Devil’s choice: Ricardo Jorge, the ‘Spanish flu’ pandemic and the pneumonization of plague, 1899-1933

To the Editor Humans tend to place present events in the context of past experiences, especially during crises, when society's vulnerabilities become apparent. In these times, reflection on the learning processes from the past is initiated. All non-pharmaceutical public health countermeasures currently being taken against the COVID-19 outbreak are based on experience gained from past pandemics over the last several centuries,1, 2 which were mostly caused by influenza (1889/90, 1918/19, 1957-59, 1968-70, 1977/78, and 2009) and twice by coronaviruses (2003 and 2019/20). Among these pandemics, the 1918/1919 influenza outbreak (Spanish flu) remains the most devastating, as it caused an estimated 20-100 million deaths worldwide and continues to exemplify the worst-case scenario.3 Over the last few months, during the current worldwide COVID-19 outbreak, we have noted a unprecedented and sharp increase in the public and scientific interest toward the influenza outbreak of 1918/1919. A first look at the Google search trends since 2004 (https://trends.google.com) revealed marked increases in searches for Spanish flu on the web and on news pages in March and April 2020 (Figure 1A). Further, according to a non-systematic PubMed search using the tool PubMed by Year (https://esperr.github.io/pubmed-by-year/), the number of listed scientific studies per 100,000 citations using the search terms Spanish flu or influenza 1918 in their abstract/title reached an all-time high in 2020 (Figure 1B). Of the 31 studies that were published in 2020, some can still be attributed to the centenary of the Spanish flu. However, the number of studies explicitly referring to the Spanish flu in the context of COVID-19 is increasing. Many of these publications tried to identify similarities and differences between the two pandemics in attempts to adapt the lessons of the past to current challenges.4 This pleasingly increased interest in the past and the lessons learned from in itself is not surprising. To highlight this fact however is important, because this valuable historical knowledge should be considered with thoughtfulness, especially since many questions about the Spanish flu are still unanswered.5 While research will certainly have more urgent problems to solve at the moment, in the future, historical epidemiologists should also analyze how researchers and the public recall the past during a new pandemic outbreak. What aspects of the past outbreaks are discussed where, in which context, and over which channels? Are these reflections scientifically balanced, and do they have an influence on the resilience and the reception and management of the current outbreak? Kaspar Staub: Conceptualization (equal); Formal analysis (equal); Investigation (equal); Methodology (equal); Supervision (lead); Visualization (equal); Writing-original draft (equal); Writing-review & editing (equal). Joël Floris: Conceptualization (equal); Formal analysis (equal); Investigation (equal); Methodology (equal); Visualization (equal); Writing-original draft (equal); Writing-review & editing (equal). The peer review history for this article is available at https://publons.com/publon/10.1111/irv.12806.

The 1918-1919 influenza pandemic was the most devastating epidemic in modern history. Here, we review epidemiological and historical data about the 1918-1919 influenza epidemic in Spain. On 22 May 1918, the epidemic was a headline in Madrid's ABC newspaper. The infectious disease most likely reached Spain from France, perhaps as the result of the heavy railroad traffic of Spanish and Portuguese migrant workers to and from France. The total numbers of persons who died of influenza in Spain were officially estimated to be 147,114 in 1918, 21,235 in 1919, and 17,825 in 1920. However, it is likely that >260,000 Spaniards died of influenza; 75% of these persons died during the second period of the epidemic, and 45% died during October 1918 alone. The Spanish population growth index was negative for 1918 (net loss, 83,121 persons). Although a great deal of evidence indicates that the 1918 A(H1N1) influenza virus unlikely originated in and spread from Spain, the 1918-1919 influenza pandemic will always be known as the Spanish flu.

Objective — to analyze historical data on one of the largest in the history of humanity pandemic of influenza, «The 1918 flu pandemic» or «Spanish flu», which claimed about 100 million lives according to various data and caused significant changes in the social and political life of mankind. Conclusions. In 1918–19, humanity faced one of the most dangerous pandemics in history — «Spanish flu». The causes of the mass spread of the influenza pandemic in 1918–19 were the World War, mass migration of the population, and the poor state of medical care in the disease itself. 100 years after «Spanish flu» we have a clear understanding of what humanity encountered, the nature of the virus itself and can predict future pandemics of the disease. The value of information regarding the «Spanish flu» pandemic lies in its historical as well as purely scientific significance for scientists and humanity as a whole. Recent pandemics and the flu epidemic show the importance of a retrospective analysis of previous outbreaks of the flu to prevent a large number of both the sick and the victims of this ailment.

