THE PANDEMIC

Dominion, Volume 12, Issue 142, 11 March 1919, Page 6

THE PANDEMIC

HOW CAME THE SCOURGE?

FACTS AND THEORIES

GRADUAL GROWTH IN

VIRULENCE

NIAGARA IDEA DISCREDITED

The Epidemic Commission sat in Wellington yesterday. Sir John Denniston presided, and with him sat the other commissioners, the Hon. E. Mitchelson and Mr. David M'Laren. About Inoculation, John Alexander Hurley, Government Bacteriologist, was the firit witness called. He said that he had strongly advised in October last against the use of vaccination as a prophylactic ineasuTe. The circumstances were: (1) That Auckland was then the centre of an epidemic of influenza; (2) that inoculation would render healthy individuals more susceptible to the disease for an uncertain number of days, and would be dangerous for those who were actually infected but were showing up 'to the time of inoculation no symptoms of the disease; (3) that after inoculation there would bo many severe castes through neglect of medical advice; (i) that there was a scarcity of medical officers to inoculate; : (5) and that there was a lack of scientific data as to the probability involved by suoh inoculation before or during an epidemic. "As to the benefit of an influenza vaccine to, be used at an uncertain time before an epidemic, this is still a moot point," he said. "The committee appointed by the War Office reported at tho end of October _ 6tating that such prophylactic inoculation might be expected to be of benefit,, and recommending to the effect that inoculation should be carried out on troops and proper data acquired. There .was no sufficient evidence in October, nor is thcro up to the present date, that the prophylactic use of influenza vaccine during an epidemic is advisable. Reports and memoranda have been issued since October by the Royal College of Physicians, London, the Academie de Medicine ds Paris, and by the British Board of Health in regard to the treatment of the pandemic, and no recommendations have been made as to the use of vaccine prophylactically." Before and since October there was and is not sufficient evidence to Indicate that prophylactic vaccination would be benefiial in a district close to an infected district. Since October a report has been received from England which increases the probability that prophylactic Inoculation in other' districts would probably be of benefit. The question of prophylactic treatment is in the experimental stage, and the technique and dosage is still uncertain." Replying to questions, Mr. Hurley said that'he had no information as to the experiments in vaccination in Australia, although an endeavour had been made to secure .tliis information. He gave it as his opinion that there was no difference bactcriologically between the virulent influenza, sometimes called "Spanish" influenza, and the ordinary severe influenza which had been present sporadically in the country, previously to October. In both sorts of cases influenza germs and pneumococci were present.

The Cause Unknown, , "The whole point is," ho said, "that we ■do not know what causes these bacilli suddenly to become more virulent. We know of this' added virulence, but we do not know the cause of it. AVo have not isolated any new or previously unknown organism which might account for the disease. There is, nothing but a suspicion." '>'. Ho gave his opinion that the disease was not brought to l\ew Zealand in October. The disease followed thosamo course hero as in other countries. Tho disease was present here in a mild form and it became more virulent afterwards. There was infiueuza of a sovere typo here prior to October, and prior to the date of the arrival of the Niagara at Auckland. Before that time there were present three types of influenza just as there were in the pandemic period. The only bacteriological difference was in the number and the vigour of the bacteria. There were strains or families of bacilli, and while the organism might be the same in kind, some strains were more virulent than others. This last influenza sickness might be the result of a fresh strain of influenza- bacillus brought into New Zealand from overseas. He could not say at what time "tho bacillus was brought in. But, on the other bawl, thore might be a condition, of wnich they, were all now ignorant, which caused the influenza already here to become more virulent. As to the distinction between cases of ordinary influenza and Spanish influenza, all that anyone could say was that one type of case was more virulent than the other. Before the Niagara. Michael Herbert Watt, District Health Officer at Wellington, [.resented a written history of the disease—a discussion of and a record of the facts of its epidemiology. He quoted from the writings of medical authorities regarding the great pandemics which have swept the world. In all these pandemics the death rate, in proportion to the morbidity rate, was low. He thought the New Zealand epidemic was a secondary epidemic, in which there were 'pneumonic complications. In all previously known secondary waves with pneumonic complications the death rate was higher. During 1918 the first country to report influenza was Spain, but the sickness was mild. , The first Spanish influenza was a very mild influenza. The secondary. waves came later in practically every country in Europe.

