Worse than ‘Flu?

13th October 2020

UK COVID Deaths – Daily 143 / Total 43,018

UK COVID Deaths with COVID-19 on the death certificate - Total 57,347 (up to 25 Sep)

James Cook Hospital – Total COVID deaths – 268

All COVID cases within South Tees Hospitals Trust – 34

James Cook Critical Care COVID cases – 4 (1 ventilated)

Following his melodramatic recovery from COVID-19, President Trump tweeted and posted the following comment on Facebook - “Flu season is coming up! Many people every year, sometimes over 100,000, and despite the Vaccine, die from the Flu. Are we going to close down our Country? No, we have learned to live with it, just like we are learning to live with Covid, in most populations far less lethal!!!”

Facebook removed his post stating that it was their policy to remove incorrect information about the severity of Covid-19. Twitter allowed the tweet to remain but hid it behind a warning that it was "spreading misleading and potentially harmful information". They also limited the ability of users to share the tweet.

The belief that COVID-19 is no worse than influenza (the ‘flu) is a myth that refuses to die, so I thought I’d compare the two viruses in order to better inform those of you who care about the truth. There are certainly many similarities between the two but they are different in some important ways. Before I go any further, I'd like to apologise for the length of this post. I went into the history of 'flu pandemics more than I had originally intended. Probably best to make yourself a cuppa or a stiff drink before sitting down to read the rest of this post.

First we need to differentiate between an epidemic of ‘normal’ seasonal influenza and an influenza pandemic. Seasonal influenza is the regular outbreak of influenza that occurs during the colder, winter months. Seasonal influenza occurs at different times of the year depending on whether you live in the north or south hemisphere. An influenza pandemic is an epidemic of influenza that spreads world-wide. The most recent was the Swine Flu Pandemic of 2009 and the most famous (and lethal) was the Spanish Flu Pandemic of 1918. More on those later.

Influenza is a highly infectious virus in the same way that the COVID-19 virus (SARS-CoV-2) is. Rapid transmission of influenza occurs in crowded areas (especially schools and nursing homes). Coughs and sneezes propel infectious droplets into the air over a distance of one metre and can infect people nearby when the virus enters the nose, mouth or eyes. Influenza is also spread when contaminated hands touch a surface. Spread of influenza is enhanced during winter due to a variety of mechanisms: People spend more time indoors during the colder months, there is less ultraviolet radiation from the sun that can kill the virus, cold air dries out mucous membranes in the mouth and nose adversely affecting immune mechanisms, the same cold air allows the virus to linger on surfaces and vitamin D levels may be lower amongst the population.

The time from infection to illness, (the incubation period) for influenza, is about 2 days, but ranges from one to four days. The incubation period for COVID-19 is about 5-6 days but ranges from one to fourteen days. This means that influenza can spread faster than COVID-19 but COVID-19 appears to be more infectious than influenza. The reproduction number or R number of a virus is the average number of secondary infections produced by one infected individual. This appears to between 2.0 and 2.5 for COVID-19, compared to about 1.25 for seasonal influenza.

Most people with ‘flu are contagious for one day before they develop symptoms and for about seven days afterwards. For COVID-19, people can be contagious for 2 days before symptoms and remain contagious for about ten days.

As we all know, the symptoms of influenza include fever, a dry cough, headache, muscle and joint pains, severe malaise (feeling very unwell), a sore throat and a runny nose. The cough can be severe and can last 2 or more weeks. Some of these symptoms are similar to COVID-19 but ‘flu does not appear to cause a loss of smell or taste like COVID-19 can. It is a myth that you can’t have the ‘flu unless you feel dreadful. Like COVID-19, an influenza infection can be asymptomatic. In fact, in some studies, up to 75% of all people infected with influenza had no symptoms. The proportion of people who are asymptomatic following infection with COVID-19 is still uncertain but a recent UK study conducted in Manchester estimates the rate at up to 80% which is pretty similar to the ‘flu.

The illness caused by influenza can range from mild to severe. Most people recover within a week but hospitalisation and death may occur, mainly among high risk groups. These high risk groups include pregnant women, children under 5 years of age, people over 65 years of age and those with underlying chronic medical conditions or conditions that suppress their immune system (such as patients with cancer and/or those undergoing chemotherapy, organ transplant patients etc.). Not surprisingly, healthcare workers are also at increased risk of contracting influenza. These at risk groups are not dissimilar to those most at risk from COVID-19 although very young children are much less at risk of becoming infected or developing severe COVID-19 infections.

