What Worked in 1918-1919?

The influenza pandemic of 1918 was the most contagious calamity in human history. Approximately 40 million individuals died worldwide, including 550 000 individuals in the United States...[C]an lessons from the 1918-1919 pandemic be applied to contemporary pandemic planning efforts to maximize public health benefit while minimizing the disruptive social consequences of the pandemic as well as those accompanying public health response measures?

That’s the question Markel et al. analyzed in 2007 by gathering historical data on outcomes and what 43 US cities, covering about 20% of the US population, did to combat influenza in 1918-1919.

Nonpharmaceutical interventions were considered either activated (“on”) or deactivated (“off”), according to data culled from the historical record and daily newspaper accounts. Specifically, these nonpharmaceutical interventions were legally enforced and affected large segments of the city’s population. [1] Isolation of ill persons and quarantine of those suspected of having contact with ill persons refers only to mandatory orders as opposed to voluntary quarantines being discussed in our present era. [2] School closure was considered activated when the city officials closed public schools (grade school through high school); in most, but not all cases, private and parochial schools followed suit. [3] Public gathering bans typically meant the closure of saloons, public entertainment venues, sporting events, and indoor gatherings were banned or moved outdoors; outdoor gatherings were not always canceled during this period (eg, Liberty bond parades); there were no recorded bans on shopping in grocery and drug stores.

The authors define “public health response time” as the number of days from the day the excess death rate was double baseline to the day that at least one of their three key public health measures was implemented. Cities that responded very early have a negative public health response time. The basic result is shown in the figure below. The longer the public health response time the greater the total excess deaths (the arrow is my least squares eyeball).

Moreover, although it’s difficult to control for other factors, cities that combined school closures, isolation and quarantining, and public gathering bans tended to do better. Some cities let up on their public health interventions and these cities seem to correlate well with bi-modal distributions in excess death rates, i.e. the death rate increased. Denver was an example where the public gathering ban was dropped and the school ban was lifted temporarily and the excess death rate rose after having fallen.

The authors conclude:

…the US urban experience with nonpharmaceutical interventions during the 1918-1919 pandemic constitutes one of the largest data sets of its kind ever assembled in the modern, post germ theory era.

…Although these urban communities had neither effective vaccines nor antivirals, cities that were able to organize and execute a suite of classic public health interventions before the pandemic swept fully through the city appeared to have an associated mitigated epidemic experience. Our study suggests that nonpharmaceutical interventions can play a critical role in mitigating the consequences of future severe influenza pandemics (category 4 and 5) and should be considered for inclusion in contemporary planning efforts as companion measures to developing effective vaccines and medications for prophylaxis and treatment. The history of US epidemics also cautions that the public’s acceptance of these health measures is enhanced when guided by ethical and humane principles.

Addendum: Another way of putting this is that China has largely followed the US model. Can the US do the same?

Comments

Translated: Good news for China and South Korea. Bad news for Europe and the US.

I should have been tomorrow at the Geneva Motor Show, FWIW it was cancelled.

Other public gatherings are also being cancelled in Switzerland. The hockey league playoffs will be played without public, only TV cameras =)

Milano and surrounding Lombardy in Italy are going full lockdown as China. Sporting events in Italy are also without public. When is the first football match in the US going to be played without public? 2 or 3 weeks more?

What you call football matches have always been played largely without an audience in the US. It's the other sports we have to worry about ... :)

I'm talking about the US football. When is the first match without an audience? Wonder if venue owners are liable for contagions in the stadium.

There are no football games being played in the U.S. right now. The season ended last month. The new season doesn't begin until next fall, by which time the pandemic will almost certainly be under control. Given the time of year, your question is really more relevant to basketball and baseball.

There are XFL football games being played in the U.S. right now. Just not NFL or college.

March 26 is opening day for baseball.

"I'm talking about the US football. When is the first match without an audience?"

Pfft. You ever see a Mid American Conference game in November?

Look closely at the report DTRA (Defense Threat Reduction Agency) compiled on 1918 Spanish Flu. NPI worked quite well in Gunnison CO, Yerba Buena Island CA, and a site back East. All three closed their locations to outsiders on first hunt of pandemic. All three locations had zero cases of Spanish Flu.

Link: http://chm.med.umich.edu/wp-content/uploads/sites/20/2015/01/DTRA-Final-Influenza-Report.pdf

Didn't American Samoa also close everything and had no problems?

Yes, thanks to it's Naval Governor, this guy https://infogalactic.com/info/John_Martin_Poyer

On the other hand, thanks to this guy https://infogalactic.com/info/Robert_Logan_(politician) Western Samoa had 90% of its population get infected, and about 20% die.

What does it mean "excess death rate"?