Dr. Watt gave ovideucc that early in August an outbreak of severe influenza was reported from Waione School,-near Dannevirke. In this obscure outbreak, which was of short duration, there were oases of pneumonia supervening, and one death. It was the opinion of the doctor of the district, who attended some cases, that the sickness was identical with that of the later pandemic in Octobo- and November. In August and September there was a general epidemic of mil'l influenza, but in this outbreak there were reported symptoms of. swelling of throat of bleeding at the nose. Those were not symptoms of such influenza as wo had known in Now Zealand in recent years, but they, had been reported as symptoms in previous epidemics. In August and September there was an outbreak of influenza among Maoris at Waipiro Bay, in which there were complications of pneumonia, bronchitis, and bronchial pneumonia. He drew attention to the evidence furnished by, the figures for this outbreak, showing the increasing numbov from mouth to month of cases with complications, with several deaths. This district suffered more from this outbreak than from the "later wave in October and November. The medical man of the' district, in a letter describing the disease and the symptoms, 6aid that only those died who had been previously addicted to alcohol in excess, or who had weakened constitutions owing to their habits of life. No previously healthy persons had died. The doctor at Tolngo Buy also reported influenza during the winter in May last. There were then complications of pneumonia, but the cases were not serious. A new strain of the germ came to the district in October, probably brought by steamer, owl in this period there were severe symptoms and a few deaths. Tt was noticed that sufferers by the first epidemic csciiped the later wave. By reference to tables which lie had compiled, Dr. Watt said that before October, 1918, there was noticeable an iucreaso iu the. monthly figures showing the numbers of deaths from respiratory diseases. He produced figures for 1917 and 1918, and it appeared (hat in August ! and September there were more .deaths in 1918 than in the same months of 1917 from these diseases. Two Phases, From a general survey of the information available about the epidemic in all countries it would appear that there had been two phasesof tho epidemic:—(l) A I primary epidemic of mild influenza, ! which, owing to the mildness ef the disease and its gradual onset, caused no leaving America. In these cases bacterio-

logical examinations in February of last disorganisation of trade. (2) A tecondary epidemic of severe influenza with rnoumonic and septicaemia' complications.Thia disease was highly fatal, end was explosive in its onset, and it caused great disorganisation of trade end traffic. The Effect of the War. Dr. Watt offered the opinion that the virulence of the disease- might have been attributable in some measuire to fho war. In the war years the attention of medical men had been directed to outbreaks of virulent infectious diseaso in bodies of troops. In New Zealand troops we hiid had cerebro-spinal meningitis, pneumonia following measles, and purulent bronchitis. It was probable that the concentration of troops in large bodies had set up conditions which allowed the disease to increase in virulence, and that the movement of troops, and the j."eatly increased amount of inter-communication had aided in the dissemination of the disease.

Department Under-staffed. P. J. Frengley, Deputy Chief Health Officer, who had given some evidence, in Auckland, was. recalled. He said tliat he had acted as Chief Health Officer duffing the time that Dr. Valintine' was loaned to the Defence Department. During that time the Public Health Service was not, he considered, adequately staffed, with the iTesult that n,o professional member of the staff had time to devote to events outside New Zealand. Nor was information available. Only since the signing of the armistice had full information been disseminated by the medical Press.'' Referring to the outbreak here, he said that he had been smitten with influenza early in October—an attack of a type which he had not experienced since an occasion over twenty years ago, in Dublin. When he recovered he went to Dunedin. and there heard of professors and students being down with influenza. It was while he was in Dunedin that he heard of the coming of the Niagara on October 12. He agreed with Dr. Watt's general statement of the facts that the fatal wave was preceded by a mild wave in August and September.

No Warning; "It must be pointed out," he said, "that adequate and timely warning could not have been obtained since the fact is no*' established that the peak of the severe epidemic occurred at approximately the same time for England, America, and New Zealand, viz., the latter half of October and the first weeks of November. It is clear,' therefore, that New Zealand was not infected from the cases occurring in the fatal waves overseas. Earlier information during September raised no suspicion. It was generally known that influenza of a mild type was prevalent in England in ithe earlier part of 1918, but so far from the Home experience having a tendency to direct precautionary measures in other parts of the Empire, it would rather tend in the opposite direction, for after mid-August there was a marked diminution in the deaths recorded in London. ' Quarantine Precautions. "The history 06 influenza thows that cases in a mild wave may under circumstances, the causes of which are as yet unknown, work up in virulence, and be succeeded by a wave of fatal type. If this be the true interpretation of the Nev Zealand outbreak, then any precautionary measures would have had no influence unless they were exercised on those cases which gave rise to the mild influenza wavo of August-Septem-ber in New Zealand. But there U _no known means of distinguishing serious influenza from the mi'd influenza which has been prevalent generally in the winter months for years past in New Zealand, which did not cause many deaths and did not give rise' to succeeding waves of increasing virulence. 'It is not possible to produce facts to show that epidemic influenza originated in several parts of the world at one and the same time from micro-organisms already present amongst the commuuity afflicted. A conclusion more.' in accordance with the facts is that Drdinnry endemic influenza is stimulated to severity by the introduction cr replenishment by more virulent infection from other territories, and such infection doubtless was brought to New Zealand by vwsels prior to and including the Niagara,

I More Perplexing Farts, "The difficulty with n hard to quarantining against influenza is the determination when, to be effective, quarantine should bo initiated. ]f pandemic iLfluenza always arises from milder tvpes, then quarantine would require tc be insisted upon against persons suffering from influenza in its mildest form—that is., practically nothing more than a cold in the head. Nowsholme (who is acknowledged head of the Public Health Service of the Empire) lays stress upon this point, that the prevention of pandemic influenza 15 intimately wrapped nip with tho prevention of catarrhal diseases. If, on the other hand, pandemic influenza only spreads from definitely marked pneumonic and septicaemic types, then quarantino of such cases might bo expected to have effectively prevented .the introduction of pandemic influenza into New Zealand. There is, however, no evidence that only the definitely severe cases spread the virulent type of the disease. It is well known that though apparently infected from the same generally virulent typo of organisms, different persons contracting the disease in New Zealand suffered from illnesses varying from the very mildest malady to those fatal within a few hours. There are no facts to show that virulent cases contracted their illness only from other virulent cases and mild 'cases from mild cases.

