THE PANDEMIC

Dominion, Volume 12, Issue 143, 12 March 1919, Page 8

THE PANDEMIC

HOW THE SICKNESS CAME THE WAR AND THE WEATHER ■'• REVIEW OF ALL THE FACTORS EFFICACY OF QUARANTINE The Epidemic Commission continued its sittings in Wellington yesterday. .Sir , John Denniston presided, and the Hon. B. Mitchelfion and Mr. D. M'Laren sat with him. . ( Effect of Quarantine, ' Watt, District Health Officer at Wellington, recalled, said that fho in- ; formation concerning the outbreak of influenza at Waione School was received "by'him from the secretary of the Weljlington Education Board on August 5, 1918. Hβ telegraphed the medical nian of the district at once and wae informed, that all the cases were then con : va-lesoent. The school was disinfected. By analogy with other infectious diseases, he would say that tho convalescent influenza patients who were allowed to go ashore at Auckland ware .very probably carriers. He could not say this definitely. The influenza bacillus ctrried by a patient be much ivoro .vir» . lent ascertain times, than at others. Aβeuining that the cases landed from the Niagara, had been suffering from a viru- ] lent form of influenza, he,would certainly recommend quarantine. ' He thought , the .Australian practice was to be advised— quarantine for one week—but there Tyas really no evidenco that this would be effective. He would adviso it n-.erely fts a. precau/tion which it would be wrong to negleot. He knew of no country in the world except Australia which adopted quarantine against influenza. The use of inhalation chambers di-ring (ho period of quarantine would minimise tho risk from infection by carriers, but it was not possible to say (hat it v-ould obviate it altogether. The wild or pritnary ware of the epidemic did not necessarily precede a secondary virulent ■wave. Speaking generally, the secondary .wave followed the milder wave in the succeeding winter months, but very seldom had , it happened that the avero wave followed the mild wave at an. interval of only, a few weeks. England ivas caught unprepared for the speedy recurrence of-the disease there. In the 1559 epidemic Portugal had the secondary wave three months aftsa- the mild wave, but usually the period was much longer | •—in some cases twelve months. Thero might be an almost instantaneous increase in, the virulence of the disease without its being the result of any foreign, invasion. Such an ?ve.nt as the coming of the Niagara might easily be only a coincidence. ' i

Partial Immunity, .. Lieutenant-Colonel, 'ft. H. Makgill, N.Z3I.G, discussed the nature d the disease as manifested, in the camps, and the. degree, of immunity of a patient attacked with mild sickness against tho severe wave.- His opinion was that there was evidence, of at least partial immunity, but there was lack of definite data. The records kept by tho sanitary officer at Feathevston showed that out of 301 cases of pneumonic infection in' November, 23 had suffered from a prior attack :■•• Anwmt, September, 'and October, and of these M died. This high death-rate suggests that these were cases specially susceptible to 'infection, but the. total number was not great. He 'believed that j a partial immunity was established for eome weeks. The point was of importance since by> the existence or absence of such immunity one could judge as to the value of the use of vaccine.. Isolation Impossible, ; "No one who has studied the history of influenzal epidemics," he said, "can doubt that complete isolation would absolutely protect a. community. Many cases can be quoted, and in regard to military -units the freedom from infection of the' German internment camps in New Zealand can bo cited. Theoreti-, cally it is possible, but in actual practice no means exist whereby we can secure perfect isolation if the country's work _is to be carried on, since the disease is of so insidious a character that anyone developing a catarrh, would have to be ieolateu as a possible harbinger of more serious infection. Sir Arthur Neweholme, president of tho Local Gov- j ernment Board, an eminent authority on | epidemology, says he knows no mea'sure j which can resist the spread of' a 'pan-1 demic of influenza,." . i ■•'..;■•' -Inhalation Chambers, ! '.Djr. ;Slakgill said • that "experience in ■ the camps since the. systematic iuhala.- ; tion treatment of recruit's and contacts' was adopted had been emphatically in j favour of this measure, as a means of i coping with all catarrhal infections of '■ -tlie naso-pharynx, especially measles, j The absence of diphtheria in the camns, ■ despite the existence of a widespread j epidemic ,in the civil, population, was j significant. Since the systematic use : sf the inhalation chamber on the troop- j Ihips tliere had been a lessened inci- j dencis of severe infection. On the other hand,.the systematic use of the inhala-', iion chambers failed in eome measure to j prevent, the spread of influenza, even j of the mild type ;in September. It j totally failed to check the spread of i the second virulent wave, though it was j impossible to say whether or ■ not the use of the chambers had. modified tho j "severity of the disease. But to be effec- j tive, the disinfection of tho nose .and throat must be. frequent. It ;seenied certain that the organism could establish itself under twelve hours, so that ;to be really effective the inhalation ■/would require to lie repeated shortly after any exposure to infection. His con- ! elusion was-that with the evidence we had we could not afford to' ignore the inhalation chamber ns one of the meaBuree to be adopted during an epidemic. ■ The second wave of the epidemic was traceable to Auckland, and it travelled southwards rapidly. . •11

