America / Healthcare

What Lessons Have We Learned?

Introduction

Debate over mishandling of the ongoing coronavirus pandemic may sound surprising when the world has been experiencing pandemics from as early as 3000 B.C., but as we enter April of 2021, the country is reportedly closer than ever to ending the COVID-19 pandemic. Proper sanitation and isolation are common methods in pandemic-response but may seem unsettling to newer generations that have not yet experienced a global pandemic. As the world has just passed its one-year anniversary since the declaration of the COVID-19 pandemic, this overview will discuss the evolution of infectious outbreaks in comparison to where we currently stand in pandemic-response. It is important to note that overview is not an exhaustive list, but rather a means to highlight common themes still present today and compare governmental and public response over time.

There are two main lessons we can learn from the progression of pandemics:

  1. Quarantine and distancing work and are always unpopular methods of pandemic-response
  2. Each pandemic has produced genuine enhancements in the public health system and will continue to do so

COVID-19

2019-TBD

To give an accurate comparison of previous pandemics, it is important to understand the origin and implications of COVID-19. The coronavirus disease 2019, also known as COVID-19 was first discovered in December of 2019 in Wuhan, China. The term “coronavirus” is actually a collective term referring to viruses known for the crown-like spikes on their surfaces and are commonly found in both people and animals, but COVID-19 is caused by a novel virus not previously seen in humans. The current understanding is that the coronavirus emerged from an animal reservoir—likely a bat, resulting in over 2.8 million deaths worldwide and over 128 million total cases thus far.

In order to tackle the COVID-19 pandemic on the rise, mandatory quarantines, mask mandates, social distancing and travel restrictions were implemented and still upheld in most regions. As a result of the pandemic, Americans experienced economic loss and increased unemployment rates, negative impacts on mental health, loss of loved ones, and many new challenges. Former President Trump enacted “Operation Warp Speed” in March of 2020 to expedite the vaccination effort considering the fastest vaccine developed prior to COVID-19 took nearly 4 years. Since the declaration of the COVID-19 pandemic, lawmakers enacted six major bills, amounting to nearly $5.3 trillion in mitigation and support efforts and the Food and Drug Administration has already approved and began vaccination of three different vaccines—having already fully vaccinated nearly 19 percent of the United States population. While lawmakers and Americans continue navigating the pandemic, hope continues to rise as we grow nearer to the finish line.

Bubonic Plague

1347-1665 (40 outbreaks in 300 years)

The famous fourteenth century plague claimed the lives of an estimated 200 million across the world in a matter of four years. This outbreak of the bubonic plague became known as the “Black Death” in reference to the blackened and swollen lymph nodes of the infected. The bubonic plague is caused by a zoonotic bacterium called Yersinia pestis, generally transmitted through infected rats harboring infected fleas which then transmit the bacterium into humans. Rats and fleas were found all over medieval Europe and would typically inhabit ships—making the plague easily transmissible throughout the world. The period between symptom onset to death was nearly a matter of hours for some so doctors to refused to treat patients, shops were closed, people abandoned infected loved ones, and priests refused to provide last rites before death.

At the time, no one understood how the disease was transmitted, nor how to treat or even prevent the plague. When physicians did treat the disease, they typically utilized dangerous and unsanitary practices. For many the disease could only be explained as God’s punishment in retribution for sins. This caused communities to lash out against their neighbors and act in unfavorable ways. This episode of the plague never really officially ended, as it returned nearly every decade, some with more aggression than others. Officials of the fourteenth century enforced social distancing and isolation measures by requiring the newly arrived sailors to be kept in isolation for 40 days—also known as “quarantine.” This was not the first-time quarantine had been used as a means of prevention—Italian authorities also engaged isolation practices during outbreaks of leprosy and other diseases prior to the Black Death.

After the Black Death, many other governments adopted quarantine practices, but it was not until the end of the sixteenth century that England adopted quarantine and isolation practices in their books of orders regarding outbreak control. These measures were implemented quickly, and public response of such measures was not favorable. Researchers suggest a misunderstanding and clash between the English government and public perception as isolation measures were portrayed as a means of punishment as opposed to public benefit.

While the many outbreaks of the bubonic plague did not occur when the country of the United States was yet established, much can be learned from these outbreaks. Modern sanitation and public health practices have significantly reduced outbreaks of the pandemic, and mortality rates have reduced to nearly 11 percent. Treatment has been successful through antibiotics, but a couple thousand cases are still recorded annually. In 2018, a study suggested evidence of human body lice being a primary vector of the disease.

Smallpox

1877-1977

Over the course of a centennial, smallpox claimed the lives of nearly 500 million people globally but is said to have existed for nearly 3,000 years. Origin of smallpox remains unknown but the disease, caused by the variola virus and spread by touching an infected person or object, presented as a fever and a skin rash. While many recovered, those that were infected had a mortality rate of about 30 percent. Scientist Edward Jenner became known as the “Father of Immunology” due to his discovery of a smallpox vaccine in 1796, indicating hope that smallpox could be controlled.  During a previous outbreak back in the 1600s, Parliament passed the

King James’s Act allowing enforcement of isolation and quarantine in response to the pandemic and upheld such statute during earlier outbreaks of smallpox within the colonies.

