Turkish Journal of Medical Sciences Turk J Med Sci

(2020) 50: 515-519

http://journals.tubitak.gov.tr/medical/
© TÜBİTAK
Review Article doi:10.3906/sag-2004-133

Understanding dynamics of pandemics

1 2,
1
Levent AKIN , Mustafa Gökhan GÖZEL *
Department of Public Health, Faculty of Medicine, Hacettepe University, Ankara,
Turkey
2
Department of Infectious Diseases, General Directorate of Public Health, Ministry of Health, Ankara,
Turkey

Received: 13.04.2020 Accepted/Published Online: 16.04.2020 Final Version: 21.04.2020

Abstract: Along the centuries, novel strain of virus such as influenza produces pandemics which increase illness, death and
disruption in the countries. Spanish flu in 1918, Asian flu in 1957, Hong Kong flu in 1968 and swine flu in 2009 were known
pandemic which had various characteristics in terms of morbidity and mortality. A current pandemic is caused by novel corona virus
originated from China. COVID-19 pandemic is very similar to Spanish, Hong Kong, Asian and swine influenza pandemics in
terms of spreading to world by the mobilized people. Burden of pandemic is considered in terms of disease transmissibility and the
growth rate of epidemic and duration of pandemic can be calculated by transmissibility characteristic. The case definition, finding
out cases and first case cluster, proper treatment, sufficient stockpiles of medicine and population cooperation with the containment
strategy should be considered for reduction of burden of pandemic.

Key words:Pandemic, new coronavirus infection, COVID-

19

1. Introduction May 1918, and spread to Italy, Spain and Germany at

Pandemics, are well-known as the epidemics on the basis the same month. After that North Africa India, China,
of worldwide spread and cause excessive number of New Zealand and the Philippines were suffered from
sickness, deaths in the world and cause disruption for pandemic flu, infection expanded to every country in a
social economic situation of the countries which were short time. At the end of the First World War, Spanish
affected. As the result of the globalization, change of flu caused many more deaths than all the troops. The
lifestyles, social and economic improvement caused the pandemic has widespread to all continents with the
emerging infection and accelerated occurrence and mobilization of the military troops. Although pandemics
circulation of new microbial agents beside this in mankind history spread mostly along trade and
globalization has also facilitated sharing information and communication lines, the spread of the 1918 Spanish
experiences. flu was transmitted from region to region through
Many pandemics have occurred throughout the military mobilization and trench warfare, limited health
history of mankind. Primarily plague, smallpox, cholera services poor sanitation made easy transmission [2].
and Spanish flu are the longest-lasting, repetitive, and In course of 1918-1919 influenza pandemic, adults
caused large numbers of human deaths. In the beginning were affected mostly when compared with children and
of 20th century, at least 20 million people deaths were older people [3]. According to mortality statistics of
estimated due to1918 Spanish flu. The first originated US, the mortality rate of people aged 20–34 and
place of the pandemic is not clear, but many experts pregnant women were higher than mortality of the older
assumed that the possible origin was in China. However, than 50 years of age. This pattern is also occurred in other
the first outbreaks occurred at the same time in North influenza pandemics1.
America in March 1918 [1].
Influenza spread to across the US country. Infection 2. Dynamics of pandemics
was spread to France in April 1918 by US naval forces. Spanish flu pandemic is reported to spread in three waves:
From France, infection transmitted to British Military first wave in spring 1918 was moderate but rapidly spread,
Forces in
1
Institute of Medicine of the National Academies (2005). The threat of pandemic influenza: are we ready? Workshop Summary
[online]. Website https://www.nap.edu/catalog/11150/the-threat-of-pandemic-influenza-are-we-ready-workshop-summary
[accessed 08 April
2020].
* Correspondence: ggozel@yahoo.com
 515

