Influenza pandemics then and now - the 100th anniversary of the Spanish Flu pandemic
As the First World War was grinding to its end in 1918, reports started to emerge of an infectious disease in the trenches, army barracks and medical hospitals crowded with soldiers. The first outbreaks were reported in March 1918, although initially doctors weren’t sure if it was flu or some other infectious disease. The Spanish flu pandemic ranks with the Justinian plague and the Black Death as one of the worst medical disasters in human history. It spread around the world in at least two waves, with the second wave in 1919 being much deadlier than the first. While it’s estimated that around 16 million people died as a result of the First World War, at least 50 million people across the world died who from the Spanish Flu pandemic. One-fifth of the world’s population was infected with the disease, and global mortality rates (the number of people infected who died) are estimated at between 10% and 20%.
It was a particularly vicious strain of influenza, spreading quickly between countries, appearing suddenly for a few weeks, then disappearing just as quickly. The Spanish Flu attacked and killed patients rapidly, reaching all corners of the globe, such that it contributed to falls in global life expectancy. Lives were lost, families devastated and society up-ended.
How the world manages influenza pandemics today compared with 100 years ago has changed dramatically. Back in 1918, there were no flu vaccines, no anti-viral medicines, no antibiotics to treat secondary infections, rudimentary public health measures, no global pandemic plans, no World Health Organization (WHO), little research, no government stockpiles of vaccines, no genetic understanding of how the virus evolved, and generally not a lot of preparation.
In 2018, we have all of these. There is a wealth of technology, medical care, strategies and players to manage, treat and avoid influenza pandemics today that simply did not exist 100 years ago. In contrast to the Spanish flu pandemic of 1918, the H1N1 Swine flu pandemic of 2009 was managed very differently. Governments around the world threw their emergency plans into action, vaccine stockpiles were mobilised, vaccine manufacturers coordinated with the World Health Organization, public research was shared, anti-viral medicines were made available, and there was international cooperation to manage the outbreak.
Today, each year companies develop seasonal vaccines to treat that year’s strains of influenza in partnership with researchers, government and international organisations like the WHO. Today there are up to 20 companies manufacturing influenza vaccines for the world, operating in at least 13 countries, and more manufacturers are starting to emerge in developing countries. There are annual influenza vaccines for seasonal flu, a capability to rapidly increase manufacturing of vaccines for pandemics, and a suite of anti-viral medicines and antibiotics to treat influenza and its complications when it strikes. There have been various technological developments in influenza vaccines that facilitate greater dose sharing, allow more efficient and quicker production, and provide broader strain coverage.
Today there’s a complex process of cross-sectoral collaboration to ensure that companies can produce the right vaccines in enough quantities to ensure people are immunised against seasonal flu. The WHO’s 10-year Global Action Plan for influenza vaccines finished in 2016 and a big part of its work was preparing the world for future influenza pandemics. Potential global annual production capacity of pandemic vaccines quadrupled from 1.5 billion doses in 2006 to 6.4 billion doses a decade later. Although still short of the 10 billion doses expected to be needed, today’s potential supply does allow countries to vaccinate a significant portion of the world population in the event of a pandemic.
There is a Pandemic Influenza Preparedness Framework that was developed in 2011 that brings together governments, industry, health experts and civil society to work together with WHO to help ensure that the world is better prepared to respond to pandemic influenza. Moreover, today 115 out of the 194 countries that are members of the WHO have national influenza plans to manage seasonal influenza and prepare for future influenza pandemics, an increase from 74 in 2006.
This is not to say that everything is solved. Vaccination coverage rates in countries are not increasing which poses risks of future pandemics and the Pandemic Influenza Preparedness Plan needs to be better funded and managed. The fact that 79 countries still do not have a national influenza plan, and that the bulk of these are low income developing countries, is a cause for concern. There is still a shortfall in production of doses to immunise everybody in the event of major influenza pandemic, to the tune of 3.6 billion doses.
There is a need to ensure viability for companies and health system readiness by ensuring sufficient use of seasonal influenza vaccines to maintain a standing preparedness and capability to respond to the next pandemic. There are questions about whether genetic sequencing data of influenza can be quickly shared in the event of a pandemic due to inadvertent regulatory barriers created as part of new international agreements. There is the ongoing search for a universal flu vaccine and there are still lessons to be learned and implemented from the last flu pandemic in 2009.
While there is still much to do, the fact is humanity has much more to fight a flu pandemic today than it did 100 years ago because of the good work of scientists, medical experts, governments, international organisations and the pharmaceutical industry. A century ago doctors weren’t sure what the strange, infectious disease was that had struck down the troops on the Western Front. Today we have arguments about things like influenza policy, genetic strain sharing and funding levels.
It’s an important, but often forgotten, sign of how we have progressed.