Lessons from a past pandemic -The Spanish flu vs COVID-19 strategies
Key Learnings contained in this article:
How effective were the strategies of the Spanish flu compared to COVID-19 strategies and have we learnt from them?
Historians argue that in order to understand the present we must look to the past. Can this be the case for managing pandemics? One of the most well-known pandemics in history is the 1918 deadly strain of influenza that spread around the globe, known as the Spanish flu. It infected one-third and killed between 3% to 5% of the global population. In more recent times, Coronavirus disease 2019 (COVID-19) was initially speculated by some to be as serious as the flu, although many of those recovered from a COVID-19 infection claim it to be much worse than the common influenza. When the World Health Organisation (WHO) declared COVID-19 as a global health emergency on January 30 2020 the extent of the threat started to be better appreciated by some, but not all. National strategies determine national health outcomes. In this article we will be examining the US’ and New Zealand’s (NZ) response to Spanish flu in comparison to their response to COVID-19 threat during the first 100 cases. Did we learn from the Spanish flu pandemic strategies or have we fallen into the same pitfalls?
Although both viruses are transmitted via respiratory droplets and the surfaces they land on, we must be cautious when comparing the two pandemics. There are many differences; therefore, extrapolating information beyond their conditions and using it under other conditions can be dangerous.
The first known case of the Spanish flu in the US was reported at a military base in Kansas on March 11th, 1918. Cities that implemented a fast initial lockdown saw better health outcomes. Philadelphia reported its first case on September 17, 1918. The following day a health campaign was launched to promote the public against coughing, spitting and sneezing in public. Social events were still occurring and the city hosted a parade with an estimated 200,000 attendees. As cases continued to increase public gathering places were shut down. Eight days later Philadelphia experienced their highest peak death rate.
St. Louis is a great example of a strong initial response to the pandemic. Two days after experiencing their first case they implemented strict social distancing measures. This resulted in a low mortality rate compared with other cities. However, St. Louis also provides an example of what can occur when lockdown measures are lifted too early. A significant increase of deaths was observed when restrictions were temporarily eased.
The Spanish flu caused 9000 deaths in NZ. The death rate was much higher among Maori, the indigenous people, compared with people from European descent. Historian Geoffrey Rice states that this may be due to Maori having lower imunity as they had not been exposed to the same respiratory diseases and infections as the Europeans. Another factor could be due to differences in social living including distancing between Maori villages and European settlements.
The initial response to a pandemic is crucial to control the spread of the virus. The US’ COVID-19 strategy was fragmented with contradicting actions from officials. On January 20th 2020 three airports, Los Angeles, San Francisco and JFK International, began screenings in response to COVID-19 cases being reported in Japan and Thailand. These airports were chosen due to the frequent travellers arriving from Wuhan. Although efforts were made to keep the virus out of the country, they were insufficient. Within 24 hours the first case of COVID-19 in the United States was reported. Shortly after, president Trump stated that they had it completely under control in response to a reporter asking if there were any worries about a pandemic. Just nine days later the US declared a publichealth emergency. On February 2nd 2020 a two-week self-isolation at home order was given to travellers who had been to the Hubei province. Media outlets including the Washington Post reported that Trump continued to downplay the threat of COVID-19 . By late February community transmission was occurring with cases of COVID-19 being reported with no recent travel to known infected areas. By March 2nd 2020 there were 100 cases of COVID-19 in the country with no clear strategy. As of January 31st 2021, 9.41 vaccine doses have been administered per 100 people in the total population of the US. There is still no clear COVID-19 strategy in the United States with the government recently having changed hands, giving rise to further challenges.
In NZ however the pandemic threat was treated differently. Transparency and disclosure were critical to New Zealand’s COVID-19 strategy. Uncertainty was communicated before and during the first outbreak and a nationwide approach was implemented.
NZ had the advantage that it had witnessed the spread of COVID-19 in other countries before it reached the shores of NZ. The NZ government placed a temporary entry restriction on foreigners travelling from or transiting through mainland China from the 3rd of February and was reviewed every 48 hours. NZ’s first case was confirmed on February 28th 2020 and a Technical Advisory Group was formed by the Government. By mid-March, everyone entering NZ had to self-isolate for 14 days with an exception made to those arriving from the Pacific. On the 20th of March the borders closed to anyone who was not a resident or citizen and indoor gatherings of larger than 100 were cancelled.
