As the world deals with COVID-19, it is important to keep in mind that this is not a novel situation we find ourselves in, and neither is it new to the Maltese community.

Furthermore, it was also reported in local medical journals, published in 2005, that an influenza pandemic was 'inevitable'.

The influenza virus has caused repeated pandemics throughout the 19th and 20th century. The worst pandemic, known as the Spanish Flu, occurred during 1917-19, in World War I, as the transmission of the virus was expedited by large movements of troops.

During those times, warnings to avoid spitting on the floor and allowing sunlight into one's house were today's equivalent of getting vaccinated and washing one's hands.

 

On 14 September 1918, a circular was issued to the British Garrison in Malta on prevention measures against the Spanish Flu.

 

According to a journal article, published in the Malta Medical Journal in 2005, by Charles Savona-Ventura, past pandemics had varying effects on the Maltese community.

Compulsory notification of infectious disease was introduced in Malta in 1871. However, the original ordinance failed to include influenza in the list of notifiable infections. Influenza was made a notifiable infection on the 20th January 1890 with the appearance of 1889-90, Asiatic Flu, influenza pandemic in Malta.

The Asiatic Flu made its first appearance in Malta during the end of December 1889, or the first fortnight of January 1890, when mortality data for that fortnight suggests a total of 24 deaths occurring from influenza. In the latter weeks of January, after the infection was made a notifiable disease, a total of 859 cases were reported with 39 deaths.

The disease subsequently abated to disappear completely by the end of March 1890. A resurgence of the infection became apparent in January-May 1892 with a total of 2017 reported cases and 66 deaths.

The Spanish Flu - Malta the 'Nurse for the Mediterranean'

In 1917-19, the Spanish Flu pandemic took over the world, which was in World War I. This flu is estimated to have caused the loss of more than 20 million lives, a figure significantly greater than the direct mortality caused by the conflict. The estimate is that 200 to 500 million individuals were affected by the virus, but the origin of the virus is still unknown.

The Maltese Islands during World War I served as a 'Nurse for the Mediterranean' and was also economically severely impacted. These two factors set the stage for the introduction and spread of the virus among the Maltese population.

Spanish Flu made its appearance in Malta around June 1918 and persisted until June 1919. Influenza is reported to have affected a total of 20,388 civilians with 807 deaths. The incidence was very much higher in Gozo than Malta.

It was reported that Gozo had higher incidences because the community there could have had lower immunity. Since Gozo is a bit more isolated they may not have been exposed to the flu in previous years.

The most affected by the Spanish Flu, in the Maltese Islands, were adults in the 20 to 40 age group, and mainly women who would have become infected from their children. Since women used to care for quite a few children at a time, and their nutritional intake was poor, women may have been more at risk.

At the time, a railway service used to run from Valletta to Hamrun, Birkirkara, Attard and Rabat, which probably was a major factor for spreading the flu.

The response of the Maltese Health Department in 1918/9

In response, the Department of Health undertook several precautionary measures to attempt control the spread of the infection, including the prevention of overcrowding in public places, cinemas, theatres and other places of entertainment.

Localities were to be kept clean, well-aerated and disinfected and the disinfection of public places including railway carriages and ferry boats was ensured. Other measures included reducing visiting times in the various charitable institutions and discontinuing the pawning of clothes at the Monte de Pieta'.

In 1918, Albert Bernard, the Chief Government Medical Officer, suggested that schools and the University remain closed given the Spanish Flu epidemic.

 

Eventually, schools were also closed and visits to suspected dwellings by sanitary inspectors were also increased.

A public propaganda campaign to emphasis the contagiousness of the infection, its mode of transmission, the necessity of maintaining personal and domestic cleanliness; and simple isolation at home of early non-severe cases.

Severe cases were either forcibly isolated in the home or at the Infectious Disease Hospital with disinfection of their habitations and property. All cases occurring in the Charitable Institutions, prisons, and ships in the harbour were isolated at the Infectious Disease Hospital at Manoel Island.

The Asian Flu - Probably brought in on a ship

Between 1957 and 1959, the Asian Flu (H2N2), hit the world and significantly affected the Maltese population. The infection was first observed in Malta after a ship carrying convalescent cases docked in Malta in August 1957.

A total of 8783 cases and 11 deaths were reported [case fatality rate 0.13%], though the caseload was probably greater since cases with minor clinical symptoms often did not require professional help.

The 1977-78 Russian Flu (H1N1 virus) pandemics did not exhibit any particular influence on the Maltese population.

With the last pandemic dating to the 70s, a significant influenza pandemic is now considered to be long overdue, according to several medical journal articles. In one medical article, also published in 2005, it was noted that "in the case of Malta, it is conceivable that the first cases would be seen some weeks after the appearance of outbreaks in larger European capitals