The Sickness on the Niagara., The'passengers who arrived in New Zealand by the Niagara must have left • Britain before' there was any outburst of virulent influenza. They passed through America before there wns''any -general i development of the severe type of infection, and left Vancouver on September 21, at which time there was no infection on'the west coast of Canada or the United States. The epideinic began after | ■the* ship left Honolulu, and records show-1 ed that., only mild cases existed at the i port. It was mild on the ship, for after '■ n fortnight the disease, had scarcely af-1 . fected the passengers, and only one denth ! occurred among,the crew. Certainly the : infection on this boat was not the'disease j which'in'November caused over 3000 -cases •within a fortnight in Featherston Camp. ! That there were two or three pneumonic cases- on the ship was not "significant, since we had sudli cases here in New ' ' Zealand long before the ship was berthed. Inquiries showed that among the pas-1 centers who landed no sickness arose j while they stayed at the hotels at Auck- ! land. If these people had been carriers one would have expected little foci of ' "infection to burst out all over New Zealand at the places to ■which the passengers ■ weie scattered.. Yet a fortnight later' the disease was traceable in Auckland only. Also the patients from the Niagara ■ were isolated in Auckland.' Was it to be ; supposed that this isolation was so im- ! perfect that the public of Auckland, and , ■ultimately the whole of New Zealand, I were infected within a fortnight? This could scarcely be the case. The ,incubation period was short—about 48 hours— l>iit the. epidemic was not severe in Auckland until October 2C or 28. while the Niagara arrived on October 12. Dr. Maksjll said that ho had advised that the Niagara be berthed, with cor--1 tain precautions, and his advice was taken. At the time- he gave the advice he did not know that Sir. Jfassoy and , Sir Joseph Ward were on the ship. j From Within or From Overseas? ,' Dr. Makgill dismissed the proposition that the virulence of the disease was increased by tlio outburst among the Na--3 tives lit Narrow Neck Camp. Was the epidemic of November a natui-iil[.ftoi;kiflg up, i,u, ■virulence of. the Influenza germ already epidemic in New Zealand ?—"This seems actually to have taken place in .Australia recently, and it would satisfactorily explain the in-

crease in deaths from, catarrhal disease in the spring of 1918. Yet why should it culminate in Auqklaiid particularly and not in various other parts in New Zealand simultaneously? It actually did so culminate in several instances, as, for example, in the cases reported by Dr. Watt as occurring among tho Natives at Waipiro Bay and Waiono in August and September. But these outbursts did not spread and take on general epidemic character. That the virulence of infection increased during Septombor and October is evident, but this alone cannot account for'tlie Auckland outburst." Did tho arrival of the Niagara and other vessels add to tho already existing influenza epidemic an elomont previously unknown ?—"One can that on these vessels which arrived on or about October 12 wore carriers of highly virulent pneuinococci and streptococci organisms, the virulence of which had been rajeed by the epidemic, conditions amongst troop.) and other aggregations of population overseas. We know that persons, possibly carriers, were present on the troopships among the convalescent soldiers. Yet why did not such carriers— if they existed—convey infection to others on board the vessels, producing an epidemic snch as we learns:? aroso on the transport Tahiti? And, agcin, aa transports, equally likely to convey carriers, came into other ports in New Zealand, why did they not start outbursts at ouch ports? We have also arc pie bacteriological ovidence,- from the camps and clinical evidence in civil lite that the influenza bacillus and the attendant complicating organisms were already widelv distributed in _ active virulence throughout the Dominion. Dr. Jlakgill mentioned as influences affecting the spread of infection movements of troops and infection in ships' crews.

