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Influenza Epidemics / Pandemics in Malta


The first mention of influenza in an epidemic proportion was in a petition sent by the Gozo Apothecary to the Grandmaster on the 18th of February 1682 to obtain remuneration from the government of the day for the drugs which he had supplied to the poor sick of Gozo during the epidemic (1).

In the last days of February 1730, a layman recorded in his diary the onset of a ‘catarrhal influenza’ with slight fever which infected almost the whole population of Malta

In March 1733, another grave ‘influenza of catarrhs, headaches and fevers’ was reported

January 1746, another outbreak started among the crew of the Order’s fleet and in the following months it spread to the civilian population with many sudden deaths.

In 1754, another influenza outbreak caused many deaths in Mdina and the Seminary of this city was evacuated and pontificial ceremonies were suspended.

Few persons escaped the influenza wave in 1836.

Another outbreak started in early November 1847 when ‘numbers of persons, afloat and ashore, civil and military, high and low, rich and poor’ again had the disease. This subsided by the end of the month and although no statistical data exist, it was recorded that ‘the viaticum is constantly to be seen and the voice of the Priest heard on the dismal mission to shrive the dying’.

Compulsory notification of infectious disease was introduced in Malta in 1871 but did not include influenza. This was included on January 20th 1890.

In 1873, the epidemic had all the typical manifestations of influenza, the first cases being reported in Senglea but then spread rapidly to Bormla, Paola, Zejtun and the surrounding villages. Hundreds of people were affected but the usual pulmonary complications were not observed and the mortality was slight.

The 1889-1890 Asiatic Flu started in Russia and quickly spread globally. It reached Malta at the end of December 1889 – beginning of January 1890 and subsided by March same year. A total of 859 cases with 39 deaths were reported. The case fatality rate was estimated at 4%.

A resurgence of the disease occurred in January – May 1892 with a total of 2017 cases and a case fatality rate of 3.3%.

Similar resurgences occurred in 1894 with 615 cases and a case fatality rate varying between 2.4 – 3.6 % In 1904-05, 760 persons were affected.

The 1918 – 1919 Spanish Flu (H1N1) was already spreading globally in May 1918. It first appeared in Malta, in June 1918 and continued till June 1919. The total number of cases reported was 20,388 civilians with 807 deaths. The incidence was tentatively estimated at 20% and the case fatality did not exceed the 1.5%. The number of deaths in Gozo was higher than in Malta (3 persons per 1000 in Malta and 3.4 per 1000 in Gozo) and it was higher in females than males (364 and 321 respectively). Three waves were documented in the Spanish flu.

  • The first wave lasted three months (June-August) and was relatively mild with 93 cases reported and two fatalities (case fatality rate 5.1%). The cases were mild and many may have gone unreported.
  • The second wave (September – November) was more contagious and severe, with 10281 cases (8846 in Malta and 1435 in Gozo) and 402 deaths (case fatality rate 3.9%). A number of cases had severe pulmonary complications and in most, the disease was abrupt in onset.
  • The third wave was ushered in towards the middle of February peaking between the 7th and 24th of March 1919, with 4507 reported cases.

Epidemiological features that were documented included:

  • Short incubation period, rarely more than 36-48 hours
  • Abrupt onset in the more severe cases
  • Epistaxis a common presenting symptom especially in the young
  • Haemorrhages – subcutaneous or otherwise was reported as an unfavourable sign
  • Hyperpyrexia – common
  • Skin eruptions as in measles
  • Large pleuritic effusions and empyema and occasionally lung abscesses
  • Pulmonary Oedema
  • Grave toxaemic symptoms
  • Cerebral symptoms were uncommon
  • Relapses were not infrequent but true second attacks were few. True influenza gave sufficient immunity
  • In the third wave, the proportion of elderly persons attacked was much larger than in the second wave

Table 1: Summary of number of cases and deaths in Malta and Gozo

 

MALTA (Population – 200,209)

WAVE

1918

No. of cases

No of deaths from Influenza & complications

No. of deaths from Bronchopneumonia and pneumonia not stated to be due to Influenza as the 1o cause

Jun-Aug

93 cases

2

1

698 Military

1

Sept

4197

66

30

2

Oct

4651

294

55

Nov

1036

68

36

Total

9884

428

121

Dec

427

18

8

1919

Jan

659

36

12

Feb

546

19

4

Total

1632

73

24

March

4412

99

15

3

GOZO (Population – 24,446)

WAVE

1918

No. of cases

No of deaths from Influenza & complications

No. of deaths from Bronchopneumonia and pneumonia not stated to be due to Influenza as the 1o cause

1

Sept

232

3

1

2

Oct

1203

39

2

Nov

510

74

2

Total

1945

74

5

Dec

172

6

2

1919

Jan

89

1

1

Feb

2

Total

261

9

3

March

95

3

Table 2: Number of deaths by age groups due to the Influenza Pandemic in 1918-19

 

