Hit parade of respiratory disease pandemics: 2019 not far behind 1919

Updated post (27 Jul 2021) with an extra table of data .

Note to readers (21 Sept 2021)

This post needs revision with COVID-19 numbers revised upwards as deaths climb beyond 677,000 in USA

A previous post sought to clarify how COVID-19 compared with flu in terms of lethality. The conclusion was that it's a tricky conundrum to decipher, and requires a deep dive into medical stats to get some clarity. One area where decisive numbers were easier to find was overall death count increases that can be linked to the disease, and the USA is the country where those stats are most accessible. 

Here is the result of probing US mortality and medical records more thoroughly for respiratory disease outcomes during epidemics, and examining other countries with reliable data for extra comparisons:

Updated November 2021 with excess deaths through November

Vertical axis: deaths per year per million US citizens. The horizontal axis describes the time period of deaths show, and describes the predominant infectious respiratory disease concerned with excess mortality at the time. (This graph is an extension of an epidemic comparison presented by Paul Glezen in 1996).

The height of the bars indicates death increases linked to respiratory disease outbreaks. Different bars are for different pandemics, and for seasonal influenza mortality outcomes in different years.

The 1918 US influenza epidemic stands out as causing highest rates of death, standardised per million US citizens of the time of the outbreak. 

It is sobering to realise that the current COVID-19 epidemic is not far behind, given that we have far more powerful hospital intensive care resources in modern hospitals, and can now use respirators and a full array of medicines to partly tame damage to sufferers' lungs.

A more detailed analysis done by the Pundit based on a survey of additional survey of sources and countries is given below, followed by details in a Table:

(Note excess death measures are greater than Pneumonia and Influenza (P&I) numbers by a factor of about 4, but respiratory disease alone does not comprise all deaths caused by these viruses.)

Clearly, from all to data presented on the historical record of what happened in the USA, the huge death wallop of COVID-19 is worse than any seasonal influenza outbreak since 1920. 

COVID-19 is more lethal than even the nasty flu pandemics of 1957-60 and 1968-72.

We need to roll out full COVID-19 vaccine coverage before we can start equating COVID-19 infection with common varieties of the flu.

Post Script

The Pundit's did digging in the scientific literature and found Cecile Viboud did similar comparisons in a 2010 paper published in PLOS Currents. Here is their table:

For this table the death rates are standardised to the year 2000 US population (281.7 million people)

It confirms yet again that US COVID-19 deaths exceed any US flu epidemic after 1919. It also indicates that COVID-19 has about ten-fold lethal impact than seasonal flu by these measures, based on the 1979-2001 average.

The last column of the table supplies estimates of years of life lost to the disease. If epidemic deaths occur in mainly very old people, the impact is different than when the very young are also taken out by the "grim reaper". This comparison above shows that death counts alone are an inadequate measure of epidemic impact.

An decisive comparison of the 1918 flu pandemic with  COVID-19 needs to be done carefully and needs continued investigation. A thorough assessment will depends on how and when the COVID-19 pandemic ends and on many aspects of disease not yet fully documented (such as cognitive damage and the nature of long COVID). Currently it seems likely that 1918 had greater impact in terms of lost lives, and much more so in terms of years of life lost. In terms of sensitivity human tragedy, the initial title of this current (updated) post is badly chosen, but the the Pundit will let it stand.

Here are the main sources of relevant data:

CDC 2017-2018 Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths and Estimated Influenza Illnesses, Medical visits,Hospitalizations, and Deaths Averted by Vaccination in the United States

CDC MMWR https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5929a2.htm

Garten R, Blanton L, Elal AI, et al. Update: InfluenzaActivity in the United States During the 2017–18 Season and Composition of the2018–19 Influenza Vaccine. MMWR Morb Mortal Wkly Rep 2018;67:634–642. 

Glezen WP. Emerging infections: pandemic influenza. Epidemiol Rev. 1996;18(1):64-76. doi: 10.1093/oxfordjournals.epirev.a017917. PMID: 8877331. From <https://pubmed.ncbi.nlm.nih.gov/8877331/>

Goldstein E, Viboud C, Charu V, Lipsitch M. Improving the estimation of influenza-related mortality over a seasonal baseline. Epidemiology. 2012 Nov;23(6):829-38. doi: 10.1097/EDE.0b013e31826c2dda. PMID: 22992574; PMCID: PMC3516362.

Houseworth WJ, Spoon MM. The age distribution of excess mortality during A3 Hong-Kong influenza epidemics compared with earlier A2 outbreaks. Am J Epidemiol 1971;94:348–50.

Iuliano, A.D.,  H.H. Chang, N.N. Patel et al., Estimating Under-recognized COVID-19 Deaths, United States, March 2020-May 2021 using an Excess Mortality Modelling Approach, The Lancet Regional Health - Americas, https://doi.org/10.1016/j.lana.

Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis. Lancet. 2006 Dec 23;368(9554):2211-8. doi: 10.1016/S0140-6736(06)69895-4. PMID: 17189032

Nazrul,  Vladimir M Shkolnikov,  Rolando J Acosta, et al. 2021 Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries BMJ 2021;373:n1137 http://dx.doi.org/10.1136/bmj.n1137

Petersen E, Koopmans M, Go U, Hamer DH, Petrosillo N, Castelli F, Storgaard M, Al Khalili S, Simonsen L. Comparing SARS-CoV-2 with SARS-CoV and influenza pandemics. Lancet Infect Dis. 2020 Sep;20(9):e238-e244. doi: 10.1016/S1473-3099(20)30484-9. Epub 2020 Jul 3. PMID: 32628905; PMCID: PMC7333991.

Petersen E. (2021). COVID-19 is not influenza. Lancet Respir Med. 2021 Mar;9(3):219-220. doi: 10.1016/S2213-2600(20)30577-4. Epub 2020 Dec 17. PMID: 33341154; PMCID: PMC7834708.

Simonsen L, Spreeuwenberg P, Lustig R, et al. Global mortality estimates for the 2009 influenza pandemic from the GLaMOR project: a modeling study. PLoS Med 2013; 10: e1001558.

Quandelacy et al 2013 Age- and Sex-related Risk Factors for Influenza-associated Mortality in the United States Between 1997–2007 Am J Epidemiol. 2014;179(2):156–167

Shrestha SS, Swerdlow DL, Borse RH, Prabhu VS, Finelli L, Atkins CY, Owusu-Edusei K, Bell B, Mead PS, Biggerstaff M, Brammer L, Davidson H, Jernigan D, Jhung MA, Kamimoto LA, Merlin TL, Nowell M, Redd SC, Reed C, Schuchat A, Meltzer MI. 2011. Estimating the burden of 2009 pandemic influenza A(H1N1) in the United States (April 2009-April 2010). Clin Infect Dis. 2011 Jan 1;52 Suppl 1:S75-82. doi: 10.1093/cid/ciq012. PMID: 21342903.

Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States.2003. JAMA 289:179–186.

Viboud C, Miller M, Olson D, Osterholm M, Simonsen L. Preliminary Estimates of Mortality and Years of Life Lost Associated with the 2009 A/H1N1 Pandemic in the US and Comparison with Past Influenza Seasons. PLoS Curr. 2010;2:RRN1153. Published 2010 Mar 20. doi:10.1371/currents.rrn1153

 See also 

The bitter pill: COVID-19 is much worse that the pill.

for further evidence about COVID-19.