This work is licensed under a Creative Commons Attribution 4.0 International

License.
 AKIN and GÖZEL / Turk J Med
Sci
second wave in autumn 1918 was completely severe and many countries. The global trade and travel served swine
destructive and third wave in spring 1919 was more flu to spread as 122 countries in six weeks, however
severe than the first wave but not worse than second past pandemics had spread in six months [13]. H1N1
wave2. Many countries experienced the second and pandemic profile had a course with three waves in spring,
third waves of more virulent form of infection. It is summer, and fall. The pattern was generally mild wave
estimated that 50% of the world’s population have in the spring and early summer, but reemerged more
infected, 25% manifested clinical signs [4]. After almost severe after opening the schools. Studies showed that
forty years of Spanish flu, a new influenza strain was adults older than 50 years of age were less susceptible
detected in China. The 1957 pandemic was caused by A to 2009
H2N2 strain [5]. The virus spread to Hong Kong, H1N1 infection than younger adults. While compared
Singapore, Taiwan, and Japan and in summer spread to the previous pandemics, the infectivity was higher among
world in the summer of 1957. Two main routes of spread children than among adults (Table) [14].
were: firstly, across Russia to Scandinavia and Eastern Household studies explained the serial interval of
Europe, and secondly from the US to other countries. the disease. Serial interval estimates are provided data
Asian flu pandemic had spread to the world in 6 in spreads speed to inform recommendations on the
months. The pandemic affected approximately 40 ± period that patients should stay home, and to estimate the
50% of people, and 25 ± 30% of them had clinical effect in treatment on transmission [15]. The R0 for 2009
signs. Most of the deaths were due to secondary Pandemic Influenza A (H1N1) has been estimated to be
bacterial pneumonia. Mortality rate was calculated as 1 between 1.4 and 1.6 [16]. Secondary attack rates in
per 4000. The mortality was high among children and pandemic showed significant variation, i.e. estimates of
elderly people [1]. The 1957 (Asian) influenza pandemic, 33% in children and for adults 22% in different regions.
estimated the basic reproduction number (R0) was 1.8 Case fatality rates were obtained from high-income
and 60%–65% of infected individuals were manifested countries and varied three to nine times among the
clinical symptoms [6]. studies. According to one study, people younger than 64
Excess mortality due to Spanish flu was 598 deaths years accounted for 80% of these deaths. Southeast Asia
per 100,000 people per year. However excess mortality and Africa had highest mortality among of the other
of Asian flu was only 40.6% [7]. continent [17]. After three influenza pandemics in
After a decade occurrence of Asian flu pandemic, the 20thcentury, it is expected when the first pandemic will
new flu strain H3N2 was caused a new pandemic known be seen in 21st century. Humankind did not encounter a
as the Hong Kong flu in 1968. Although new virus was new influenza pandemics but a novel corona virus
pandemic (Figure). As in pandemics in history, its
extremely transmissible, degree of severity was milder
spread to all over the world through people traveling
than the Asian flu. Excess mortality of Hong Kong flu
between countries in two-three months. In the past,
was
pandemics spread somewhat predictably along military
16.9%. Virus was spread through Vietnam War
passages or important trade routes, but globalization
veterans returning to the United States. Then Hong
has multiplied and obscured the dominant routes. Given
Kong flu was seen in Japan, England, Wales, Australia,
their sheer number, and the speed with which human and
and Canada in
animal transmission vectors can move, there is no longer
1969 [8,9]. At this pandemic the characteristic mortality
a single dominant pathway for the geographical
shift towards younger populations, the case
movement and expansion of infectious diseases.
fatality rate was highest among children [10]. Hong
Pandemics are inherently uncertain, considering
Kong flu is estimated to have caused between 500,000 experiences and preparations that we have gained from
and two million deaths worldwide in two waves [11]. past pandemics, the epidemiologic characteristics of
The burden of pandemic was higher in countries with pandemic should be evaluated. By the way the impact
increases in excess all-cause mortality of 9.1%–13.0%, of the control measures are be able to evaluate during
than in US. Impact of pandemic was present the the COVID-19 pandemic’s days.
geographic heterogeneity [8]. Hospitalization was
significantly high amongthe elderly. Hong Kong flu 3. Discussion
pandemic showed that public health intervention When a COVID-19 was identified, the information was
strategies and medical science were insufficient and not obtained in various studies that epidemiological and
improved between the 1957 and 1968 pandemics [12]. clinical evidence or clues were needed to indicate when
In April 2009, a new pandemic occurred that and what type precautions should be implemented. In
H1N1pdm09 virus was causative agent, emerged from general, acute respiratory infections are the leading,
Mexico. Within few weeks, the disease had spread particularly affecting the youngest and oldest people in
across

516 516
 AKIN and GÖZEL / Turk J Med
2 Sci (2005). The threat of pandemic influenza: are we ready? chapter 1: the story
Institute of Medicine of the National Academies
of influenza [online]. Website https://www.ncbi.nlm.nih.gov/books/NBK22156/pdf/Bookshelf_NBK22156.pdf [accessed 8 April
2020].

517 517
Table. Baseline characteristics of different pandemics.

