Myths and echoes: the 1918 pandemic and today.

RCMI SITREP Jun 2020

Does history repeat itself or does it rhyme? Is it wise to design strategy based on old wars? We are rightfully sceptical of writers, who predict the future based their reading of our past. The Spanish 'Flu pandemic of 1918 has been a favourite segue in recent commentaries regarding COVID-19. Commonly repeated myths include assertions that influenza arose in military camps, from swine or poultry kept as sources of fresh food, and that it was spread by allied soldiers of the First World War, particularly North American troops. Reports of influenza outbreaks in neutral Spain, especially when the King became sick, morphed into its origin story in our censor-conscious press. For Canada, it is still said that influenza arrived with soldiers returning from the war in the Summer of 1918. While most of these 'facts' are untrue, remarkable echoes of 1918 can be found in the current pandemic.

Pandemics may be named for the year or place of their appearance or the causative agent. Historians prefer to use the year. Place-names can be used pejoratively and are irrelevant in pandemics. Agents might repeat themselves. H1N1 influenza, now thought to be the infectious agent of the 1918 pandemic, reappeared in 1977 and in 2009 when it was associated with swine. The current pandemic's name is made of 'CO' for corona, 'VI' for virus, and 'D' for the disease caused by the 2019 novel coronavirus. 19 refers to 31 December 2019 when China declared the outbreak of a new transmissible respiratory disease. Coronavirus is a different class of contagious respiratory virus than type A influenza but the diseases that they cause have many commonalities.

The source of the 1918 pandemic is not known for certain. A First World War army camp at Étaples, France experienced a respiratory illness with a high mortality in late 1916. It was followed by another outbreak at an army transit camp in Aldershot, England. These outbreaks disappeared. Influenza appeared at Camp Riley, a US Army training camp in Funston, Kansas in January 1918. But these origin stories don't match our experience before or since then. They didn't make sense to Mark Humphries who was investigating the Canadian experience of the 1918 pandemic, for his Ph. D., at the University of Western Ontario, in 2008. Humphries, now a professor at the Wilfred Laurier University, described an epidemic respiratory illness in north western China in 1917 and tracked the movement of the Chinese Labour Corps, through Canada to England and France, as the likely origin of the first wave of the 1918 pandemic.

Transmission of infection to Canadians, by the Chinese Labour Corps, as they travelled westward from Vancouver, was limited by the use of closed trains to prevent desertion. Poor quality medical care failed to recognize the disease. Other routes, to Europe of influenza, have been linked to outbreaks there. Chinese labour was recruited by France, which used a marine route through the Suez canal, and by Russia, which used train transport. The official US Chinese Labour Corps, which had been with Pershing in Mexico before the pandemic, had a low rate of influenza but other Chinese contract labourers were the first to report sick in Camp Riley. The first wave of influenza in the US spread eastward as the country mobilized for war. Thus it was Europe and the eastern US seaboard that held the reservoir of influenza by the end of the first wave.

Canadian army camps were well prepared for contagious disease. Many army medical officers had experience in the quarantine service, including Canada's Surgeon General, Guy Carleton Jones. Indeed Jones' tenure was marked by a determined policy to prevent, and respond, to contagious disease within the armed forces. For example in 1916, the No 10 Canadian Stationary Hospital, manned by personnel from the University of Western Ontario, successfully managed simultaneous outbreaks of three contagious diseases (measles, mumps and typhus) among allied soldiers in Eastbourne, England.

On the other hand, Canada was vulnerable for several reasons including: 1) a contagious disease program that was directed toward immigrants; 2) a chief of public health, Dr Frederick Montizambert, who was at the tail end of a distinguished, but overlong, tenure; and 3) a list of quarantinable (reportable) diseases that did not include influenza. This came to a head when the troop ship Araguyan approached Halifax in July 1918, with a quarter of those on board, sick from influenza. Two ships, the Nagoya and the Somali, heading to Montreal to pick up troops for Europe, stopped at the Grosse Isle quarantine station because of an outbreak of 'flu among the crew. All three ships were refused assistance from the quarantine service because of a dispute regarding jurisdiction. A scandal and a tragedy came to Canada's rescue. The scandal was an unwarranted attack upon the leadership of Surgeon General Guy Carleton Jones and, although vindicated, he had been returned to Ottawa in 1917. Carleton Jones, a former quarantine officer, was thus the senior army medical officer present in Canada. He was alerted by the local medical officers to the risks aboard the ships, which he contained until he convinced Montizambert, who was the same age as Dr. Anthony Fauci is today, to take them into quarantine. The tragedy was the sinking of hospital ship Llandovery Castle, and the massacre of its survivors, in June 1918, which caused Canada to suspend the movement of personnel westward across the Atlantic. These two events, and the eventual addition of influenza to the list of quarantinable diseases, prevented returning soldiers from being a source of influenza here. Indeed it might be said that the Canadian Army Medical Corps played a significant role in preventing spread of the disease at that time.