There are also some similarities when it comes to the complications of both viruses. Both can cause pneumonitis (inflammation of the lung), viral pneumonia and respiratory failure, a sepsis-like syndrome, multiple organ failure, heart attacks, heart damage, strokes, inflammation of the nervous system, brain and muscles and secondary bacterial pneumonias. COVID-19 can cause major blood clots in the veins and arteries of the lungs, heart, legs or brain. This is a serious complication that is not usually seen in influenza infections.

The pattern of deaths in influenza is a little different from that seen in COVID-19. The risk of young children dying from COVID-19 is much less than the risk of death from influenza. As you age, that risk appears to change; middle-aged patients are more at risk of dying from COVID-19 when compared to seasonal influenza. Amongst the over 80’s, the risk of dying from COVID-19 gradually decreases whilst the risk of death from influenza increases. Perhaps these very young and very elderly patients are the ones Trump means when he claims that COVID-19 is “in most populations far less lethal”?

So, onto the sixty-four thousand dollar question: how many people die from the ‘flu each year? On average 17,000 people have died from the flu in England annually between 2014/15 and 2018/19. The number of deaths each year varies from a high of 28,330 deaths in the winter of 2014/15 to a low of 3996 in the winter of 2018/19.

The number of confirmed deaths in the United Kingdom due to COVID-19 currently stands at 57,347 (deaths where the death certificate mentions COVID-19). The figure for England alone is 49,612. This figure is already three times higher than the average number of ‘flu deaths in a year and is obviously going to rise further. The important point to get across is that this high number of deaths has occurred despite widespread measures to try to keep the death rate low.

World-wide, the WHO estimates that seasonal influenza kills between 290,000 and 650,000 people. To date, COVID-19 has killed nearly 1.1 million people around the world and it is widely acknowledged that this figure is a significant underestimate of the true number of deaths.

So, there’s no doubt that COVID-19 is much worse than seasonal influenza. COVID-19’s mortality rate is not fully known at the moment but it is felt to be possibly ten times worse than seasonal influenza.

But what of President Trump’s statement? Was he telling porkies when he claimed “many people every year, sometimes over 100,000, and despite the Vaccine, die from the Flu”? Well, yes and no. The Center for Disease Control and Prevention (CDC) states that the number of deaths in the USA from seasonal ‘flu varies year on year but is between 12,000 to 61,000 deaths each year. So it would appear that the President’s pants are indeed on fire. However, technically he is correct - there have been two years in his nation’s history when the death toll from influenza has exceeded 100,000. Those were 1918 and 1919 and the high death rate was the result of an influenza pandemic.

Early Pandemics

It is likely that influenza pandemics have been occurring for centuries. The Greeks in 412 BC describe what may well have been the first recorded one. However, a lack of any accurate information makes it difficult to know exactly which pathogens were causing outbreaks of disease until the sixteenth century.

In 1580 there was an outbreak of an illness in Asia that disrupted society and caused many deaths. The illness sounds very much like influenza. The disease spread along trade routes to North Africa and Europe and eventually to ‘The New World’ in America. However, it wasn’t until 1650 that the use of the word ‘influenza’ first appeared in medical literature. The word came from the Latin word meaning to influence, as historically the symptoms of the virus had been attributed to the influence of the stars rather than an infection.

The first influenza pandemic of the 18th century began in Russia in the spring of 1729 and spread across Europe within six months. Worldwide spread continued over the next three years. The outbreak occurred in multiple waves which each wave killing more people than the one before. The next pandemic began in China in the autumn of 1781 and spread across Europe over the next eight months. It had a tendency to attack young adults leading to many deaths in this age group.

During the nineteenth century there were two recorded influenza pandemics. The first began in the winter of 1830, again in China and spread around the world the following year. The infection rate was high but relatively few people died. In 1889 the second pandemic began in Russia and was rapidly spread by a relatively new invention, the railway. This strain of influenza was more virulent and killed about one million people worldwide.

Spanish ‘Flu – 1918-1920

There were five influenza pandemics over the next 140 years. The most famous of these was the first of the 20th century - the 1918 or Spanish ‘flu epidemic. This has been described as a ‘medical holocaust’ by some. The pandemic started in the spring of 1918 with second and third waves arriving in the autumn and the winter. The first and third waves were relatively mild but the death rate during the second wave was enormous. It is believed that over 50 million deaths occurred and that over half of the world’s population was infected. In the UK as many as 250,000 people died, whilst in the USA the death toll rose to at least 675,000. This strain of influenza appeared to target young people and deaths occurred in many previously healthy people between 18 and 40 years of age. The deaths appear to have been due to a combination of a hugely exaggerated immune response to the virus (much like that seen in COVID-19) and secondary bacterial pneumonias. The virus’ predilection for the young is not easy to explain. It’s possible that previous exposure to a similar influenza strain in the past may have protected many of the older population.