We study the lasting repercussions of the 1918 influenza (‘Spanish Flu’) pandemic on health measures and literacy rates in São Paulo, Brazil, the most populous city in South America today, but significantly poorer a century ago. Leveraging temporal and spatial variation in district‐level estimates of influenza‐related deaths for the 1917–20 time period, combined with a unique database on demographic and literacy outcomes as well as a detailed set of socio‐economic, infrastructure, and regional determinants newly constructed from historical data, we find that the pandemic had significant impacts. In particular, infant mortality and stillbirths rose, sex ratios at birth fell, and there was a marked improvement in male literacy rates for those 15 years and above in 1920. Further analyses reveal that these impacts are most pronounced in districts with older populations, less literate districts, and districts where access to doctors was relatively limited. We find evidence that the male literacy effects persist in 1940. These results highlight that ramifications of the 1918 Spanish Flu pandemic were experienced for at least two decades after the event in a context where institutions were relatively weak and resources for mitigation were limited.

If you believe what you read in the newspapers, the world is poised for a pandemic. The scourge is likely to be infection with the influenza A virus. Although there may be some doubt concerning these cataclysmic predictions, they are based on solid epidemiological and historical data. It is well documented that during the past several centuries, an influenza virus pandemic has raced through the human population every 20–40 years or so. In 1918–1919, a pandemic due to influenza virus infected one out of every five humans. This “Spanish Flu,” which was also known as “La Grippe,” is estimated to have killed more than 30 million people in less than 2 years (Mills et al., 2004). To put this in perspective, this influenza pandemic killed one out of every four soldiers that died during World War I (Oxford et al., 2005). Luckily, there has not been a repeat of the 1918–1919 pandemic. However, recent events such as the emergence of the avian influenza that is currently causing mortality in Asia may signal the evolution of a new, highly virulent influenza virus that might cause a serious worldwide influenza epidemic.

Part I of this article is a summary of some of the major economic effects of a pandemic, especially a pandemic entailing a severe strain of influenza. The study is mainly quantitative in nature and is based on several models created and run by government and private agencies in the United States and by international organizations involved in public health. The principle scenarios analyzed are based on the influenza pandemics of 1918 (“Spanish flu”), 1957, 1968 (“Hong Kong flu”), 2003 (SARS) and 2005-to-present (H5N1 avian flu). Both actual historical and forecast model data are included. Pandemic economics is a topic of research & teaching at Texas A&M University’s Integrative Center for Homeland Security. Part II of this article summarizes many of the nation-specific and multinational systemic effects of a pandemic, especially a pandemic entailing a severe strain of influenza. The study is mainly qualitative in nature and is a collection of information from a variety of sources from the US, other nations, and international organizations. Recent events have demonstrated the fragility of the major systems that civilization depends on. Natural disasters, terrorist attacks, and financial breakdowns may only be preludes to a systemic collapse precipitated by an uncontrollable pandemic. In today’s world, we are all dependent on the continuation of complex and interdependent systems that are the operational “machines” of societies, economies, governments, and businesses.

After the Spanish flu pandemic in 1920s, the world experienced another one named the COVID-19 pandemic in 2019. It has significantly impacted human life in various aspects. In response to this, not only countries but all actors in international relations take part including the World Health Organization (WHO). One of its moves was the formation of the ACT-Accelerator, which includes four pillars of COVID-19 management namely diagnostics, therapeutics, vaccines, and the health systems and response connector. In this case, WHO formed a multilateral cooperation called COVID-19 Global Access (COVAX). This collaboration incorporates several international organizations and agencies; namely, GAVI, CEPI, and UNICEF. COVAX aims to provide equal access for countries that need vaccines, especially developing countries. This study examines the global health diplomacy strategy carried out by the World Health Organization in procuring world vaccines through the COVAX program in Indonesia. The authors used a descriptive qualitative method with secondary sources to analyze the phenomenon in this study. Based on the conceptual framework, namely international organizations and global health diplomacy, the authors analyze the strategies pursued by WHO in realizing global health in Indonesia. This study found that the efforts of WHO global health diplomacy through the COVAX program to Indonesia include conducting vaccine research and development and raising funds and negotiating vaccine purchases. This study finally argues that the COVAX program serves as a concrete example of how WHO’s global health diplomacy strategies are implemented, offering a detailed case study of international cooperation in vaccine distribution.

