Lessons from the 1918 flu epidemic could help us fight Covid-19

An army hospital at Camp Funston, Kansas, US, filled with the first victims of the Spanish influenza epidemic in 1918. We can learn from when and what public health measures were successfully implemented to decrease the number of deaths from this epidemic for the current Covid-19 pandemic. — US National Museum of Health and Medicine

The World Health Organization (WHO) has attributed the rapid spread of Covid-19 to “alarming levels of inaction” by many countries.

Although social-distancing measures such as working from home, closure of educational institutes and banning of public events, are essential components in mitigating the impact of the Covid-19 pandemic, there appears to be a delay in adoption of these measures in many of the affected countries.

Reasons include being afraid of “over-reacting” and “hurting the economy”.

Opponents to some of these public health measures, such as closure of schools, have argued that there is a lack of evidence to support their implementation.

However, a really old lesson from a century ago may be applied to contemporary pandemic mitigation measures.

Effective measures

An archival study that was published more than a decade ago highlighted that an early, sustained and multi-layered public health response to a pandemic was strongly associated with better outcomes, such as lower death rates.

In this study, researchers in the United States examined whether city-to-city variation in death during the 1918-1919 influenza pandemic was associated with the timing, duration and combination of public health actions that were taken in 43 American cities.

Historical data on public health interventions like school closures, cancellation of public gatherings, isolation and quarantine, were retrieved from popular newspapers, municipality records and other documents.

This was examined in relation to excess deaths from pneumonia and influenza covering the 24 weeks from Sept 8, 1918, to Feb 22, 1919, in the 43 cities, in comparison with weekly deaths from pneumonia and influenza occurring between 1910-1916, before the influenza pandemic.

Results revealed that school closure and public gathering bans activated concurrently represented the most common combination implemented in 34 cities (79%).

Overall, it took between one to 10 weeks from the onset of the epidemic before these cities adopted the above measures, with half of the cities implementing them at four weeks.

What was striking was that while all the American cities eventually implemented some public health interventions, the timing of activation, duration, and choice or combination of these interventions, were key determinants in their success or failure.

Delay in banning public gatherings for instance, appeared to lead to very high death rates in Pittsburgh, Pennsylvania.

In comparison, much lower death rates were observed in St Louis, Missouri, where a timely and comprehensive public health response, including school closure and cancellation of public gatherings, were sustained for close to 10 weeks.

Notably, the cities that implemented earlier public health interventions also had greater delays in reaching peak death, while also attaining lower peak death rates.

Public health interventions work

While this archival research offers valuable lessons for modern-day pandemic management, it is acknowledged that we live in a modern era where other factors, such as better understanding of infectious diseases among the public, ease of access to information, advances in medical technology, and the ease of flow of information, goods and people across political and geographic boundaries, also need consideration.

Nonetheless, this study serves to remind politicians, health professionals, senior management teams and the public that a suite of classic public health interventions that are implemented in a timely and sustained manner can lead to success in mitigating a pandemic by flattening the epidemic curve.

This in turn may reduce the strain on healthcare systems and reduce the number of deaths from the disease, which we hope to see through the movement control order initiated by the Government on Mac 18 (2020).

Associate Professor Dr Nirmala Bhoo Pathy is a public health physician and epidemiologist at Universiti Malaya. For more information, email [e-mail]. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.