A four-tier alert system was announced on March 21st 2020 and specified the public health and social measures to combat against COVID-19. The levels are “prepare, reduce, restrict and lockdown”. On the same day the alert system was announced, the country was put at level 2 “reduce” due to the potential of limited COVID-19 community transmission occurring and the existence of active clusters in more than one region. By March 23rd the number of cases in NZ exceeded 100 and the country moved into a stricter alert level. On March the 25th at 11.59 pm the country entered a countrywide lockdown with the entire nation going into self-isolation. On March 29th NZ reported its first COVID-19 related death. NZ had a strong stance to eliminate the virus from the country and its aggressive approach was cited as an example by other countries. After 100 days without community transmission another breakout occurred. To some, it came as a shock but experts Dr Siouxsie Wiles and Professor Michael Baker had stated that people shouldn’t get complacent. NZ continues with an elimination strategy and is expected to move in and out of elimination in the future until appropriate vaccination is achieved.
With the absence of a readily available vaccine the fundamental tools in fighting a pandemic remain mostly the same as they did a century ago. Social distancing and quarantines have been around for long and remain critical for pandemic strategies. Pandemic strategies should reflect and be tailored to the context. Additionally, regardless of the context, transparent medical communication is vital. As scientist Carl Sagan stated “You have to know the past to understand the present” and although the Spanish flu does not hold all the answers for successful COVID-19 strategies it provides us valuable knowledge when travelling through a sea of many unknowns.
New Zealand
Days since first COVID-19 case in the country
Day -25
Temporary entry restriction on foreigners traveling from or transiting through mainland China from the 3rd of February 2020
Day 0
First case of COVID-19 confirmed in New Zealand on the 28th February 2020
Day 16
2 cases reported outside of Auckland on 15th of March
Day 17
Two-week self-isolation order given to everyone entering New Zealand except those arriving from the Pacific on March 16th 2020
Day 22
Four-tier alert system was announced on 21 st March 2020. Country put on level 2
Day 24
102 COVID-19 cases confirmed on 23rd March
Day 26
Country moves into nationwide lockdown on 25th March 2020
United States
Days since first COVID-19 case in the country
Day -5
COVID-19 cases reported in Japan and Thailand
Day -1
Los Angles, San Francisco and JFK Internation airports start screenings in response on 20th January 2020
Day 0
First case of COVID-19 in the United States reported on 21st January 2020
Day 10
Government declares a public health emergency on 31st January 2020
Day 12
Two-week self-isolation at home order was given to travellers who have been to the Hubei province on 2nd February 2020
Day 36
Community transmission occurring in late February
Day 43
More than 100 cases by 4th March 2020
References:
https://pubmed.ncbi.nlm.nih.gov/11875246/
https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm
https://www.who.int/vietnam/news/detail/14-07-2020-q-a-how-is-covid-19-transmitted
https://pubmed.ncbi.nlm.nih.gov/17416679/
https://pubmed.ncbi.nlm.nih.gov/16961567/
https://pubmed.ncbi.nlm.nih.gov/30543612/
https://nzhistory.govt.nz/culture/influenza-pandemic-1918/maori-and-the-flu
https://www.washingtonpost.com/outlook/2020/03/09/unique-incompetence-donald-trump-crisis/
https://www.cdc.gov/mmwr/volumes/69/wr/mm6922e1.htm
https://covid.cdc.gov/covid-data-tracker/#county-view
https://ourworldindata.org/covid-vaccinations
https://www.beehive.govt.nz/release/new-zealand-restrict-travel-china-protect-against-coronavirus
https://www.health.govt.nz/news-media/media-releases/single-case-covid-19-confirmed-new-zealand
https://covid19.govt.nz/alert-system/history-of-the-covid-19-alert-system/
https://www.health.govt.nz/news-media/news-items/covid-19-media-update-23-march
https://www.health.govt.nz/news-media/media-releases/sadly-first-death-covid-19-new-zealand
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