It is not clear exactly where the pandemic began but as Spain was neutral during the First World War, its uncensored newspapers were the first to report this new infection. Those nations that were at war did not want their newspapers to report anything that could disrupt the war effort. The first documented case occurred at an army training camp in Kansas in the USA but it looks like China was the probable origin of the new strain. The virus was likely spread by the Chinese Labour Corps (CLC), a group recruited by the British Government, who sent 10,000 labourers to Europe to support the war effort.

The pandemic caused widespread social and economic disruption. Many people were unable to work due to illness and many schools and businesses closed and went bankrupt. Various measures were used to try to contain the spread of the infection - quarantines, closing schools, banning public gatherings and health education programmes were used to stop people coughing and sneezing dangerously. Facemasks were used but the gauze masks of the time that were designed to stop bacteria did not stop viruses. Many people refused to wear masks anyway. Advice from governments was poorly understood or often ignored.

Spanish ‘flu was the worst pandemic in human history. The high number of deaths was partly the result of a the virus encountering a malnourished population living in the unsanitary, overcrowded conditions that were to be found during and immediately after the First World War. Of course, the lack of any real treatments such as supplemental oxygen and the poor general state of healthcare at the time contributed enormously. Following the pandemic there was a sense of urgency for nations to improve public health and by the time the next pandemic arrived, countries were better equipped to deal with it.

Asian ‘Flu – 1957-1958

The world enjoyed 37 pandemic-free years, during which time the influenza virus was identified. In 1929, after the discovery of penicillin there was now a treatment for the secondary bacterial pneumonias that so often complicated ‘flu. The first vaccine for influenza was developed during the early 1940s. These vaccines were not as safe as their modern equivalents and it was difficult to match the vaccine to the circulating seasonal influenza strain. This meant that sometimes a vaccine would be ineffective. The polio epidemics of the 1950’s were responsible for the birth of Intensive Care Medicine and the development of the positive pressure ventilator as an alternative to the use of ‘iron lungs’ to treat severe respiratory failure.

The Asian ‘flu pandemic began in February 1957. Once again the outbreak originated in China and a new strain of influenza spread around the world. Despite the growing popularity of air travel, the virus was still spread mostly by land and sea. Like Spanish ‘flu the virus travelled the world in waves, with the second wave being the most deadly. When schools opened in the autumn of that year, viral transmission rates shot up. Those under 65 appeared to have little immunity which suggested that older people had been exposed to a similar strain at some point in the late 19th century. Fortunately, this strain of influenza was less virulent that the one that caused Spanish ‘flu although between one and two million people died worldwide. There were at least 20,000 deaths in the UK and approximately 80,000 in the USA.

Children appeared particularly vulnerable to infection and there were many school closures. My mother remembers being infected by Asian ‘flu when she was a child and being very unwell for a couple of weeks. There was some disruption to society due to high rates of sickness but those most affected were teachers and healthcare workers. Economic damage as a result of the pandemic was mild. Hospitals came under pressure but they were able to accommodate the surge in cases by repurposing wards, reassigning doctors and nurses and cancelling routine surgery and appointments.

Development and distribution of a vaccine took some time and had relatively little impact on the numbers of deaths. The use of modern healthcare techniques, widespread use of supplemental oxygen and new antibiotics however, were critical in reducing the death rate. Intensive Care Medicine was still a new idea and not widely available; ventilators played little role in reducing the death rate. Very few social restrictions were used to limit the spread of the virus. There were some limits imposed on public gatherings but the closure of schools, offices, factories and mines was a result of the high levels of sickness rather than a deliberate attempt to halt the spread of the virus. The press at the time thought it their duty to down-play the effects of the pandemic for fear of panicking the public.

Hong-Kong ‘Flu – 1968-1970

The Hong Kong ‘flu pandemic arrived ten years later in 1968. It was named after the then British colony where the first cases were reported although it is suspected that the outbreak began in mainland China. Worldwide transmission was helped in part by soldiers returning to the USA and other countries from the Vietnam War. This was the first pandemic in which air travel played a key part in the spread of the virus.

Once again, waves of infection were seen with North America suffering most during the first wave and Europe and Asia suffering more during the second. Like Asian ‘flu, this virus tended to infect younger people, particularly children. Older people who had been infected during the Asian ‘flu pandemic appeared to be protected as this particular strain of influenza was the result of a shift in the surface protein structure of Asian ‘Flu rather than a distinct new strain. This altered strain of influenza appeared to be less lethal than the previous one and the worldwide death toll is estimated at between 500,000 and 2 million deaths. There were 30,000 deaths in the UK and up to 100,000 deaths in the USA.

