key: cord-0872825-iievpxqy authors: Scerri, Mariella; Grech, Victor title: The Spanish flu, COVID-19 and Malta's reactions: Contrasts and similarities date: 2020-11-12 journal: Early Hum Dev DOI: 10.1016/j.earlhumdev.2020.105252 sha: 2ae97a8eab5f59d8d6064bc808d7ac01e522b7bb doc_id: 872825 cord_uid: iievpxqy The historical seriousness of the challenge of the Spanish flu and COVID-19 is well documented as both diseases, then and now, spread indiscriminately across the planet. A century apart, these two pandemics have devastated the world. The advances in health and science over the past hundred years have proved only partially effective against the current pandemic. At the moment, the therapeutic strategies to deal with the infection are only supportive and prevention is aimed at reducing transmission in the community. This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis. Western health care systems have been built around the concept of patient-centred care but a pandemic requires a change of perspective toward a concept of community-centred care. Malta has painfully learned this the hard way. This paper examines the sources of variability during both pandemics in shaping the morbidity experience of the Maltese islands which in turn allows for a better understanding of how developments of isolation, exposure, history and physical distancing could play important roles in shaping the epidemic experience. In order to cause a pandemic a virus must meet three criteria: little or no pre-existing population immunity, the ability to cause illness in humans and efficient transmissibility between humans [1] . The H1N1 virus which caused the 1918 influenza pandemic, and the latest novel coronavirus, SAR-COV-2 which is the cause of the COVID-19 pandemic met all three criteria. A century apart, these two pandemics wreaked havoc and death at a global level. The world was then and now, thrown in a battle against an invisible adversary, and humanity had to ignore past conflicts and collectively seek to make sense of unprecedented circumstances through the language of war. This metaphor illustrates the historic seriousness of the challenge of both pandemics as both diseases spread indiscriminately across the planet. Understanding epidemics in human populations is a central theme in the study of novel and re-emerging pathogens. This paper examines the sources of variability during both pandemics in shaping the morbidity experience of the Maltese islands which in turn allows for a better understanding of how developments of isolation, exposure, history and physical distancing could play important roles in shaping the epidemic experience. Malta, a Southern European island country is an archipelago in the Mediterranean Sea. With a population of 493,000 over an area of 316km 2 , Malta is the world's tenth smallest country in area and fifth most densely populated sovereign country. Its strategic location has historically given it importance as a naval base. Malta became a British colony in 1813, serving as a way station for ships and the headquarters for the British Mediterranean Fleet. The country gained independence in 1964 and became a republic in 1974. Malta joined the European Union Malta had a good reputation for preventing epidemics, having a lazaretto with quarantine facilities to house people and store goods until deemed safe for entry into the country. These facilities date back to the days of the Knights of St John (1530 to 1798). The British reinforced the island's repute by creating a post of Superintendent of Quarantine, its first office holder being William Eton [2] . Nowadays, a robust health service is dealing effectively with the current COVID-19 pandemic. The 1917-19 pandemic, which is also commonly known as the Spanish flu, made its appearance in Malta around June 1918 and persisted until June 1919 [3] . The 1918-19 epidemic affected the Maltese population in three phases. The first phase of the infection lasted about three months and was relatively mild with 93 cases reported and two fatalities. The first wave was quickly followed by a second more severely contagious phase. During the subsequent two months of September-October 1918, the total number of cases in the civilian population amounted to 10,281 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 epidemic appeared to subside in the subsequent months, only to be followed by a resurgence in March 1919 when a total of 4507 cases were registered. This third wave of the epidemic rose rapidly to its culminating point in the mid-March, falling rapidly in April to be almost over by May 1919 [4] . In response, the Department of Health undertook a number of precautionary measures in order to attempt to control the spread of infection. General prophylactic measures included the prevention of overcrowding in public places while ensuring that these localities were kept clean, well aerated; the disinfection of public spaces including railway carriages and ferry boats; reducing visit times in the various Charitable Institutions; discontinuing the pawning of clothes at the Monte de Pieta'; the closure of schools; increasing visits to suspect dwellings by Sanitary Inspectors; and temporary surveillance of arrivals from overseas with disinfection of belongings were necessary. Individual prophylactic measures introduced included a public propaganda campaign to emphasise 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 harbour were isolated at the Infectious Disease Hospital at Manoel Island [4] . The pathways through which the influenza pandemic increased health burden across the Maltese Islands at the time occurred through a complex series of factors. In both Malta and Gozo, the prevailing conditions during the late nineteenth and early twentieth centuries were such that high population density, a high birth rate, inclement weather and a low standard of living were the norm [4] . It is against a background of poverty and social unrest that the Maltese found themselves during the 1918 outbreak [4] . Data collected at the time also revealed that females were affected