What The 1918 Spanish Flu Can Tell Us About The Coronavirus

Given the continued spread of the Wuhan coronavirus, we urgently reached out to John Barry, author of the award-winning New York Times best-seller The Great Influenza: The Epic Story of the Deadliest Plague in History.

Two years ago, we interviewed John about the expected implications should a pandemic of similar scale break out in today world. Little did we realize at the time how quickly his insights would prove relevant.

John was the only non-scientist to serve on the US government’s Infectious Disease Board of Experts and has served on advisory boards for MIT’s Center for Engineering System Fundamentals and the Johns Hopkins Bloomberg School of Public Health. He has consulted on influenza preparedness and response to national security entities, the George W. Bush and Obama White Houses, state governments, and the private sector.

John remains quite concerned at how the world’s readiness for a pandemic is woefully lacking, exacerbated by the hyper-connectedness of our modern society (i.e., the ease and speed with with people can travel):

An often-overlooked part of the damage a virulent pandemic can do is its impact on supply chains and the economy.

If you’ve got 20 to 30% of your air traffic controllers sick at the same time, what’s that going to do to your economy?

Most of the power plants in the United States are still coal powered. They get their coal, most of them, from Wyoming. You see these enormous trains – that’s a highly skilled position, the engineers who move those trains which are a mile and a half long. Suppose they’re out. You’re not going to have power in many of the power plants.

These are things that we don’t automatically think of as relating to a pandemic. Even a mild one that makes a lot of people sick without killing them will wreak an economic impact.

In terms of the health care system, practically all of the antibiotics are imported. If you interrupt those supply chains then you start getting people dying from diseases that are unrelated to influenza that they would otherwise survive. We had a small example of that with saline solutions bags which were produced in Puerto Rico. Because of the hurricane, Puerto Rico was no longer producing them; so we had tremendous shortages in those bages after the hurricane. Other suppliers worldwide have picked up the slack, so that’s not a problem today.

But in a pandemic, you’re going to have supply chain issues like that simultaneously all over the world. So you’re not going to be able to call on any reserve, anywhere, because everybody’s going to be in the same situation whether you talk about hypodermic needles or plastic gloves — any of that stuff. The supply chain issues in a moderate pandemic are a real problem. If you’ve got a severe pandemic, the hospitals can’t cope. There are many fewer hospital beds per capita than there used to be because everything has gotten more efficient. In this past year’s bad influenza season, many, many hospitals around the country were so overwhelmed they all but closed their emergency rooms and weren’t talking any more patients for any reason.

There’s just no slack in the system. What efficiency does is eliminate as much as possible what’s considered waste, but that waste is slack. And when you have a surge in something, you need that slack to take care of the surge. If I were grading generously I would give us a D in terms of overall preparedness. If we had a universal influenza vaccine, maybe we’d be relatively okay, but we don’t.

And while good data is scarce in these early days, what we do know so far about the coronavirus does not encourage him. If the virus is indeed as contagious as suspected, he sees no hope of containing it before it becomes widespread:

Understanding the incubation period is very, very important.

The critical question is: Can you infect someone else when you’ve been infected but don’t have any symptoms?

The Chinese have made statements that they think that’s the case. If that’s in fact true, then there’s no chance of controlling this.

Exacerbating things, when facing an influenza pandemic, you have to sustain anything that you’re doing to be successfully preventive. And that’s extremely difficult for a public health official to get the public to do; sustaining the right behavior.

Unless you get in the habit of washing your hands all the time – and do it constantly, three, four, five days after you start doing it – you’re going to get tired of it. But that kind of behaviour has to be sustained to be effective.

I guess I’m a pessimist when it comes to changing human behaviour, even something as simple as handwashing – and good luck trying to prevent people from touching their mouth or eyes.

Even the “good” masks, like N95 respirators, have to be fitted almost perfectly for them to be effective. And they’re uncomfortable.

So for those who get sick, just stay home. It’s that simple. That runs counter to American culture; you’re supposed to tough it out – you’re sick, you go into work. But in this case, that’s not useful. Employers should emphasize that to their employees: If you’re sick, stay home.

Click the play button below to listen to Chris’ interview with John Barry (43m:34s).

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This is a companion discussion topic for the original entry at https://peakprosperity.com/what-the-1918-spanish-flu-can-tell-us-about-the-coronavirus/

Sparky1 note: This video presentation marks a significant shift in the narrative to-date regarding the 2019-nCoV, representing a call to action from a credible messenger to acknowledge and mitigate the pending global epidemic–if possible. The video is about 30 minutes long and well worth viewing. I’ve summarized the content as an assist, into three posts on this thread for readability. I put the introduction and study findings in this first post; recommendations and study model in the second post; and further discussion in the third post.
[h/t “ReadyMom” on Flutrackers]
1/27/20 Presentation by Dr. Gabriel Leung, Dean and Chair of Public Health Medicine, Hong Kong University
[Sparky1 Summary 1 of 3]
Introduction: Dr. Leung presented results of a study which had just been completed the evening before and released to WHO head quarters and HK officials earlier that morning (1/27/20). He stated that the WHO Director General and the “top team” in infection control were arriving 1/27 or 1/28 in Beijing to meet Chinese officials.
This video is the English version of a news conference to alert governments, health professionals and the public regarding the study’s dire findings. Dr. Leung noted that the study models and findings are consistent with those of 3-4 other epidemiologist teams globally. Dr. Leung stressed that this was not a prediction, but a forecast to prompt action to increase preparedness. In discussing his recommendations, he noted that the question is not if/whether to proceed to prevent the global epidemic, but how to proceed in ways that are feasible, implementable and enforceable.
Study findings and conclusions [my summary gleaned from video presentation]:

