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It was the sickness to put an end to all the others, to infect a third of humanity, to kill tens of millions of people in their bed and to create panic over the end of days on continents still under the shock of war .
One hundred years after the outbreak of influenza known as the Spanish flu, scientists say that, if the lessons were drawn from the deadliest pandemic in history, the world is poorly prepared for the next world murderer.
The deadly flu of Hong Kong in 1968 killed more than one million people
In particular, they warn that demographic changes, antibiotic resistance and climate change could all complicate any future epidemic.
"We are now facing new challenges, including the aging of the population and people with underlying diseases, such as obesity and diabetes," says Dr. Carolien van de Sandt of the US. Peter Doherty Institute for Infection and Immunity of the University of Melbourne.
Scientists predict that the next influenza pandemic – which will likely be a strain of bird flu that infects humans and spreads rapidly around the world through air travel – could kill up to 150 million people.
Van de Sandt and his team looked at a lot of data on the Spanish flu, which ravaged the planet in 1918.
They also studied three other pandemics: the "Asian" flu of 1957, the "Hong Kong" flu of 1968 and the 2009 swine flu epidemic.
They found that although the Spanish flu infected one in three, many patients managed to survive a serious infection and others had only mild symptoms.
Unlike most countries that resorted to wartime censorship to suppress any spread of the virus, Spain remained neutral during the First World War. The numerous reports on the disease in the Spanish media have led many to assume that the disease was from that city and that the name remained.
It is now widely accepted that the 1918 influenza strain was in fact provoked by American soldiers and killed a disproportionate number of soldiers and young people.
Researchers say things will be different next time.
An important lesson from the 1918 influenza pandemic is that a well-prepared public response can save many lives.
Dr. Carolien van de Sandt, University of Melbourne
In 1918, in a world grappling with the economic consequences of the world war, the virus was made more deadly because of the high rate of malnutrition.
A study published in the journal The boundaries of cellular and infectious microbiologysays the next epidemic will spread in the developed world among a population struggling with record rates of obesity and diabetes.
Is Hong Kong ready for the next deadly epidemic?
"What we know about the 2009 pandemic is that people with certain diseases (such as obesity and diabetes) were much more likely to be hospitalized with the flu and die from this flu," says Kirsty Short of the University of Queensland School of Chemistry and Biosciences.
The team warns that the world faces a "double burden" of serious illness due to widespread malnutrition in poor countries – exacerbated by climate change – and overeating in the richer ones.
Global warming could have an impact in other respects.
Van de Sandt says that since many strains of influenza begin in birds, a heating planet could change where the next outbreak would occur.
"Climate change could alter bird migration patterns, bringing potentially pandemic viruses into new places and potentially with more bird species," she said.
The 1918 survey revealed that older people behaved much better than younger adults.
The team believes that this is partly due to the fact that older people have acquired some immunity in previous infections.
Most of the people who died in 1918 died as a result of secondary bacterial infections, which antibiotics helped relieve in subsequent pandemics.
But today, immunity to antibiotics is a problem.
"This increases the risk that people will experience secondary bacterial infections and die as a result of the next pandemic," said Katherine Kedzierska of the Doherty Institute in Melbourne.
The authors cite the avian H7N9 virus, a virus that kills about 40% of the people it infects, even though it can not currently switch from human to human.
"At the moment, none of these viruses have acquired the ability to spread among humans, but we know that the virus only needs a few minor modifications for this to happen and could create a new influenza pandemic." says van de Sandt.
How the SARS outbreak has left its deadly mark on Hong Kong
While the world in 2018, with more than seven billion people, megacities and air travel around the world, is hardly recognizable for a century, the team insists that the Spanish flu can give many lessons to governments today.
By nature, strains of the pandemic virus are unpredictable – if the authorities knew for sure that the flu was going to spread, they could invest in a widely available vaccine.
While waiting for a universal vaccine to be created, "governments must inform the public of what to expect and how they should act in the event of a pandemic," van de Sandt said.
The study indicates that governments can use the power of internet communication to help raise awareness and disseminate instructions in the event of a new pandemic.
"One of the important lessons from the 1918 influenza pandemic is that a well-prepared public response can save many lives," said van de Sandt.
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