Despite the previous pandemic having occurred only ten years before, the world had done little or nothing to prepare for another similar event. Some of the effects of the Hong Kong ‘flu pandemic sound eerily familiar: New York City was declared a state of emergency, some hospitals were unable to cope and turned away patients, and new ‘Intensive Care Units’ reported patients dying on ventilators. However, in many other ways the response to the Hong Kong ‘flu pandemic was very different to the current COVID-19 pandemic. Because the virus was less severe than the strain that caused Asian ‘flu, there were no restrictions on public life; schools and workplaces remained open where they could, although in parts of France, half of the workforce was bed-ridden. In Britain there was severe disruption to the postal and rail services and many teachers became ill. In Germany, bodies were stored in subway tunnels and bin-men had to bury the dead. Despite this, the economic impact of the pandemic was relatively small and those economies that did suffer recovered quickly.

Work done on the vaccine for Asian ‘flu meant that a vaccine for Hong-Kong ‘flu was discovered relatively quickly. Unfortunately, a delay in manufacture and distribution meant the vaccine was only widely available after infections had peaked in many nations. The large number of elderly people admitted to hospital caused problems in many countries but was dealt with in much the same way as the Asian ‘flu pandemic: Extra wards were created and healthcare staff were reassigned to look after the influx of ‘flu patients. Most routine work was halted. Today, such measures would not be possible as unfortunately hospital bed capacity per head of population has decreased dramatically over the last fifty years, meaning most 21st century hospitals have no spare capacity for pandemic patients.

Reports from the time reveal that doctors and the public were quite fatalistic when it came to accepting the high number of deaths, especially amongst the elderly. The media of the day devoted relatively little attention to the pandemic, concentrating instead on events like the Troubles in Northern Ireland, the Vietnam War, the moon landing, civil-rights protests, Woodstock and the arrival of the Raleigh Chopper. Curiously, my mother remembers very little fuss being made about the Hong-Kong ‘flu pandemic. In fact she remembers very little about it at all. She swears that this had nothing to do with 1960’s drug culture…

Swine ‘Flu – 2009-2010

The most recent influenza pandemic occurred in 2009 and was due to Swine ‘flu. This was a strain of influenza that, despite appearing to arise in Mexico, had probably emerged in pigs in Asia and then migrated to humans. It appeared worryingly similar to the strain that caused Spanish ‘flu. Like Spanish ‘flu, this virus predominantly affected adults under 65 years of age. In a small number of patients it caused a severe pneumonitis not dissimilar to that caused by COVID-19 and was also associated with a high incidence of secondary bacterial pneumonia.

However, unlike Spanish ‘flu, the overall mortality rate fortunately remained low; the number of deaths worldwide was somewhere between 150,000 and 575,000. This was similar to the death rate seen in seasonal ‘flu. However, because of the predilection for the virus to cause severe illness in younger people there was a disproportionate effect on hospitals. I remember that many of our swine ‘flu patients were very unwell and that we frequently experienced shortages of both beds and staff. Of course, having subsequently experienced the first wave of COVID ICU patients, I’m tempted to adopt a Monty-Python Yorkshire accent and exhort – “Swine ‘flu!? We used to dream of Swine ‘Flu! Luxury!”

The economic effect of swine flu, whilst far from large, was surprising given the relatively low severity of the outbreak. Nations reported a 1% fall in GDP but this was mostly due to a loss of productivity due to high rates of sickness. Most nations saw large rises in their healthcare costs. The pandemic is estimated to have cost the Canadian healthcare system two billion Canadian dollars. Interestingly, airlines reported falls in their profits as global tourism saw a decline, although the economic crisis that began in 2008 will have played some part in this.

Many people were angry with the WHO for exaggerating the danger of swine ‘flu when it declared its first ever "public health emergency of international concern." The same criticisms have been levelled at its warnings regarding the SARS and MERS outbreaks of 2003 and 2012 respectively. Unfortunately, this appears to have led to the world ignoring subsequent warnings about the dangers of the COVID-19 outbreak when it first began in Wuhan. The WHO appears to have been mistakenly cast in the role of the boy who cried wolf.

So, is COVID-19 worse than the ‘flu? The answer is a definite yes, unless you happen to be talking specifically about the cataclysmic Spanish ‘flu pandemic of 1918. The world-wide death rate due to COVID-19 has already reached that of previous influenza pandemics and it clearly isn’t over yet. These deaths have occurred despite all that the world has done to try to prevent them and despite the huge advances in healthcare that have occurred over the past fifty years. You can argue all you like about whether the world’s response to COVID-19 is proportionate or whether the economic cost of restrictions is a price worth paying, but please, don’t claim that COVID-19 is no worse than the ‘flu.

Public Health Poster – Philadelphia, USA, 1918