Andrew MacPhail reported that 45,960 Canadian soldiers contracted influenza, of whom 766 died. Troop movements did contribute to the spread of influenza within Canada but the source of the disease in the second wave, which occurred in the Fall of 2018, was the United States. By late Summer 1918, influenza had spread to US army camps along the eastern coast and to the city of Boston. US recruits were sent to a new National Polish Army training camp at Niagara-on-the-Lake, which became the site of Canada's first large outbreak of influenza that September. Other military recruits from Boston brought influenza to Montreal. A troop ship destined for England from New York had to make an emergency stop in Cape Breton because of influenza aboard. Humphries described how the secret westward movement of Canadian troops across the country caused the spread of disease from these sources, back to the west coast, where it had landed silently a year before. These troops, destined for deployment to Siberia in the Allied effort to thwart the Soviet withdrawal from the war effort, were associated with outbreaks of influenza in northern Ontario, Winnipeg, Saskatchewan and Alberta.

In Canada and the United States, efforts to contain the spread of influenza varied according to the wishes of local authorities. Studies were undertaken to design masks that prevented the spread of harmless bacteria, that had been gargled by volunteers, and grown on petri dishes at varying distances from the subject. A 1920 Californian study comparing towns which mandated the use of masks in public, to those towns that did not, found no difference in infection or death rates. The author, Dr. W.H. Kellogg, blamed a lack of compliance for the negative result. In Canada, jurisdictional disputes between Federal and Provincial governments failed to consider the essential role of municipalities. Concerns led to the establishment of a Federal department of health but its role in Canadian healthcare was never agreed. Dr. Montizambert, who took a month long vacation during the pandemic, remained absent in the design of the Federal mandate. An opportunity to develop a strong centre for disease control was lost then and that we still feel its effect a century later.

Neither influenza nor coronavirus has inherent wave characteristics. It is not necessary to posit a mutation to explain a change in severity. Whether or not an outbreak occurs locally, and the severity of its effect, depend on the prevalence of infected individuals. If the disease remains confined to a low number of isolated individuals, the outbreak is aborted. This is what happened in Canada in early 1918. It is also what happened in the early months of 2020 with COVID 19 travellers from China and Iran. Analysis of the next wave of patients with COVID 19 shows that the outbreak in Canada came with the return of Canadians from the United States, repeating the pattern of September 1918. Outbreaks of COVID 19 in Ontario and Quebec have not had the severity of those in Michigan and New York because the prevalence of infected individuals has been kept below a certain threshold. Outbreaks of influenza in 1918 can be explained by mass transit. Mechanized transport permitted spread over great distances, while it allowed a few individuals to infect a large number of companions, confined in close quarters, who then seeded the new location. Modern travel became the vector which magnified and dispersed local epidemics to form waves of the pandemic. It remains so today.

Estimates of mortality vary many fold. Records kept in 1918 are similar to those kept today. The number of locally recorded deaths were underestimated when all-cause mortality was compared to previous and subsequent years. Seventy years later, mortality from the 1918 pandemic was calculated to be 50,000 per million population (PMP) in India and 22,000 PMP in China, the most affected countries, compared to 5,000 PMP in Canada, the US and other developed countries. Deaths from COVID 19 stands at 797 PMP in Belgium, the most affected country, and 168 PMP in Canada as of 24 May 2020.

It is hard to shake the notion that every so often we are tested in a new round of a game that has set rules. We can sense, but do not fully understand, these rules. Interestingly, the process can be reversed, so that we can use our current experience to develop a better understanding of the past. And thus, in a cyclical process back and forth, we might begin to understand the rules of the game. Respiratory disease pandemics have been recorded every 25 years or so since the 1850s. Certain bat populations appear to be the source of the respiratory disease viruses as well as of Ebola, Nipah, Hendra, Marburg and other contagious diseases. A second vector seems to be required to prime the virus. Swine, birds, horses, civets, and recently pangolins have been implicated. In 1918 they failed to spot the emergence of influenza, despite being far-better contagious disease doctors than we are today, and having a military medical network that spanned the globe. The reason was likely the all-consuming First World War. The western world needs to maintain a deep partnership with scientists close to the reservoirs of infection. In July 2019, our collaboration with the Wuhan Institute of Virology was disrupted by the arrest of two Public Health Agency of Canada scientists in Winnipeg. In the US, the Center for Disease Control terminated its program in China after the election of the current president. As in 1918, we may be allowing unrelated events to cast a long shadow over our ability to deal with pandemics.

The 'second wave' of the 1918 pandemic resulted in the equivalent of 150,000 deaths in Canada today. Canada was vulnerable because it had avoided the negative consequences of the first wave of influenza. It is a situation in which we find ourselves again.