What Britain can learn from 1918’s devastating Spanish flu outbreak

The global pandemic that killed 50million people returned in a second – and much deadlier – wave

The Government’s coronavirus “action plan” contains a table comparing the impacts of the major respiratory virus outbreaks of the last 100 years.

It is these past pandemics and epidemics that have shaped the plan. Top of the list is the 1918 Spanish flu, an influenza pandemic with a fatality rate of two per cent or more which killed at least 50million people globally – many more than the total deaths in the First World War.

The Government notes it caused 200,000 excess deaths in the UK alone, with “young adults, the elderly and young children” most affected.

Could coronavirus cause anything like the same damage?

In human terms at least, the answer is almost certainly no. We know much more about the control of epidemics today and medical science has grown exponentially since 1918.

Nevertheless, Public Health England uses the Spanish flu to broadly define its “reasonable worst case scenario” for contingency planning.

An article last week by Resolve to Save Lives, a think tank specialising in epidemics, says the existing, somewhat sparse, data on Covid-19 suggests anything between a “moderate to severe” outbreak on the standardised framework for epidemic classification.

“Even though there is likely little or no population immunity to the virus, with proactive planning and implementation, the impact of this pandemic can be mitigated to avoid the worst-case scenario,” it adds.

One lesson of the 1918 Spanish flu is apparent in the Government’s action plan. “It is possible that an outbreak or pandemic of Covid-19 could occur in multiple waves and therefore … it may be necessary to ensure readiness for a future wave of activity,” it says.

This happened with Spanish flu, which hit Britain and Europe in the late spring of 1918 but faded, causing the public and the authorities to drop their guard, before returning in two waves stretching deep into the following year. The second wave

‘Globally about 3.4 per cent of Covid-19 cases have died. By comparison seasonal flu generally kills far fewer than 1 per cent of those affected’

was the most virulent and deadly.

Coronavirus has not so far hit the young in the same way Spanish flu did. But the Government’s plan makes clear they are not immune. “Children can be infected and can have a severe illness but based on current data overall illness seems rarer in people under 20 years of age”, it says.

It is older adults who are at greatest risk. “So far the data we have suggests the risk of severe disease and death increases amongst elderly people and people with underlying health risk conditions (in the same way as for seasonal flu).”

Another parallel is that coronavirus is a respiratory disease. The precise mechanism it uses to attack the lungs is different, but attack them it does, causing pneumonia, breathing difficulties and, in severe cases, death.

For planners, this is not an academic observation but a practical one. Respiratory diseases necessitate specialist hospital treatment for a sizeable proportion of those who become symptomatic in the form of ventilation and the need for antibiotics to fight secondary infections.

Anticipating a possible rush on critical care beds, the plan proposes that existing hospital patients will have to be discharged and cared for at home to create space. In hospitals, “some non-urgent care may be delayed to prioritise and triage service delivery”.

This sort of rationing was unfortunately another feature of the Spanish flu, which caused medical services to become overwhelmed and accounted for many deaths.

So how worried should we be? Dr Gail Carson, a University of Oxford infectious diseases consultant, said: “Such plans can always read coldly … the bullet-pointing does not put across well empathy for a worried population, but it shows collaboration across government and a strong and ready government response”.

Less optimistic perhaps, Dr Tedros Adhanom Ghebreyesus, the World Health Organisation’s director general, warned yesterday not to compare coronavirus directly with previous outbreaks. “It is a unique virus with unique characteristics,” he said. “Globally about 3.4 per cent of Covid-19 cases have died. By comparison seasonal flu generally kills far fewer than 1 per cent of those affected. We have vaccines and therapeutics for seasonal flu, [but] none for Covid-19.”