On "Insanitary Conditions." "It has been suggested," he said, "that in Auckland insanitary conditions exist favouring the developing of a more virulent type of influenza. Yet my experience tells me'that conditions equally insanitary can be found in any of our main centres. Moreover, catarrhal pneumonias arc not nearly so prone to epidemic form, or to take on a severe type among slum dwellers as among strong healthy, young people brought up in the. country. ' This is a •universal experience, which has been greatly emplineised in the military camps all over the world. . A child brought up ii crowded conditions in a slum either succumbs in infancy or survives by developing an increased natural resistance to microbic invasions. The country-bred child, not having to fane this struggle of its body cells and phagocytes against infection, reaches adult life without aequirinsTtbis natural immunity, and thereforo when transported in conditions whereby he meets varieties of invading organisms hitherto unknown to him, falls an easy prey. Thus, when, he enters a camp I where he has to live among crowds of men from towns and other countries, jt is the country-dweller who suffers. This i was conspicuously the case with the I meningococcal pneumonic infection in the camps in 191G, whom 72 per cent, of tho victims were farm workers. The effect of insanitary urban conditions cannot, therefore, be regarded as accounting for the outburst having begun in Auckland. Whilst this is the case, we cannot overlook the influence of crowdins and of living in dark, ill-ventilated conditions. Persons among such surroundings undoubtedly' suffered more severely, and the proportion of pneumonic cases was higher. This was exemplified i:i the poor c!ns.« lodging-houses, and :;i the crowded qnwtere sometimes allotted to ruiiters ami shearers.

: Bad Weather. ' ' "Inil'isnza is generally a winter di- ! sense, Mid. for .the Inst tare years th* ' weather id! over the world has been unusually wet and cold both in summer and ■ I winter. In New Zealand we have sufteieii fiieo. and catarrhal diseases have been thereby fincouraj»ecl. It 1 is of interest; to noee that horticulturists throughout Britain. Anuria , .;' and. New Zealand have suffered from a series of epidemics among fruit trees and vegetables during the samn period. AVct and cold favour the development of ali low forms of vegetable life, whether preyin? >on human being. o - or on the hiKher plants. October seems to have been a particularly wet, stormy month in -Auckland, and this must have had an influence in stimulating the ac- . tivity of organisms producing the epidemic, more particularly those causing pneumonic infection. . . . It is obvious that one effect of bad weather—the driving of people into shelter—must directly influence the spread of infection, by con'tact. In'addition to.this, the effect of cold and wet in diminishing resistance i must be considered." . ■ I Dr. Makgill spoke of the spread of i'u- ! fection by aggregations of people at race i meeting!, peace celebrations, and such I gatherings. An important factor also j was the lack of natural immunity' among j the New Zealand population. J The Whole Story. I I "Reviewing those factors making for I j the eeverity of the influenza outburst .of I November last, we are able," he said, j "in u measure to piece together the j whole story. The influenzal infection I found, in 1918, world-wide climatic conj ditions favouring its nproad. l>. found I gatherings of troops to exalt its viru- ! lence, and by- the transference of such • troops about the world it was able to j reach other countries with ever-increas-j ing infectivity, The influence of the I appalling prison camps in Germany and i , Austria has not been. discussed, but j among the starved, crowded soldiers there j abnormal infections would find a good I breeding ground. Either in this way, ox ! simply from camps' of unprotected- per- | sons, 'the ordinary influenzal virus be- | came associated with pneumonia-prodiic-J ing organisms capable of_ unusual potency under favourable conditions. Such conditions presented themselves in New Zealand in the climatic disturbances, the unusual r/'ovements and aggregations of troons, and the natural lack of immunity of the.people. The .virulence wniiM inj crease naturally as the primary epidemic ' spread over the country, and as the successive accretions of higher virulence came from overseas-" , ,