There seems to have been different strains of the Spainsh Flu, with significant differences in fatalities. Difficult to see how that was controlled for.

Since nCoV-19 (COVID-19) mutates fast, there's also different strains of the Wuhan virus. So it's a wash.

Bonus trivia: as I pointed out weeks ago, well before anybody, the stock market responds to the total new cases *in China*, found here: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 Today (Sunday 3/8/20) is the first day that total new CHN Covid-19 cases have not increased. So Monday should be green for worldwide stock markets. You read it here first. Assuming of course one trusts the China numbers (not entirely clear to me).

Great find. That's why I read MR. I hope this gets noticed in the right places.

The Spanish flu pandemic spread because it was wartime (WWI) and the government suppressed information about it. Indeed, in America, Philadelphia planned its largest parade ever, and physicians pleaded with officials to call off the parade. Nope, the parade went on, attended by 300 returning soldiers who had been infected. Within 48 hours, the flu had spread throughout the city, a death toll exceeding 12,500, with the dead lying in their beds and even in the streets. There are differences between the Spanish flu and the coronavirus, the former being more deadly among young adults. But there are similarities: politicians suppressing the truth.

What worked in 1918 were millions of health care volunteers, as janitors, cooks, stewards, body-carriers, etc. as well as nurses. Legal liability issues, plus the glacier-like speed of bureaucracy, mean the federal government must immunize health care providers from liability for the duration of the emergency ASAP to make such health care volunteering possible now.

But that won't happen until it's way too late to save more than a handful of people. As a practical matter, we should be calling for volunteers now with the feds paying for such training of them as is possible. But it is unlikely that, when we finally make their use possible, that they will get any training at all.

This is why government should be flexing its muscle to rightfully infringe on people's rights in a time of need. Today large gatherings, tomorrow Big Gulps and guns. Big Gov 2020!

It is precisely for such purposes that we have a government.

The free market solution is that you pay me when you infect me. As this cannot be measured, and hence not adjudicated, we must turn to other means, such as government, a less bad alternative.

If one wishes to think about it constitutionally, have Congress declare a war on this virus.

Kinda' reminds me of 9/11, when the federal government was sent home. It's precisely at such times that we need government most.

Free markets come from liberty, not the other way around. Free markets are irrelevant to this question. Sans a court removing my rights via trial, I have the absolute right of freedom of movement in public spaces. Bits the indifference you like between am individual warrant (legal) and a general one (not)

Well, yeah: Then I gotta pay you to not infect me!

The regime under which you keep off the street is far more efficient.

Proof: Under your regime we'd wind up dead. :-)

Once again, liberty (individual rights) is not utilitarianism and as such efficiency as a concept is irrelevant. You are free to stay home and self segregate, that is your choice to avoid infection. You are not free to deny me my dignity. To contextualize SXSW cancel "we will deny your choice to make a risk based decision by simply claiming we know better". 14m people in Italy just had a repeat of fascism, you would think the first time would have left a bad taste but it seems the Dago condition, like Slavs, is one of bootlicking going back to Rome.

It's bemusing the amount of crypto-authoritarians whom masquerade as libertarians and classical liberals who show their true color when shit hits the fan. As they say, there are no libertarians in a foxhole among the beltway crowd.

Don't hold Liberty Bond Drives or celebrate the Armistice. Seriously, look at the spike in the Denver graph after Armistice Day.

They cancelled SXSW--smart move. If we can draw only a single lesson from 1918-19, it would be don't have people congregate in abnormally large crowds.

There were 1,100 crew members on the Diamond Princess. They were not quarantined from each other and ate and slept in common quarters. They were held on a ship-prison for weeks exposed constantly to the coronavirus. The vast majority did not even become ill, and not one died.

Dudes, get a grip. Run-of-the-mill non-elderly adults are not at risk from coronavirus, and thankfully neither are children.

The threat is from hysterical mass media and clumsy government. I am a little disappointed Marginal Revolution hasn't been more insightful in this regard

Just curious, are you older than 60? Do you have living relatives older than 60? Do you have any friends older than 60? You have empathy for anyone you don't know older than 60?

Even if you don't feel personally at risk there is a herd immunity thing here.

Healthy young people should care for the same reason that healthy young people should get flu shots.

And even if it does require some lifestyle changes, I think we're only talking about 2-4 months.

Yes, lamentably enough, I am over 60, well over, in fact pointing towards the next decade.

I have the usual amount of empathy towards all fellow human beings.

Perhaps old-age homes need quarantines.

You cite "lifestyle changes." You must be aware that quarantines being considered will drive out of business many travel and hospitality industries. In fact, a global recession is quite possible in the first quarter thanks to excessive reaction by hysterical media and clumsy governments.