Emerging and re-emerging viruses (like Spanish flu, SARS-CoV-2, etc.) have substantially impacted global public health since the early twentieth century. These outbreaks are unpredictable and novel viruses are difficult to understand due to emerging variations. Advanced virology and diagnostic technologies have revolutionized viral diagnostics, enabling accurate early identification and successful treatment and containment. Next-generation sequencing (NGS) technologies, such as metagenomics and whole-genome sequencing, have played a crucial role in the detection and monitoring of emerging viruses, such as SARS-CoV-2 and its variants. Advanced diagnostic methods, such as digital PCR, CRISPR-based tools, and serological techniques like ELISA, enhance viral detection's sensitivity, specificity, and speed. Research has shown that innovations such as lateral flow immunoassays, biosensors, and aptamers have the potential to significantly enhance diagnostic accuracy in various fields. The integration of AI in diagnostics aids researchers in understanding viral evolution and outbreak management, offering new avenues for rapid response. This review aims to examine the latest advancements in virus diagnosis technologies, identify unresolved accuracy and detection issues, and discuss emerging ideas that are transforming the future of viral diagnostics. It is important to improve early identification, rendering the system more cost-effective and adaptable to new viral threats.

The Spanish influenza pandemic in the years 1918–1920 was the largest and most tragic pandemic of infectious disease in human history. Deciphering the structure of the virus (including the determination of complete genome sequence) of this pandemic and the phylogenetic analysis and explanation of its virulence became possible thanks to molecular genetic analysis of the virus isolated from the fixed and frozen lung tissue of influenza victims who died in 1918 and were buried frozen in Alaska and Spitsbergen. Epidemiological data from the course of this pandemic in Poland have not been previously published.For analysis, we used source materials such as clinical studies and case reports of doctors fighting against the pandemic and registries of influenza cases in units of the Polish Army and military hospitals.Clinically, the pandemic of 1918 was characterized by the same symptoms and course as influenza in other years. Pathologically, the disease was similar to the other pandemic, in that the destruction was mostly limited to the respiratory tract.The “Spanish” influenza pandemic of 1918–1920 took place in Poland in 3 epidemic waves. The peaks of morbidity and mortality occurred in the capital, Warsaw, in December 1918 and in December 1919 to January 1920. It is estimated that throughout the pandemic period of 1918–1920 in Poland, 200 000 to 300 000 people died.

Annuity pricing is critical to the insurance companies for their financial liabilities. Companies aim to adjust the prices using a forecasting model that fits best to their historical data, which may have outliers influencing the model. Environmental conditions and extraordinary events such as a weak health system, an outbreak of war, and occurrence of pandemics like Spanish flu or Covid-19 may cause outliers resulting in misevaluation of mortality rates. These outliers should be taken into account to preserve the financial strength and liability of the life insurance industry. In this study, we aim to determine if there is an impact of mortality jumps in annuity pricing. We question the annuity price fluctuations among different countries and two models on country characteristics. Moreover, we show the annuity pricing on a portfolio for a more comprehensive assessment. To achieve this, a simulated diverse portfolio is created for the prices of four types of life annuities. Canada, Japan, and the United Kingdom as developed countries with high longevity risk, Russia and Bulgaria as emerging countries are considered. The results of this study prove the use of outlier-adjusted models for specific countries.KeywordsMortalityAnnuity pricingLee–Carter modelOutlier-adjusted

China was not been isolated from the Spanish flu which begun in 1918. According to the reports on the influenza epidemic in China from 1918 to 1920 in the Shun Pao(, Shanghai Daily), the plague was rampant in China three times, involving at least three cities including Beijing, Tianjin and Shanghai, and more than 14 provinces including Heilongjiang, Jilin, Jiangsu, Zhejiang, Anhui and Guangdong. Among them, the first wave of epidemic reports were mainly in June and July 1918, the disease was relatively mild. The second wave outbroke on October to November, with aggravating symptoms and a significant increase in the number of patients and deaths, Ningbo, Shaoxing, Jiaxing in Zhejiang Province were the worst, and Beijing, Anhui, Henan, Hunan, Shanghai and other places were also serious. The third wave occurred in the spring of 1919, Shanghai, with more reports. In previous works on the 1918 pandemic, there are few descriptions about the epidemic in China, therefore, the reports on the 1918-1920 pandemic in Shun Pao are important historical data supplement to the most deadly natural disaster in human history.

Background The threat of 2009 pandemic influenza A (H1N1) is still causing widespread public concern. A comprehensive understanding of the epidemiology of 1918 pandemic influenza commonly referred to as the Spanish flu may be helpful in offering insight into control strategies for the new pandemic.Objective We explore how the preparedness for a pandemic at the community and individual level impacts the spread of the virus by comparing the transmissibility of the 1918 Spanish flu in two Canadian cities: Montreal and Winnipeg, bearing in mind that each pandemic is unique and the current one may not follow the pattern of the 1918 outbreak.Methods The historical epidemiological data obtained for Montreal and Winnipeg in Canada is analyzed to estimate the basic reproduction number which is the most important summary measure of transmission potential of the pandemic.Results The transmissibility of the 1918 pandemic influenza virus in Winnipeg in the fall of 1918 was found to be much lower than in Montreal based on the estimated reproduction number obtained assuming different serial intervals which are the time between onsets of symptoms in an index case and a secondary case.Conclusion The early preparedness and public health control measures could suggest an explanation for the fact that the number of secondary cases generated by a primary case was significantly reduced in Winnipeg comparing to it in Montreal.

