Comparing COVID-19 with Spanish flu and other viral outbreaks

PHOTO: Richard Wenzel, center, Francis Macrina and Michael Donnenberg at a 2018 lecture.

By Joan Tupponce

Viral outbreaks are a natural part of life, said Richard P. Wenzel,
M.D., chair emeritus and professor of the Department of Internal
Medicine at Virginia Commonwealth University’s School of Medicine.

“We tend to get surprised every time we have a new outbreak of a virus
that causes an epidemic,” said Wenzel, an infectious disease specialist.
“There is an uncertainty about when and how severe the virus will be,
but there is an inevitable march over time of them.”

Since the early 2000s, the world has experienced the outbreaks of severe
acute respiratory syndrome, Middle East respiratory syndrome and
influenza virus H1N1. VCU News asked Wenzel what these viruses have in
common with COVID-19, the novel coronavirus currently spreading
worldwide, and what past outbreaks have taught us.

How does COVID-19 compare to other outbreaks such as H1N1, SARS and

The cause of most pandemics is a zoonosis virus from an animal that
leapt over to people. HIV was transmitted from a chimpanzee. All
coronaviruses — SARS, MERS and COVID-19 — are transmitted from bats with
a secondary host. In SARS it was a cat, in MERS it was a camel, and
COVID-19 is a pangolin, which is prized for its meat and used for
traditional medicine in China. H1N1 was a hybrid from birds and cows.

When I went down to Mexico during the height of the H1N1 epidemic,
instead of sitting and looking at statistics, I made rounds. Almost all
of the people on respirators were in their 20s and were obese or
pregnant, and that is really unusual. Seeing patients helps you get
accurate numbers and clinical data. You have to be there.

What’s different, I think, is that COVID-19 is going to turn out to be
an equal-opportunity virus with a high risk for bad outcomes for the
elderly, newborns, babies and people who are immunosuppressed. Like H1N1
and seasonal flus, COVID-19 is highly communicable. What’s different is
it has 10 times greater mortality rates than the seasonal flu.

The major difference from SARS, MERS and H1N1 is that SARS and MERS had
high mortality rates but were less transmissible. SARS only affected
8,000 people, but 800 people died, giving it a 10% mortality rate. For
MERS, the mortality was 1 in 3. We are fortunate that this coronavirus
is much less deadly. Looking ahead, we have to see if it changes or has
a genetic mutation allowing it to be more lethal. That is always the
worry. So far, we have seen no changes at all.

How does COVID-19 compare to the Spanish flu outbreak a century ago?

Both were pandemics — the 1918-19 flu and now COVID-19 — and zoonoses,
meaning both probably originated in animals and then transferred to man.
The bat was the primary reservoir for COVID-19, and birds are thought to
be the reservoir for the flu of 1918-19. The other thing is, clinically,
the flu of 1918-19 is a little bit like H1N1, and like H1N1, which came
through here in 2009-10, it primarily attacked young adults. That’s
different than what we are seeing today with COVID-19.

PHOTO: Influenza ward No. 1 at a U.S. Army camp hospital in
Aix-Les-Bains, France, 1918. (Public domain photo, uncredited U.S. Army

It’s a hundred years later than that flu epidemic, and now we have a
chance to have a drug  — maybe within six months  — and a chance to have
a vaccine in a year or year and a half. We have good public health
response and obviously a more crowded world with a lot of flight travel,
which complicated things for us initially.

What lessons did we learn from H1N1, SARS and MERS?

We should be building up a robust response to the next pandemic. We need
a new definition of “pandemic,” such as a response to an infectious
threat requiring international surge capacity. It should measure
incremental resources needed, including medical protective equipment,
personnel, ICU beds, food and water, diagnostics tests, drugs and the
percent of domestic gross product that we need for control. Imagine if
we had this for H1N1, SARS and MERS.

We need help from other countries. We need international cooperation —
legal, medical and administrative. Calling it the Chinese virus doesn’t
help. We need their data to see what they did and compare that to
another country that did it differently. We have lost weeks in
responding to this pandemic.

How is COVID-19 spread?

When people cough, sing or speak, droplets come out from their nose and
throat, and these droplets, called “large droplets,” travel to 6 feet or
so and then fall to the ground. This happens with the common cold and
strep throat. So if you stay away 6 feet, you are unlikely to get it. We
are concerned that there may be different droplet sizes with some small
droplets less than 1/100th of a millimeter in diameter. They are tiny
and hang in the air. They are like microscopic hot air balloons. They
can hang out for a couple of hours. They can be inhaled and cause
infection because they don’t get trapped in the pharynx or large
airways. They can get to the sacs of the lung and, if they get inflamed,
can cause pneumonia.

Should we be concerned about getting the mail or picking up items at the

Those are low risk. Most viruses die out. However, they can stay on the
surface for days on plastic and stainless steel. Plus, you don’t know
who touched the item. You can wipe them off if it makes you feel more
comfortable. Also, the virus doesn’t last very long on cloth, but it
would on the railing of a cruise ship, for example. The bigger risk is
not handwashing and touching your face.

What are we missing when we talk about COVID-19?

We need to focus on the mental health impact that a lot of people are
coping with day to day. If you say the word “pandemic,” or talk about
isolation or getting the virus, it might be enough to push them over
their coping capability. Some people live paycheck to paycheck so there
is no money for medicine or food. Drugs could become unavailable because
a lot of drugs come from China. If enough people get stressed, we could
see civil unrest.

Are there any drugs in the works that could help fight COVID-19?

What is happening is the company that is making remdesivir, an
investigational drug, is undergoing several different trials. They would
like to get a larger number of people enrolled to get answers. Some
early patients got the drug for compassionate use. It might be harder to
get that now. The drug chloroquine is also being used, but there is a
limited amount of that.

What can we expect in the next eight weeks?

We still don’t have test availability to meet demand. There are people
out there with the virus and, once we start getting those tested, the
numbers will go up. I won’t be surprised to see really big numbers.

Why are some people still refusing to do social distancing and

Despite overwhelming science, they seem to be holding their position.
You can’t influence their behavior by facts or logic. No one has said to
them, “If you get ill, you have family — brothers, sisters, parents and
grandparents — that could get the virus. If you transfer the disease,
it’s grossly unethical behavior.”

What’s the light at the end of the tunnel?

What will guide us is the numbers. Looking at other epidemics, and this
one in China, at least the curve should peak in mid-June, or it could be
earlier in May. We don’t know how steep the curve will be on the decline
side. If it lingers on, it will be in the summer when it finally ends. I
would say be prepared for what you are doing now for at least four
weeks, but it depends on what the numbers are. We are in a time of

What happens after COVID-19 is over?

The U.S. Agency for International Development had a program under the
Bush and Obama administrations called “Predict” that looked at
prospective systemic new viruses in bats. That was abolished a year and
a half ago under the current administration. That weakened our
foundation. Also, the U.S. pandemic response team was decimated in the
last two years. It was bad timing. The pillars of preparedness have been
weakened. We need to get back to those robust preparations and build
robustness nationally and internationally. We need to plan for the
worst. – VCU News

PHOTO: Influenza ward No. 1 at a U.S. Army camp hospital in
Aix-Les-Bains, France, 1918. (Public domain photo, uncredited U.S. Army

PHOTO: Richard Wenzel, center, Francis Macrina and Michael Donnenberg at
a 2018 lecture.


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