Influenza

The Spanish flu, also known as the 1918 flu pandemic, was an unusually deadly influenza pandemic caused by the H1N1 influenza A virus. Lasting from February 1918 to April 1920. The term “Spanish” flu was coined because Spain was at the time the only European country where the press was printing reports of the outbreak, which had killed thousands in the armies fighting World War I (1914–1918). Other countries suppressed the news in order to protect morale.

Most influenza outbreaks disproportionately kill the very young and the very old, with a higher survival rate for those in between, but the Spanish flu pandemic resulted in a higher than expected mortality rate for young adults. Scientists offer several possible explanations for the high mortality rate of the 1918 influenza pandemic. Some analyses have shown the virus to be particularly deadly because it triggers a cytokine storm, which ravages the stronger immune system of young adults. In contrast, a 2007 analysis of medical journals from the period of the pandemic found that the viral infection was no more aggressive than previous influenza strains. Instead, malnourishment, overcrowded medical camps and hospitals, and poor hygiene, all exacerbated by the recent war, promoted bacterial superinfection. This superinfection killed most of the victims, typically after a somewhat prolonged death bed.

The Spanish flu claimed around 50 million lives around the world regardless. Globally, the death toll eclipsed that of the First World War, which was around 17 million. It infected around 500 million people about a third of the world’s population at the time in four successive waves. In South Asia, more than 20 million people died of this. Pathogens ignore national borders, social class, economic status, and even age. While influenza is typically more deadly in very young or elderly people, the 1918 influenza pandemic, for instance, was unusually fatal among men aged 20 to 40 years. the 1918-19 flu hit the women hard.

An influenza pandemic would also likely have significant impacts on the overall functioning of a country’s health system, as it would draw heavily on resources and health workers. Pandemics disrupt the economy and social functions like school, work and other mass gatherings.

Source: https://en.wikipedia.org

As what had happed in the case of COVID-19, influenza came to Sri Lanka from abroad. In the 1918-19 case, in World war 1, soldiers were returning from European battlefields to India and the US, brought it to their home countries. Travel and trade between the West, India and Sri Lanka brought it to Sri Lanka through then important sea ports of Colombo and Talaimannar. In the case of COVID-19, the carriers were tourists, business travelers and migrant workers entering through the airport in Colombo.

Sri Lanka has had the experience of going through a horrendous pandemic the Spanish flu or influenza, which claimed nearly 20,000 lives according to the academic paper published in 1992 by C.M. Langford and P. Storey (Page3) of the Department of Population Studies, London School of Economics, tells the sad tale of the past.

Here are some extracts from the paper: As elsewhere, there was a mild first wave followed by a virulent second wave which was characterized by fatal pneumonic complications. Fertility fell about 1.1 per cent of the population died. Mortality seemed to be concentrated among those aged 20–40 and especially those aged 25–35. There was also a third wave in some cases.

The first wave was in the spring-summer of 1918 and was apparently fairly mild. The second was in autumn-winter of 1918. This showed a terrible propensity to lead on to pneumonic complications and death. About 20% of those contracting the flu developed pneumonic complications and eight out of these 20% died. The third wave (where there was one) came in the early part of 1919. It was serious but its overall impact was much less.

United States then as now

As in the COVID-19 case, the US had a big part in the flu epidemic. In the current case, though the coronavirus started its journey in China, it was when it went to the US that it became a pandemic. A century ago, according to Langford and Storey, the flu began in the US in March 1918 and spread across the world in the next four months.

It struck Britain in June and July, reached Bombay in June 1918 and came to Colombo and Talaimannar thereafter. At that time, Talaimannar was second only to Colombo in terms both of the number of vessels using the port and the size of their crew. About 200,000 people passed through Mandapam quarantine camp in Tamil Nadu in 1918 en route to or from Sri Lanka.

In 1918-19, death due to influenza in Sri Lanka was 19,102 of which 18,887 were recorded in the last quarter of 1918.The first to get the flu were Colombo dock workers. But by September and October 1918 nearly every province and district in the island was affected.

A notable feature of the disease was a rapid onset of pneumonia which is a lung inflammation caused by bacterial or viral infection in which the air sacs are filled with pus and become solid. Deaths were mostly due to Broncho-pneumonia.

Malaria complicated matters

At the end of November 2018, influenza abated, but malaria surfaced in a big way. The latter made the people so weak that when attacked by flu they succumbed to it. Many cases of malaria were complicated by a pneumonic sequel probably due to influenza, local health officials reported.

Districts in the Dry Zone (such as Anuradhapra) suffered more than those in the Wet Zone. According to the authors, the Dry Zone suffered more because it was generally less healthy, less developed and less well provided with health and sanitary facilities than the Wet Zone. And the Dry Zone was also much more prone to malaria than the Wet Zone. Malaria combined with flu proved to be deadly cocktail.

In the South, the plantation sector suffered a lot because of the congested living conditions, the unhealthy environment in the “Line Rooms” where the tea workers lived, and the poor health of the estate workers who were poor laborers from impoverished South India.

Ethnic differences

According to the 1911 Sri Lankan census, 66% of the population were Sinhalese, 13% were Ceylon Tamils, 13 % were Indian Origin Tamils and 6% were Ceylon Moors.

In the short term, and in the worst months, the Indian Origin Tamils bore the brunt of the pandemic. The Muslims were next in line, and the Sinhalese were third. This position of the Sinhalese may well have reflected the fact that their habitations were much more scattered while other communities tended to live in close proximity.

However, over a longer 15- month period, ethnic differences in morbidity disappeared, the researchers noted.

It is clear from the data that women suffered higher mortality than men. A possible factor is the risk associated with pregnancy and childbirth. In most pandemics up to and including that of 1918–19, there were reports of abortions and stillbirths due to influenza.

In 1918–19, a series of 1350 pregnant women who had influenza were observed and it was found that abortion, stillbirth or premature labor occurred in 26% of those without pneumonia, and 52% of those with pneumonia.

But the authors state that the higher mortality experienced by females during the 1918–1919 epidemic could not be entirely explained by pregnancy-related factors. The real answer may be that, in general, at that time in Sri Lanka, mortality tended to be higher for females than males, they pointed out. The mean expectation of life at birth in Sri Lanka, in early 20th Century, based on the ‘normal’ rates, was 32.7 years for males and 30.2 years for females.

Mortality rates were higher for females than males in all ages except during infancy and in the 45–54 age group. Indian Origin Tamil women tended to suffer heavier mortality than men in the 1918–1919 epidemic partly because they were already in a somewhat worse health than men.

Food shortage

The effect of the epidemic on agricultural production, and the possible significance of food availability for mortality in the 1918-19 epidemic cannot be ignored Langford and Storey said.

There is little doubt that the influenza epidemic disrupted agricultural production in Sri Lanka. Low local production and the Indian ban on exports of food items (India was also suffering from the epidemic) were at least partly to be blamed for the food shortage and the consequent nutritional deficit and mortality in Sri Lanka, the authors stated.

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