In comparison to COVID-19, vaccination efforts to achieve herd immunity of smallpox did not come with ease and was met with civic distrust of the government, a woe the United States currently experiences. Jarrett Bencks reports that during the 20th century “the federal government passing nationwide vaccination measures would have been unthinkable,” but the time period generated legislation still relevant today such as the Biologics Controls Act of 1902, setting regulations for vaccine safety and drug manufacturing. Additionally, in 1905, the Supreme Court upheld the constitutionality of compulsory vaccination in Jacobson vs. Massachusetts, which also gave permission to the city of Cambridge to mandate the smallpox vaccine and a five dollar fine to those incompliant. In other words, a state can mandate vaccines and even mandate criminal fines to refusers, imposed as “reasonable regulations” for protecting public health and has been debated in its support for school vaccine mandates still relevant today.

By 1980, smallpox was declared officially eradicated—a major public health milestone. Smallpox remains the only human infectious disease that has been officially eradicated, but was done so by mas vaccination campaigns in conjunction with isolation efforts, surveillance systems, and public trust.

Spanish Flu

1918-1919

Over the course of another centennial, the Spanish flu infected nearly 500 million people, approximately one-third of the world population during that time. The number of case-related deaths from the Spanish flu remains uncertain as estimates range from 17 to 100 million with an estimated mortality rate of 2.5 percent. The origin of the Spanish Flu also remains uncertain but was coined because the Spanish king had become infected with the virus, finding itself at the forefront of conversation and reporting, however, the virus is suspected to have originated in France, England, China, or even the United States.

At the time of the outbreak in 1918, health experts believed the infection was caused be a bacterium instead of a virus, but antiviral drugs were still not yet available, and antibiotics were not developed until a decade later. When trying to manage the disease, only 50 of the 435 members of the House were present in the discussion of pandemic-response due to illness, yet were supposed to be physically present under a practice called “quorum,” a practice also engaged when voting on the CARES Act during the ongoing COVID-19 pandemic. Ultimately, a bill was passed reserving military health personnel for deployment in response to the doctor shortage of World War I, as a means for public health planning and response.

While short-lived in comparison to other pandemics, there was no vaccine protecting against the flu nor antibiotics for treating secondary infections, meaning elimination required behavioral intervention such as practicing isolation, proper sanitation, and limiting social gatherings. It was not until 1997 that researchers were able to determine the genetic sequence of this influenza infection, determining this virus was a novel A (H1N1) virus, originating from humans and pigs. Studying the virus was not easy and required reconstruction of the live virus and considering researchers would be recreating the deadliest flu virus of the 20th century, such mission required strict safety protocols.

While this flu wreaked havoc during World Word I, it highlighted the shortcomings of the United States public health system. The Public Health Service Bill enacted during the time created a reserve corps of doctors, but it was not until the Second World War that authorities decided to consolidate the US public health system into a single agency. While this round of the H1N1 virus came to a close, it served as a primary influence in the creation of the Communicable Disease Center in 1946, now known as the Centers for Disease Control and Prevention.

Swine Flu

2009-2010

The emergence of the 2009 Swine Flu became the second H1N1 pandemic in world history, the first being the Spanish flu as aforementioned. This strain was caused by a mutation in H1N1, originating in Mexico and spreading across the globe. Symptoms of swine flu typically presented as fever, cough, headache, fatigue, and chills—similar to symptoms experienced by those with COVID-19. Within the United States, nearly 12,500 deaths out of the total 60.8 million cases were reported, indicating a mortality rate of roughly 0.02 percent. Nearly 80 percent of deaths were in individuals under 65 years of age due to immunity already established, similarly to herd immunity seen with seasonal outbreaks of the flu.

With a robust public health system developed by this time, the genetic sequence of the swine flu was released just nine days after its initial detection—in comparison to five days for the release of the genetic sequence of COVID-19. Within two-weeks of the first swine flu detection in California, domestic and global shipments of H1N1 tests began distribution. By June of 2009, Congress had approved a near $8 billion toward purchasing vaccines, antiviral drugs, and other medical needs. By September, the FDA announced approval of four 2009 H1N1 influenza vaccines with doses beginning in October, enabling Former President Obama to declare January 10-16 of 2010 be National Influenza Vaccination Week, for which he encouraged all Americans to observe by receiving the vaccination. And finally, on August 11th of 2010, the WHO declared the end of the 2009 H1N1 influenza pandemic.

This outbreak of the H1N1 virus, despite not nearly exhibiting the same magnitude of a mortality rate as the coronavirus pandemic, still shut down about 700 schools across the United States due to variation of closure and isolation protocols across jurisdictions. Even during this time, the government was debating social isolation with the risk of economic loss and instructional time. While the Swine Flu exhibited numerous lessons to be learned for public health emergency preparedness and response, each new pandemic brings about new challenges as new biology of bacteria and viruses are discovered.

Conclusion

Isolation and quarantine methodology have been used as a means of prevention for disease outbreaks for hundreds of years, which could explain the resistance and unrest to such archaic practice, however, these methods worked. Additionally, pandemics can present in various ways from being a virus versus bacteria, in structure and function of the disease, mode of transmission—and most importantly, different severity, making response to each pandemic unique. Today, the world is still navigating the seventh cholera pandemic as well as the HIV/AIDS epidemic. As mentioned in my previous blog post, the response to COVID-19 is groundbreaking with regard to the quick speed at which a vaccine has been trialed, evaluated, approved, and distributed. Given the cyclic pattern of outbreaks, unfortunately this outbreak of the coronavirus may not be the last, but the challenges and research of each pandemic serve as the foundation and influence for improving the complex public health system we have today.

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