  • the 2019-nCoV is on the verge of becoming a global epidemic
  • “self-sustaining” human-to-human spread is already present in all major Chinese cities
  • quarantine is not ineffective, but it may not be enough to substantially change the course of this epidemic in the other major city clusters in China
  • 2019-nCoV may be imported/exported to other cities/countries initially by infected Wuhan travelers; thereafter 2019-nCoV infection within these cities and city clusters, and outside mainland China may be established through “seeding” local epidemics, which in turn, become self-sustaining/perpetuating
  • 5 major cities in China connected to the Wuhan travel hub account for 53% of all international travel in the country and 70% of all international travel to Asia originating from China
  • population size and traffic volume/travel intensity were positively associated with increase of 2019-nCoV spread
  • the largest Chinese city cluster peak of 2019-nCoV is expected in April/May 2020–about 2 weeks after Wuhan peak, which has not yet occurred
  • other large city clusters in China are expected to peak thereafter in waves about every 2 weeks
    [Summary continued in 2nd post, this thread]

1/27/20 Presentation by Dr. Gabriel Leung, Dean and Chair of Public Health Medicine, Hong Kong University
[Sparky 1 Summary 2 of 3, continued]
Recommendations for increased preparedness [to mitigate 2019-nCoV global epidemic]

  • Substantial, draconian measures limiting population mobility should be taken immediately
  • Cancellation of all mass gatherings, school closures, and instituting work-from-home arrangements
  • Should containment fail and local transmission of 2019-nCoV is established, mitigation measures during previous major public health outbreaks (e.g., SARS, MERS or pandemic flu) could serve as a useful reference
  • Regions within the closed travel links with major Chinese ports’ preparedness plans should be readied for deployment on short notice
    Study model:
    Model took a one-day (1/25/20) snapshot of number of 2019-nCoV confirmed cases in Wuhan (N=25,630; R0 = 2.13 (range 1.92-2.31)) vs. number of infections (including pre/a-symptomatic) in Wuhan (N =43,590; R0=6.2 (5.4-7.4, i.e., doubling every 6.2 days). The study assumed up to 2-week lag time between infection–>incubation–>symptom onset–>confirmation. Clinical outcomes such as admission to hospital/treatment, recovery OR death were not estimated or projected in this study. Taking into consideration the one-day number of Wuhan confirmed cases vs. number of infections, RO and travel patterns, they forecast the spread of the 2019-nCoV epidemic to 5 major cities/city clusters in China over time, the impact of mobility quarantine on the epidemic spread, and the potential impact of initial 1/25/20 Wuhan 2019-nCoV “exports” and spread to other destinations and ports outside of China.

1/27/20 Presentation by Dr. Gabriel Leung, Dean and Chair of Public Health Medicine, Hong Kong University
[Sparky1 Summary 3 of 3]
Dr. Leung cited several problems with the lack of reliable, available data regarding 2019-nCoV. A key unknown at present is whether the those with no/mild symptoms are infective and, if so, to what extent are they infective to others. (Viral shedding used as a proxy for infectivity.) The “severity profile” of the virus in unknown. He hopes that the infectivity of the virus is “to scale” with the symptoms, i.e., that asymptomatic/mild symptoms result in lower viral shedding as an indicator of lower infectivity. If so, he feels that will give us a “better fighting chance” to control the epidemic. But at present, we don’t know so we must prepare for the possible outcome that even asymptomatic individuals are just as infective as those with symptoms.
He noted that current 2019-nCoV practice is impeded due to incomplete, inconsistent, biased data collection/reporting and “best guess” assumptions based on SARS and MERS experience–which may/may not apply to 2019-nCoV. Dr. Leung is advocating for research that includes an extensive sample of individuals along the case severity spectrum (e.g., from general public with no symptoms, close contacts w/confirmed infected, those w/mild symptoms, those with severe symptoms, and outcomes of recovery or death). He cited other challenges in securing reliable, timely and actionable data, including human resources, quality control in collecting samples, laboratory supplies, and laboratory availability and capacity.
Dr. Leung acknowledged that health and medical care professionals and facilities are already operating at peak capacity. However, he stressed the necessity of implementing greater crowd and infection control measures in hospital waiting rooms in particular to prevent the possibility of “super spreaders” from infecting others visiting/working in these settings.
When asked by a reporter, “What happens when there are too many cases to count?” Dr. Leung responded that he was revisiting paper a he co-authored with a Harvard colleague and published in the Lancet 8-10 years ago about “what to do if the numbers become absolutely overwhelming.”
[h/t “ReadyMom” on Flutrackers]

I have been looking at the best info on this for a week. Yes - it is highly infectious. So it spreads easily. But outside of China this is a low-fatality illness. All international cases so far prove this. Highly infectious but low-fatality.

