Was second wave of Spanish flu worse? Did it kill at least 20 million people?

According to historic records, the second wave of the Spanish flu reportedly killed 20 million to 50 million people after the first wave killed 3 million to 5 million people.

USA Today – A Facebook post claiming the second wave of the Spanish flu killed significantly more people than the first has garnered the attention of a public worried by the potential future of COVID-19.

The post, which more than 46,000 people have shared, reads: “People are so ready to get back to life forgetting that in 1918 the second wave of the Spanish flu reportedly killed 20-50 million. The first wave only killed 3-5 million. History does indeed repeat.”

USA TODAY reached out to the author of the post with a request for comment but did not receive a response.

The conversation surrounding the influenza pandemic of a century ago is not unique to social media users. Experts have drawn similar comparisons between the two pandemics in an attempt to better contextualize and understand the COVID-19 crisis.

But many of these comparisons fail to emphasize the more stark realities of the 1918 pandemic. Less-advanced health care systems and medical technology, the lack of an intergovernmental world health agency and an ongoing world war contributed to it becoming known as the worst pandemic in human history.

An uncertain death count

Researchers have continued to investigate the Spanish flu. Its exact death toll and case fatality rate — the total number of deaths out of the total number of recorded cases —are unknown because of incomplete and inaccurate records in some less-developed regions.

“In 1918, death certificate recording and epidemiology was really in its infancy,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, explained in a recent NPR article. “We didn’t have all of that data. And there were many parts of the world that were not connected to other parts of the world. So you weren’t able to get data from some of the resource-poor areas that existed at that time.”

Alex Navarro is the assistant director of the Center for the History of Medicine at the University of Michigan. He’s researched the effects of the 1918 and 2009 influenza pandemics for more than a decade. Despite the presence of death records in the United States, “It’s really just a guess,” he said.

Navarro said influenza was not a reportable disease at the start of the 1918 pandemic, so it was difficult to know whether a person died of pneumonia or pneumonia caused by influenza.

Estimates range between 17.4 million and 100 million deaths worldwide.

Those figures come from a series of studies, including a 2018 study in the American Journal of Epidemiology, a 2002 study published in the John Hopkins University Press and a 1991 study from the Bulletin of the History of Medicine. 

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