   Under 5 years

<1

1

2

3

4

15

15

14

10

12

Over 5 years

5

10

15

20

25

33

38

68

110

230

35

45

55

65

75

85

>95

98

66

34

23

9

1

Total

776

 

Various Public Health measures were taken to contain the spread of disease:

  • Prevention of overcrowding in public places, cinemas, theatres and other places of entertainment

  • Ensuring proper cleanliness, disinfection and aeration of these places including ferry boats and railway carriages. This was considered to be more fruitful than the complete closure of these places for relatively short periods of time

  • Decreasing the visiting hours of the various Charitable Institutions

  • Discontinuing the pawning of clothes at the Monte de Pieta

  • Closure of government run schools

  • Increased visits of suspect dwellings by Sanitary Inspectors

  • Temporary surveillance of arrivals from overseas with disinfection of belongings where necessary including beddings and linen of sick individuals

  • Home isolation of mild cases

  • Severe cases were transferred to the Infectious DiseaseHospital with disinfection of their habitations and property

  • All cases reported in the Charitable Institutions, prisons and ships in the harbour were transferred to the InfectiousDisease Hospital

  • Public education campaigns to explain nature of disease – its contagiousness and transmission, the necessity to maintain personal and domestic cleanliness, the importance of taking care of one’s self as the first symptoms appear until complete cure. This was achieved through publication of leaflets and posters

 

Table 3: Population number, number of deaths and death rate per 1000 by locality

Deaths

Locality Population No.

Rate 0/00

Valletta 24164

425

17.58
Floriana 6763

96

14.19
Msida/Pieta 5384

127

23.58
Sliema/ St.Julians 17636

292

16.55
Hamrun 15650

424

27.09
Cospicua 12623

241

19.09
Vittoriosa/Calcara 7943

162

20.39
Senglea 8695

164

18.86
Rabato/Notabile 9565

203

21.22
Dingli 1045

23

22.00
Zebbug 6228

159

25.52
Siggiewi 3594

68

18.92
Birchircara 9937

199

20.02
Lia/Attard/Balzan 5008

93

18.57
Naxaro 3168

55

17.36
Musta/Imgiar/St.Paul’sBay 8229

148

17.98
Mellieha 3031

31

10.22
Gargur 1555

29

18.64
Curmi 10246

214

20.88
Luca 3800

243

63.94
Tarxien/Paula 7617

175

22.97
Zurrico 4812

88

18.27
Safi 437

10

22.88
Crendi 1638

30

18.31
Micabiba 1431

25

17.47
Chircop 833

12

14.40
Zeitun 9099

200

21.98
Zabbar 7383

145

19.63
Asciak 1907

62

32.51
Gudia 1267

20

15.78

TOTAL MALTA : Population 200785
Deaths no: 4163
Death 0/00 : 20.76

Victoria 7030

168

23.89

Xeuchia 2348

34

14.48

Nadur/Kala 5018

77

15.34

Ghainsielem 1361

12

8.81

Garbo 2475

51

20.66

Zebbug 1038

7

6.74

Sannat 1286

26

20.21

Xghara 3518

48

13.64

TOTAL GOZO : Population 24074
Deaths no: 423
Death 0/00 : 17.57

TOTAL BOTH ISLANDS : Population: 224,859
Deaths no: 4,568
Death 0/00: 20.39

 

In 1920 another influenza outbreak was documented but once again was not severe. Same Public Health measures as for the 1918-19 pandemic were adopted except for school closure. A supply of influenza vaccine was obtained from the Government Lymph Establishment, London and all medical practitioners were informed that the vaccine could be obtained from the Ministry of Health free of charge. However, because the number of cases had decreased, no vaccine was administered.

The 1921-22 epidemic started in March 1921 till June and the second wave recorded between January and April 1922. The illness was mild and hence the reported number of 5,508 cases (25.6 per 1000 population) was an under estimate. 99 deaths were recorded (case fatality rate 1.8%).

In February 1929 another outbreak was reported in Malta which peaked in March and declined over the following month. Just over a thousand cases were reported most between the 20-45 year age brackets.

Smaller outbreaks were reported in 1936/37, 1940-43, 1948, 1951-52

The 1957 Asian Pandemic (H2N2) started in Malta in August after the arrival of a ship in which the crew members were recovering from the disease. It peaked in September and the second wave occurred in November and tailed off by the end of the year. The number of cases reported was 8,783. Mortality was slight (11 cases – case fatality 0.13%) but relapses were common.

The 1968 – 1969 Hong Kong Flu (H3N2) was associated in Malta with an increased number of reporting in the subsequent years of 1969-71 with 1,024 cases reported and 23 deaths.

The 1977-78 Russian Flu (H1N1) did not particularly impact the Maltese islands.

______________

References:

  1. Medical History of Malta – Dr.Paul Cassar 1964

  2. Report of Public Health Department 1919-20

  3. Past Influenza Pandemics and their effect in Malta – Dr. Charles Savona Ventura Malta Medical Journal Oct 2005

 

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