more than males presumably given their disposition to nurture and take care of sick children within the household. Being a primary caregiver for children, a mother would have been at increased risk of influenza. Under the hardships associated with the war and an epidemic, women experienced unprecedented amplified stress levels as they tried to maintain essential daily elements of household security [5] . Lack of sleep and being in a state of perpetual exhaustion are known to be deleterious to the immune system with higher susceptibility to infection [5] . Furthermore, a high birth rate resulted in unsanitary and poorly ventilated living quarters. Therefore, large families provided ideal conditions for the spread of infectious disease through continuous contact. The unseasonably cold weather during October further encouraged indoor living [6] . Mass gatherings are an important element in the transmission of infectious diseases and the genesis of epidemics. The large number of susceptible individuals in confined spaces is an opportune setting for the spread of viral diseases, such as influenza [8] . Mass gatherings such as marriages, baptisms and burials continued throughout the year, but in the case of the 1918-19 pandemic, the carnival held in February was a crucial factor in the dispersal of the virus. The carnival is an awaited festival to this very day, consisting of five days of parades and dances in Valletta, and in Victoria and Nadur in Gozo. Carnival festivals went forward despite the continued presence of influenza cases on the Islands. There is little doubt that these large, crowded gatherings contributed to the resurgence of wave 3 [5] . The first case of COVID-19 in Malta was reported on March 7, 2020. By the end of April 2020, Malta had 458 active cases. Out of the total cases, there were only 4 deaths, 151 active cases and 303 cases which were fully recovered. During this time, Malta has demonstrated a robust health service and adopted stringent measures to combat a significant outbreak on the islands. Within weeks, government blocked all flights and closed all non-essential shops, non-essential services, bars, restaurants and gyms. Meanwhile, all schools and educational establishments will remain closed at least until the next scholastic year. People over the age of 65 years, pregnant women and people with chronic illnesses were instructed to shelter at home as a preventative measure. At the end of March, WHO Regional Director Hans Kluge recognised Malta for its sterling effort in dealing with the current global COVID-19 pandemic [7] . Widespread testing, contact tracing and quarantine measures for those at risk of infection are considered key to control the epidemic and keep the number of cases at a minimum. The repeatedly low number of cases being reported in the fourth week of April called for a proactive approach to screen for COVID-19 within the community, including offering a coronavirus test to anyone who calls Malta's helpline even if they are asymptomatic. The authorities are also actively looking for asymptomatic COVID-19 cases in the community in high risk groups such as migrants, health care workers, police and army officials. In the coming weeks, Malta will also start to implement as yet undisclosed measures to commence a stepwise reduction in the current soft lockdown. Since lifting restrictions could result in a resurgence of cases resulting in a second wave, the need for a staggered approach and timing is being advocated by Malta's Public Health Superintendent Professor Charmaine Gauci. Epidemiologically positive results, health system capacity and public cooperation are three essential criteria that guide timings. A simultaneous approach of extensive testing and automated contact tracing will continue together with ongoing social distancing, health and safety measures and local authority certification. A successful exit strategy will also take into consideration business continuity, ICT readiness and remote working, as well as an acceptable physical distance between workers. Regular pandemic outbreaks of influenza have occurred throughout the centuries causing significant morbidity and mortality. Pandemics usually occur in several waves of outbreaks with an interval of about three to nine months [3] . In both of these pandemics public health measures were paramount, and early and decisive actions taken in Malta have prevented nontrivial morbidity and mortality. Although no information has been documented on the exit strategy of quarantine measures during the local 1918 pandemic, many countries including Malta are at the time of writing envisaging an adaptation process to a new normal. A stable exit strategy that allows Malta to move carefully out of lockdown is essential. Community empowerment, community involvement and public health intervention through the use of case finding, isolation, contact tracing and quarantine measures will become the alternative to combat a resurgence of cases [8] . Having a health system that is capable of absorbing any increase in cases until the situation is once again brought under control is also paramount. A century apart, these two pandemics have devastated the world. The advances in health and science over the past hundred years have proved only partially effective against the current pandemic. At the moment, the therapeutic strategies to deal with the infection are only supportive and prevention is aimed at reducing transmission in the community. This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis [9] . Western health care systems have been built around the concept of patient-centred care but a pandemic requires a change of perspective toward a concept of community-centred care [10] . Malta has painfully learned this the hard way. No funding was required for this project. There are no conflicts of interest, actual or potential. No human subjects were involved so no ethical approval or data protection was applied for. No consent was needed. We give consent for publication of this article. 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