also increase.
However, with greater global travel also comes greater oversight, and diseases can therefore be more effectively mitigated. Constant evaluation and improvement of disease surveillance networks and emergency preparedness and response are essential for responding to pandemics.
About the Author
Dr. Jennifer Sedillo is an Associate Professor in the Public Health Program at AMU. Her background is in microbiology and molecular biology of infectious diseases. Her doctoral dissertation focused on the pathogenesis of the malaria parasite. Jennifer has co-authored several papers focused on disease pathogenesis of microorganisms. She continues to be fascinated with microorganisms and how they can be both beneficial and harmful to humans.