It took us a decade to dig out from the last recession.

I understand that in a true command and control economy there would be a real trade off between national quarantine and economic growth.

But when we were talking about voluntary lifestyle changes, that's just freedom.

All this is in the face of uncertainty of course. Any of us might have an opinion of the moment, but that should all be sensitive to change as more data arrives in the coming weeks.

I just caught a moment of Ben Carson on TV, who really should have been the head of the response. But I don't think he was completely honest. He said the CDC's recommendation was for everyone to go about their business.

Actually,

"CDC says adults over 60 should 'stay at home as much as possible' due to coronavirus"

Yes that will have economic repercussions, but it is still individual choice in an environment of uncertainty.

What is Marginal Revolution?

Run-of-the-mill non-elderly adults are at risk of being laid up in bed for a couple of weeks. If 1% of workers lost $1,000 in productivity due to lying sick in bed that would come to $1.76 billion in damages for the United States. I'd would say the US faces a much higher cost than this, but I suppose that make me hysterical and in need of getting a grip.

Because the virus is mostly dangerous to a readily identifiable subpopulation, in cost benefit terms it seems reasonable to at least consider quarantining those at significant risk until a vaccine is available, rather than quarantining everyone. Especially as the most at risk are mostly not in work. Close off the nursing homes and retirement villages, not the schools.

But children are the most undisciplined in terms of not washing hands, touching faces and noses, spreading saliva, not keeping social distance. They are all little typhoid Marys. That affects their parents, who are probably in the forties and fifties, and their grandparents, who might even be primary caregivers for some. And obviously it affects teachers and principals and staff.

And obviously we don't know the long term effects if the virus remains dormant in the body even after apparent recovery. We don't know yet if a second infection has a higher risk of provoking a cytokine storm.

In any case, the virus is still dangerous to younger adults. It kills twenty-somethings at about twice the rate that the seasonal flu kills the frailest elderly population. And it takes intensive care and respirators to keep the death rate that low, none of which will be available after the hospitals are overwhelmed. And that's just deaths; survivors often have severely impaired lung functions that will disable them for the rest of their lives.

Great, now compare those expected costs to the expected costs of a general quarantine. At least do the exercise. Alex and others don't seem to have an upper limit on the benefit of avoiding each infection, therefore any cost is justified - a real failure to think like an economist IMHO.

The primary threat here is not dying from the virus. The primary threat is that if left to it's own devices, the virus will infect enough *total* people to allow the percentage who require hospitalization and ICU to overwhelm the system.

If you don't understand that this is a legitimate danger, then you haven't been keeping up with things in China where they essentially shut down a very large segment of their economy, built a number of "hospitals" for the sick, and forced people to stay indoors I most cases. And when they did allow them to go outside, police and/or soldiers conducted spot testing for fevers and symptoms at regular intervals on the streets.

The secondary threat is to our economy. Shutting things down as China did would drop the US into a serious depression that no amount of money-printing or QE or jaw-boning would fix.

Dying from the virus is a remote possiblity. The threat of adverse economic impact is not.

"The influenza pandemic of 1918 was the most contagious calamity in human history."

Is that true? More contagious, virulent, and lethal than 14th century rounds of bubonic plague? "40 million deaths" worldwide over two years somehow does not sound exactly like locales losing a quarter, a third, or even half of their respective populations.

On another hand: WHO and CDCP accounts make COVID-19 sound exactly like the new form of SARS that it is--a fresh plague of viral pneumonia, which is not quite exactly what influenza is, or is it? Wouldn't our response to COVID-19 with the global response to the SARS outbreak of sixteen or seventeen years ago offer a more apt comparison?

What? You just inserted words into that quote that weren't there. The Spanish Flu spread worldwide in around year. The black death took half a decade to cover Europe. Whether it was inherent in the organism or not, the Spanish flu was certainly more contagious.

Almost as if railroads and steamships are faster than horses and 14th Century sailing ships.

Or it's harder to breathe in fleas than cough droplets.

Pneumonic plague spreads via airborne means, much like the flu. It was probably responsible for some of the mind-boggling death tolls we read about, like up to a quarter million people dying in Constantinople in 542 in an outbreak that lasted less than six months.

-would be instructive/educational to see the decision tree
for canceling south by southwest!
-this is prettyhot
https://www.youtube.com/watch?v=vTo0crpK8Zs

I took MR's advice (or a commentor on this blog, not necessarily endorsed by the hosts) and blew my wad on coke and Cuban hookers. If the world doesn't actually come to an end, I'm going to be in a sh*tload of trouble.

If it's good enough for Hunter Biden, it's good enough for you. And if Joe wins the Presidency maybe we can all get a job making $88k/month in a country where we do not speak the language or understand--other than corruption--the business paying us. If Joe has an expertise, its finding high-paying, no show jobs for family members.