The' Department. Dr. H. A. Valintine, Tnsucctor-General of Hospital' and Chief Health Officer, was the next witness. He said, that he had gone over to the Defence Department early in last year, and did'not return : to his civil duties until November 18— ' in the third week of the enidemic. When the sickness broke out there were only j six medical officers to deal with, an epidemic showing characteristics as regards virulence and infection never hefore expp.rinncpd by any member of the j profession in New Zealand. Tbi« w.«i thfi. position when he and Dr. ir«k<rill I resumed civil duty. The local lindips I did their work well, nnd co-nnwited wit!' ! Hie Dpnnrtment in Hip estnblishment-of I temporary hosoitals. and other mmsm-ps ! necessary, to fiffht the disease. Up till the ttniP. of the epidemic the ! general health of the Dominion, j thniicrh showing a large increase in the i notifications of infectious disease, had been comparatively good, especially when it was considered that in times of wini i(- was notorious fint the nubljc health of a coiinf'-y v»s liable to be influenced i not only by the movements of troops. I but by the ecneral di'pvcsing condition 1 inseparable from war v itich make people loss resistont to disoas<\ and pprticuliHv fo "'hat i" known os flip infectious. TTe . spoke particularly of the low infantile .'niqrhlily rate, especially in the four ' chief cpiitros. As to his own share in combating the enidemic. he rpininpd Ihe ■ Dei.vtmp.nt in the middle nf the crisis, ; and he cnnsid n md it I'is duly to enrry ' on the policy laid down by Hip ""Hnisler , and the Acting-Chief Health Officer. Aid From Defence Department, In connection with tho establishment of temporary hospitals 1,0 wished to refer j particularly to tho work done by tho officers of the Defence Department. He could not sufficiently express his grati- ■ tudc for the assistance he had received from Major M'Cristp.ll, Director of Equipment'and Ordnance, in t'he equipment and rationing of temporary hospi- , tals, from Major Gibbs, N.Z.M.C, j D.A.D.M.S., in the supply of medicines ! and medical equipment, nnd from Cap--1 tain Gentry, brigade supply officer, who carried out the large amount of transport work required. Nor must he omit to mention the very great help ho obtained from Surgeon-General' Henderson, DIG.JI.S-. who never neglected tin appeal for the help of the medical officers of the Defence' Department. There was no doubt that but for the fact that a large proportion of the medical profession of tho Dominion wns mobilised for

duty with the Defence Department the country would have Leon in a very bad way as regards a medical service, which had already been seriously depleted by the exigencies'of the war. Ho was proud to say that as legards the medical sorrico availablo there was not the slightest hitch. ■ Tho work of the students who were sent .up from the Otago Medical School was also worthy of high praise, Tho eaino aleo applied to the nursing profession and the advantage of tho nurses being 'iiobilieed for service was at once apparent. la fact one of the chief reasons why the epidemic was so promptly dealt v/ith was largely on account of the Dominion being in a state of discipline never before experienced.

More Health Officers Neaded. Dr. Valintine went on to epeak of the need for reorganisation of the Department. Ever since its inception in 1902 the Department had been "starved." He had, 'however, no 'eason to blame any particular .Minister of the Department for not doing his liesfc to place it on a sounder footing. A (inference of medical officers of the Department was hold subsequent to the epidemic. The conference proposed that New Zealand should * be subdivided into oight health districts instead of four as at present, and that junior medical officers to assist tho district officers should bo appointed for tho larger districts. _ Dr. Valintine presented other suggestions. As the Department was at present the medical officers could barely carry out their routine duties, and they had no time for study. They had no opportunities tor visiting other countries to study, other methods of public health administration. They should have regular and assured leave of at least six months in every five years, eo that they could have an opportunity of keeping themselves abreast of progress in their profession. It was no exaggeration to eay that the senior officers of tho Department, after the strenuous work of- the last four years, were thoroughly etale, and should be sent on extended leave as soon as possible. About Alcohol, Regarding , primary precautions In n timo of epidemic he said that all crowds should be avoided, and no functions held j to encourage crowds to collect. All meeting places should be closed (including hotel bars), bnt he did not consider the sale of liquor'should be prohibited altogether. Ho considered that during an epidemic it ehould be possible to purchase nlcohol. On this point he would suggest that the commission call the president of the British Medical Association, who would bs more in touch with the clinical side. His own experience was tlmt alcohol wasusefuljn the epidemic.