"If it could be effective, then quarantine would have had to> be initiated in New Zealand against tiic very mildest cases of influenza immediately upon the notification of epidemic influonza in May, .1918, and even then we are met with the undoubted possibility that no such extreme measures would have prevented an influenza carrier gaining admission to Now Zealand."

/Something May Be Done. Dr. Frengley spoko of the experience of Australia. Ho said that 130 deaths from influenza and complications occurred in New South Wales during October. No sufficient information was available to show .whether the virulent disease developed in Australia from milder types or whether it was introduced from overseas. Dr. Frengley said: "In the light of immediately past and present-day knowledge of pandemic influenza, the possibility of preventing its spread by quarantino measures seems very doubtful." But he did not say that because the way seemed difficult nothing at all should bo done. In tho light of knowledge to-day of tho devastating character of pandemic influenza we must take steps to prevent the entrance into Now Zealand of persons found to bo suffering or suspected to be suffering from influenza during, at least, such time as there is evidence of tho likely spread or existence of pandemic influenza, and the quarantine precautions should be made stringent. He spoke of tho need for improvement in quarantine stations, which were inadequate at present. ■ When tho epidemic broko out there were practically none. Motuihi and Somes Island were occupied by enemy alien internees, Quail Island at Lyltelton was a leper station, and Port Chalmers quarantine island was occupied by Army venereal cases. To be effective quarantino facilities should bo adequate to deal with 500 cases on each station. "Probably such a station would not be needed at more than two or three ports in New Zealand. Ho said that to deal with details of quarantine there should be a special medical officer, wholly employed, and not merely a port health officer, who was always a general practitioner doing the port work in addition.

Army Experience Thomas Russell Ritchie, a. medical officer just returned from England, and now Acting Government Bacteriologist, said ho hud been acting as bacteriologist in lingland in No. 3 New Zealand General Hospital. Ho had been working on influenza cases for eighteen months past:. The epidemic had, he said, been showing signs of its approach for two years.. In France in the winter of 1916-17 there were serious outbreaks of bronchial pnoumonia following on influenza, with many deaths. Similar outbreaks occurred in camps in England. When America entered the war and young recruits woro called into camp in the winter of 191718, some of tho camps (in America) wera visited by a pneumonia of a severe type. Among the Thirty-Orst and Thirty-second Reinforcements from New Zealand, who called at an American port, meases of o sevoro type broke out a fortnight after

year revealed the influenza bacillus and the streptococcus. Before the Big Wave, i It was a fact that in England the influenza genu had been giving a great deal of trouble ovou bejor,e the-primary wave of tli© epidemic' in June of last year. Before that time troops of the New Zealand Forces were "boarded" for respiratory complaints, and men with chronic bronchial affections were found to have the influenza germ and the streptococcus, in their sputum; Men would carry these germs for mouths, expelling them in sputum, and for the past eighteen months at least returning troops had been bringing now strains of those germs to New Zealand. He had found very few cases among New Zealand troops in which the pneumococcus was present. Experiment in Inoculation, As an experiment 12,000 New Zealand troops were inoculated with a.multiple catarrhal vaccine. By bacteriological test it was found that their inimunity was increased. This pointed to inoculation being of fonie value. One thousand of these men were kept under observation. It was found that in the primary wave in England 28 non-inoculated men took the disease, and' among the thousand inoculated men only two took the disease. This was about the first experiment of the kind ever made. A conference of leading bacteriologists was held in London in October, and it was decided to use the vaccine for troops. Colonial troops were more subject to infection by. respiratory disease than troops from Britain, and it was probably because of this that the epidemic played such havoc in New Zealand. A Difficulty, Evidence pointed to prophylactic inoculation being useful, though it was still in the experimental stages. But inoculation must be given during a quiesant period and not in the rage of an epidemic. It was for this reason not nearly so easy to use the treatment for the civil population as to use it in the army. Soldiers could be compelled to attend for inoculation. y 1 Sir John Denniston: And you think it would be well to compel the civil population? Witness: Having spent some'years in the Army, sir, I think it would simplify matters considerably. Witness said ? Iso that there were many people now in New Zealand carrying the organisms causing the epidemic sickness. Many would do so for months, and some would continue to carry them for years. Sir John Denniston thanked Mr. Ritchie for his "very interesting evidence." I Tire commission will 6it again to-day.