Can the U.S. do better? Obviously, as can be seen in just a few lines.

The White House said there was no indication that either Trump or Pence had been close to the infected attendee.

Asked if he was concerned about the virus getting closer, Trump said: “No, I’m not concerned at all. No, I’m not. We’ve done a great job.”

When asked whether his thousand-person campaign rallies would would continue in light of the CPAC case, the president replied: “We’ll have tremendous rallies.”

Only those with extreme TDS would expect Trump to avoid holding mass rallies aimed at keeping America great.

Or maybe people can make their own decisions and not attend if they don't want. You know that entire personal accountability concept Progressives hate. Volokh today had a blog post on how making hand shaking a criminal felony is probably Constitutional under how the Supreme Court has ignored the Constitution for centuries. That's shows you how rotten this Republic is.

The duration of the coronavirus pandemic will likely be shorter than the duration of the Spanish flu pandemic due to the time of the year: the Spanish flu hit in the Fall and peaked in the winter while the coronavirus hit in late winter and should be dissipating as temperatures rise in the spring. At least that's the case if warm weather inhibits the virus.

Completely wrong. The Spanish flu had three waves of fatalities, each separated by 4-5 months. As an influenza virus, the body is pretty effect at making antibodies that prevent reinfection once recovered, and specific influenza strains tend not to become endemic.

We have 4 endemic coronaviruses that infect people anew each fall/winter. There is no particular reason to assume that this coronavirus won't become endemic, and flare up again in 9-10 months after quieting down over the summer.

Comparing this to the flu is one of the problems. A better way to conceptualize it might be that it's a common cold virus with a high propensity to cause a lower respiratory infection that leads to pneumonia.

I should add that this may have profound implications for a potential vaccine. We've never made a coronavirus vaccine, and have no idea how protective one will be, or the rate at which COVID-19 might mutate to defeat said virus. And please note that there are already credible descriptions of people seeming to clear the infection, and then becoming infected again. It's too early to know how effect herd immunity and individual immunity will work with the unique virus.

Actually we have a lot if experience with making vaccines to coronaviruses, just not for humans. The reason is that coronaviruses infect mucosal tissues and because mucous membranes are shed regularly and often rapidly the immunity has to be local, does not last long, and must be frequently boostered. Therefore they are hard to make vaccines against that produce effective long-lasting immunity.

There was more than one wave of the Spanish Flu - it lasted more than one flu season. And the second wave was deadlier.

See the second graph above. The first wave came in the fall and the second wave came in the winter.

The 1918 influenza pandemic (January 1918 – December 1920; colloquially known as Spanish flu) was an unusually deadly influenza pandemic, the first of the two pandemics involving H1N1 influenza virus, with the second being the swine flu in 2009

and

In the United States, the disease was first observed in Haskell County, Kansas, in January 1918, prompting local doctor Loring Miner to warn the U.S. Public Health Service's academic journal. On 4 March 1918, company cook Albert Gitchell, from Haskell County, reported sick at Fort Riley, an American military facility that at the time was training American troops during World War I, making him the first recorded victim of the flu.[44][45][46] Within days, 522 men at the camp had reported sick.[47] By 11 March 1918, the virus had reached Queens, New York.[43] Failure to take preventive measures in March/April was later criticised.[48]

In August 1918, a more virulent strain appeared simultaneously in Brest, France; in Freetown, Sierra Leone; and in the U.S. in Boston, Massachusetts. The Spanish flu also spread through Ireland, carried there by returning Irish soldiers. The Allies of World War I came to call it the Spanish flu, primarily because the pandemic received greater press attention after it moved from France to Spain in November 1918. Spain was not involved in the war and had not imposed wartime censorship

Every Third World leader ought to read this paper. In the Third World, effective pharmaceutical interventions are near impossible. The fact that there are other things that can be done is an important strategy worth pursuing. In Africa especially, people will even prefer going to church to seeking medical help. Shutting schools and places of worship will prevent unnecessary deaths. Thank you for bringing this to our notice.

I'm truly shocked Cowen seems to have taken such a position here. Us behaving like China did would be a massive overreaction. China had a massive overreaction after hiding it at first. China's handling of this doesn't impress me in the least.

How low would the 2020 U.S. death tally need to be before the "yay-China" crowd agreed it was a good thing we didn't follow their lead?

IMHO, by far the most trustworthy estimates of this thing's lethality and contagiousness come from S. Korea and the Diamond Princess. Both of these make it look much, much less worrisome than would justify the authoritarian lockdown we saw in China.

Naysayers, your 401k won't start going up until the # of daily new cases worldwide starts going down. Does that simplify things for you?

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