I hope what you say is true, but in my opinion it is too early to tell.
The reason why is that the international infected haven’t been reported as recovered either. They are still under treatment.
On top of that the death percentage is somewhere around/below 3% of infected. Currently the number of international infected stands at 87. Based on those numbers we would “only” expect 2-3 deaths internationally. Having none yet could simply be because they/we are lucky so far.

Outside China, at least. Here is some proof for you-

Perhaps that is because these patients are receiving top-notch treatment from dedicated teams in hospitals which are not being overwhelmed with cases. You can’t isolate the recovery possibility from the context in which it is occurring. How high will fatality be if thousands of cases begin rolling in and our medical systems get overwhelmed, as is happening in China? My guess is fatalities rise.
And, not to be coy, but why would draconian measures be taken all across China if this was not an uncommonly high fatality illness?

While the fatality rate seems to be “only” 3%, those are still odds I don’t want to play. Also something to consider is the overwhelming of health care resources. As Sandpuppy has noted, most hospitals and ICU’s are at capacity already. If this thing causes just 10% to require ICU admission, those people would add to the fatality rate.

Perhaps the international case are disproportionately among the young (college students traveling back to campus, etc.). In China, the death rate among the young is very low.
Also, perhaps the vigilance around this is bringing milder cases to the attention of authorities while they are slipping through the cracks in China, especially in overwhelmed Wuhan. That would suggest that China’s death rate is from the subsample of severe cases while internationally it is among a broader cross-section of severe, moderate and mild cases.
Of course there is a silver lining in that - the death rate among the general public will be much lower after considering mild cases which theoretically result in immunity. Of course, this is barring mutations that make the virus more deadly among a broader cross-section of the population. Such a mutation is likely enough to be concerned about.

Appreciate you pulling all those cases together.
It does make me hopeful that it won’t be as severe, but I stand by my previous point about the numbers. There are too few international cases known to make a reliable calculation of international fatality rate vs Chinese fatality rate.
Both Germany and France now stand at 4 infected identified.

For sure you are right. If any nation gets overwhelmed like China, then more will die. But so long as cases just trickle in - in other countries - the death rate should stay low.
Sadly, China is the real “basket case” here. Imagine this going on and on for months…

It doesn’t look like this podcast was uploaded to ITunes. Coronaviruses are more deadly as one gets older, so there is a possibility that this is related to the difference in fatalities inside and outside of China.

All the other provinces are reporting very low death rates as well
encouraging signs

Thankyou, George.
But the fear itself could keep China in a downward spiral for months. The global economy may get shaky.

It is very likely to mutate and it’s anyone’s guess Great interview Chris Great questions

To followup on Syndeman’s comment:
“How high will fatality be if thousands of cases begin rolling in and our
medical systems get overwhelmed, as is happening in China? My guess is fatalities rise.”
Assume the following:

  • 1/3rd of U.S. population gets infected, say 100 million.
  • 3/4th self treat at home with bed rest and OTC medicines and survive.
  • 1/4th have a severe reaction and require hospitalization (intensive care), say 25 million.
  • With hospitalization a person with a severe reaction will survive; without hospitalization a person with a severe reaction will die.
    The total number of hospitals beds in the U.S is approximately 930,000.
    The total number of ICU beds is approximately 80,000.
    From a national perspective, 25 million people in need of 80,000 ICU beds.
    From a personal risk perspective there are many factors to consider.
    Can anyone have a severe reaction, or does it depend on age, underlying health,
    ancestral genetics etc…? Are there regional differences in the ratio of population
    to available ICU beds? Will large numbers of temporary ICU beds be quickly brought on line? And most importantly, what is the temporal production rate of new severe cases versus turnover of the available ICU beds?
    Until someone does that analysis I am going to assume the following:
    If I get infected I have a 25% chance of having a severe reaction.
    At the time of my infection my regional hospital system is overwhelmed and I
    am sent home with a hope and a prayer. Without hospital treatment I have a 100% chance of death.
    Therefore if I get infected I consider my chance of dying as 25% not 3% or 4%.
    I aim not to get infected.

the economic ripple effects will definitely be felt. In terms of “immediate emergency” for us in the states I think we can take a breather. Half of China is on full blown lockdown mode which will slow the spread. US cases are reported at 5 for several days now which is fantastic. One by one airlines are suspending flights from China. US is going to ban soon.

Is anyone else watching the WHO Press Conference on coronavirus? Maybe I’m just cynical, but the fact that it seems designed to be such a Pro-China Infomercial makes me less confident that they’re providing truly accurate scientific information.

I’m on board with Andy S. I doesn’t look like it will be too bad unless it mutates, only time will tell on that one. What most people don’t know is that the Spanish flu was different due to it’s response called the cytokine storm. The cytokine storm affected major organ function cause it had a plugging affect on major organs. This particular virus doesn’t seem to have that affect. Most people that have a healthy response to flu viruses shouldn’t have too much of a problem with this one.