Nobody can be fully prepared to a pandemic. Of course there are signs of it, the scientists can predict, alarming speeches can be made. But there are always alarmist people around, maybe that is why sometimes even the most serious warnings may be not considered by the authorities on time. The first patients may be lost without a proper diagnosis. When everybody realizes that there may be a big problem in the horizon, sometimes it is too late. That is why it is very important to monitor contagious diseases and follow the warnings and releases of national and international disease control centers and other related organizations. China celebrated Lunar New Year with more than 40 thousand families on the 18 of January 2020. Nobody seem to be expecting this emerging new viral pneumonia outbreak appeared in Wuhan, in the last days of 2019, will break the chains and turn out to be a pandemic! But maybe this time it was not too late. There were four important pandemics within the last century: Spanish Flu, Hong Kong Flu, Asian Flu and Swine Flu. Each left different story behind. Millions of people had infected, hundreds, thousands of people died. This time, the Modern World had different tools to limit the SARS CoV2 outbreak. The national and international institutions of our globe were all communicating and taking precautions in a very fast manner than ever. However, this time, unexpectedly, the SARS-CoV-2 contagion was also faster. Besides the international organizations like WHO, UNESCO and UNICEF, the roles of local authorities, health ministries, disease control centers, health protection agencies, research centers and universities are all very important in different operational levels to control and survive from the pandemic. This paper will review the immediate response of different national and international institutions and authorities to COVID-19 pandemic.

Aim: This article aims to analyze the impacts of the COVID-19 pandemic on globalization processes, the emergence of new forms of discrimination triggered by the pandemic, and the implications for current social and economic realities, with a particular focus on Central Asian countries. Considering the historical role of pandemics in transforming societies and economies, the study provides a comprehensive assessment of the global economic downturn, unemployment, poverty, and social discrimination induced by COVID-19. Methods: A comparative historical analysis was conducted, juxtaposing the societal impacts of major past pandemics (Black Death, Spanish flu) with those of COVID-19. Secondary data from international organizations and reputable survey institutions were utilized to evaluate unemployment, economic growth, and incidents of racist-xenophobic violence in Western European and Central Asian countries. Results: The COVID-19 pandemic caused severe disruptions in global supply chains-the arteries of economic globalization-leading to a marked contraction in world trade and economic growth. Government measures such as border closures, quarantines, and mobility restrictions exacerbated job losses and disproportionately affected vulnerable groups, especially youth and women. The climate of fear and uncertainty fuelled by the pandemic increased racist and xenophobic attitudes toward “others” (foreigners, migrants, ethnic minorities), conceptualized as “xeno-racism.” While such discriminatory behaviors were widely reported in Western countries, no significant evidence was found in Central Asia, though the region suffered deep economic impacts. Conclusion: The research concludes that while COVID-19 will not end globalization, neglecting the human factor may inflict greater harm on globalization and the economy than the pandemic itself. Ongoing and future studies are needed to fully understand the long-term consequences of the pandemic on economies and societies. Originality: This study highlights that pandemics generate lasting effects not only on health but also on social cohesion and economic structures, emphasizing the emergence of xeno-racism as a distinctive phenomenon during the current pandemic.

With three major viral pandemics over the last 100 years, namely the Spanish flu, AIDS and COVID‐19 each claiming many millions of lives, pandemic preparedness has become an important issue for public health. The economic, social and political consequences of the upheaval caused by such pandemics also represent a major challenge for governments with respect to sustainable development goals. The field of pandemic preparedness is vast and the current article can only address selected aspects. The article looks first backwards and addresses the question of the efficacy of non‐pharmaceutical interventions (NPI) on the trajectory of the COVID‐19 pandemic. The article looks then forward by asking to what extent viral candidates for future pandemics can be predicted by virome analyses from metagenome and transcriptome sequencing, by focusing on the virome from specific animal species and using ecological and epidemiological data about spillover viral infections in veterinary and human medicine. As a comprehensive overview on pandemic preparedness is beyond the capacity of a single reviewer, only selected topics will be discussed using recent key scientific publications. Since COVID‐19 has not run its course, a computational program able to predict the future evolution of SARS‐CoV‐2 is mentioned that could assist proactive mRNA vaccine developments against possible future variants of concern. Ending the COVID‐19 epidemic necessitates mucosal vaccines that can suppress the transmission of SARS‐CoV‐2 and therefore this article closes by discussing a promising and versatile protein nanoparticle experimental vaccine approach for inhalation that does not depend on needles nor a cold chain for distribution.