Pandemic (years Estimated Secondary Estimated

Causative Area Of Age groups
and common Reference reproductive attack rates case-fatality
agent emergence most affected
name) number (%) rate
1918–1919 Influenza A
[6] Unclear 1.7–2.8 - NA Adult, pregnant
(Spanish flu) (H1N1)
1957–1958 Influenza A Southern Children,
[8] 1.8 18.5–26.8 NA
(Asian flu) (H2N2) Chine elderly
1968–1969 Influenza A Southern
[11] 1.06–2.06 15.0 NA Elderly
(Hong Kong flu) (H3N2) Chine
2009 Influenza A Adolescent,
[18] Mexico 1.4–1.6 17,5 NA
(swine flu) (H1N1) young adults
A Novel
Wuhan,
2019–(COVID-19) Coronavirus 5.7 <2 2.3 Elderly
Chine
(SARS-CoV-2)

NA: Not applicable.

developing countries. These types of infections are asymptomaticpeople which was testing positive for
caused by viruses or mixed viral–bacterial infections and SARS- CoV-2, varied between 5% and 80%4. In China, all
spread fast. The most of the primary mode of transmission clusters investigated and 78%–85% were within
of acute respiratory diseases is transmitted via droplets, families and secondary attack rate in household was
sometimes transmission occur through contact (including found 3%–10%5. Similar study was carried out in the US
hand contamination followed by self-inoculation) or and a symptomatic secondary attack rate for all
infectious respiratory aerosols at short distance3. household contacts among all contacts was found
The distribution and the outcome of epidemic varies 10.5% [19]. Household contacts and travelling with an
according to several factors such as household infected person increased the risk (OR:6-7). The
crowding, humidity, temperature, season, hygiene, household secondary attack rate was 15%, and the
access to health- care facilities, and isolation capacity, observed serial interval mean was 6.3 days. The median
demographic characteristics of population, cigarette- incubation period was 4.8 days (95% CI 4.2–5.4).
smoking, host ability to transmit infection, immune Symptoms were manifested within 14.0 days (95% CI
status, nutritional status, prevalence of comorbidity 12.2–15.9) of infection6. R0 was likely estimated to be 5.7
diseases, characteristics of pathogenic, modes of (
transmission, transmissibility, virulence factors, etc. 95% CI 3.8–8.9) in the US [20].
COVID-19 transmitted mainly through person to The overall case-fatality rate 2.3% and this rate was
person contact via respiratory droplet by coughing and 8.0% for aged 70–79 years and 14.8% for 80 years and
sneezing. Most of the cases were 30 to 79 years of age and older. Case-fatality rate was higher and varied between
the proportion was found 87%, under 19 years and 80 5.6% and 10.5% [18].
years or older were respectively 2% and 3% [18]. The COVID-19 pandemic is very similar to Spanish,
proportion of Hong Kong, Asian and swine influenza pandemics in
terms of spreading to world. Although countries were
suffered from
3
World Health Organization (2014). Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections
in healthcare [online]. Website https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf ?sequence=1
[accessed
8 April
2020].
4
Centre for Evidence-Based Medicine (2020). COVID-19: what proportion are asymptomatic? [online]. Website
https://www.cebm.net/
covid-19/covid-19-what-proportion-are-asymptomatic/ [accessed 8 April
2020].
5
World HealthOrganization (2020). Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19) [online].
Website https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf [accessed 8
April 2020].
6
Bi Q, Wu Y, Mei S, Ye C, Zou X et al. (2020). Epidemiology and transmission of COVID-19 in Shenzhen China: analysis of
391 cases and 1,286 of their close contacts [online]. Website
https://www.medrxiv.org/content/10.1101/2020.03.03.20028423v3.article-info [accessed 8 April 2020].

pandemic, the epidemiologic dynamic varied from

country to country, from pandemic to pandemic. The
common features of pandemics are spread to all over
the world through human mobilization (such as
military troops, national or international travel for
different purpose etc.) and severity increasing for person
with chronic diseases.

4.
Conclusion
Burden of pandemic is considered in terms of disease
transmissibility and the rate of epidemic grows,
time of peaks, expected how many people to be
affected, and duration of pandemic can be calculated by
transmissibility characteristic. Hospitalization and
fatality are used as the indicators of the severity. At the
beginning of a pandemic, the characteristic of pandemic
agent is unknown. Therefore, surveillance method and
analyzing data should be planned in advance [21].
Consequently, determination of the first case cluster, case
definition and finding out cases, effective treatment to
the targeted population, sufficient stockpiles of
medicine and population cooperation with the
containment strategy and, in particular, any social
distance measures introduced should be considered for
reduction of burden of pandemic.

Figure. A pandemic is a threat for all globe (Source: Courtesy Acknowledgments/disclaimers/conflict of interest
of Levent AKIN is a member of COVID-19
Merve EVREN, PhD, Ege University). Advisory Committee of Ministry of Health of Turkey.
Mustafa Gökhan GÖZEL is a member of COVID-19
Advisory Committee of Ministry of Health of
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