He would advocate the use of masks in. public places-such as trains, trams, shops, etc., but except in crowded streets they need not be worn out of doors. Ho would not at present recommend tho use of. vaccine. Medical Inspection of Youths. "The improvement wrought in the development of young adults in. the military training camps," he said, "is known to all. Less widely known, however, are the excellent results obtained in the CI Camp, wherein men of military age with remediable defects underwent a special period of physical training under expert officers. Even among men of full adult ftjje the changes wrought were striking. Otuch more would this bo the case if adolescents were to receive such training before the defects became permanent. Such jils- as malnutrition and poor physique generally, lateral curvature of the spine, weakness in certain groups ,of muscles, functional cardiac troubles, and mnnr other conditions lending to- a weakening in the bodily resistance to disease could, if taken in time, be re-, lncdiecl to a great extent. If, in calling up for service the youths of the Dominion, such as exhibited these defects'could Iμ drafted for throe months' training in •a'camp under special'medical supervision, a large number of men who would ! bo poorly equipped for the needs ' of civilian life or military service would be added to the effectives of the nation, The course- of training would take the place of military service.

. The Nursing Service, The recent epidemic emphasised the fact that .very few of the women of. the Dominion had the slightest'idea of nursing the sick.' The ignorance shown was lamentable. Few could take a tenipera- ! hire, much less take a pulse, or even make a bed or prepare and cook a eimple milk pudding. A second line of nursing must be established, but it would be a pity to set up two grades of nursing. The second line nurses would be taught only in the rudiments of nursing work, commonly called "home nursing." He suggested that the training of this second line could best be done. by the St. John Ambulance Association, which could receive additional subsidy from the Government for this purpose. Tile association might develop a motor service, for conveying the sick in epidemic times, or indeed in non-enidemic times. The Root of All Evil. . "Finally," said Dr. Valintine, "I may conclude by saying that if this country is so unfortunate as to be visited by an-' other epidemic of tlie nature of' that of November, 1918, I hope that we shall hear little of claims for payment for services rendered. It was very stimulating during the throes of the epidemic to feel that one's co-workers., were ' inKpired by a spirit of patriotism to come forward and do ; what they could for their fellows in misfortune. It was equally depressing Inter on to have my office surrounded by a crowd clamouring for payment for services rendered, especially from some who had been most loud ini their denunciations when the payment of voluntary workers was first mooted. Lee us hope that if we have again to face the awful experience of last Novbniuer, the work will be regarded as a national duty, and payment only considered allowable to those who could not afford to give up their ordinary occupation unless compensated therefor." He said that.the services of many young people wero accepted who were not needed, and many hospitals were overstaffed. Some of these girls applied later for payment, whereas no would have thought of engaging them if payment had'been requested at first. *On the other hand there were cases in which it would have been most unfair not to pay for services given.

Referring to the Australian experience, lie said that he would have liked to send an officer of the Department to Australia to watch the progress ,of events in the epidemic there. There seemed to be no doubt that Australia had profited by New Zealand's experience. And in Australia the conditions were different. They had not a native race in which the epidemic might develop incrensed virulence. He thought it wns too soon to say yet that Australia would not comn through "a pretty vgly time." He had not been able to ybtain a record of -the 'deaths among the Ni'.tivos. The Civilian Committees. Riiniufl Robertsoli Or, minister of St. Andrew's Presbyterian Church, said that ho had been chairman of the Wellington North Epidemic Committee.. He said that it had seemed to him that the municipal authority should have had power-to isolato houses and areas where the disease broke cut first. This could not be done. On November 12' he railed a meeting,h> Wellington North area, and a little band was formed to fight the epidemic. Next r.ight the Mayor called a meeting. But before this something plight have been done, he thought, in the isolation of infected places. Wellington North wns divided into nieas, nnd every house was visited in order to collect information as to where sickness had occurred, and where nursing or medical help was required. Ho detailed the work done by l his committee. At first the medical aid was inaderiunte. This was for about five days, until (he doctors worked on the block system. So also it was difficult at lirst to get nmsiiif! assistance. In the lioardiiighousc areas there was overcrowding, and in these areas the cases were I'-orp numerous ami more virulent. He had seen three young men in a small room all ill, some delirious, and without assistance. ]T(> 'had likewise seen three sick women in one room. The total cost of Hie organisation to fight the epidemic, exclusive of medical fees, was nearly .17000. This 'had been paid .by the Government. Most of the expense was incurred for the transport of food p.ud the carriage of workers and nurses. The Commission will sit again to-day.